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September 2008
Transformational pathology

Jared N. Schwartz, MD, PhD

Individual organisms don’t evolve.
Populations evolve
.
—FAQs about evolution: The basics.
Evolution library at www.PBS.org

The College’s historic sustained campaign to transform the specialty of pathology will be launched at CAP ’08 this month. Our goal is to bring every fellow of the College on deck to fuel and catalyze this campaign.

Transformation is a big word and it’s exactly right. The context is significant: All of medicine continues to evolve and the pathologist’s particular skill set has never been more relevant. Diagnostics are becoming extremely sophisticated and therapies highly complex. We can do more for patients than ever before, and technical capabilities are only growing, but clinical colleagues need our guidance. The transformation campaign will enable the College to provide tools that members need to take on the task.

There is no question that today’s patients require the knowledge, skill, and acumen of a transformational pathologist:

  • Our clinical colleagues are deluged with information about new tests, and pathologists are the best physicians to guide decisions about test menu selection.
  • Our clinical colleagues are confronted with diagnostic information from diverse sources, and pathologists are the best physicians to analyze, integrate, and present findings to clinical colleagues and patients.
  • The new therapies will require close supervision, and pathologists are the best physicians to design plans to monitor patient progress.
  • The technobubble has a long way to go before it peaks, and pathologists are the best physicians to evaluate new tools.

Our expertise in quality systems has created important opportunities and responsibilities. Systems to sustain quality are never more important than during times of volatility, when circumstances can conspire to discourage the kind of persistent insistence on “getting it right” that has always been a hallmark of pathology.

Tragic events in Canada related to laboratory error that put pathology on the front page of newspapers last spring provided a valuable reminder of what happens when rigorous quality systems are not supported and maintained. Several separate scandals surfaced over a short period. One was the subject of a class-action suit involving 383 breast cancer patients—some now deceased—who may have been given incorrect estrogen and progesterone hormone receptor test results between 1997 and 2005. Another centered on errors in pediatric forensic pathology that have led the chief coroner’s office to suggest that 142 convictions be reviewed.

Laboratory medicine in Canada is regulated by individual provinces; there is no national accreditation program. Their experience shows that individual pathologists, however excellent, cannot prevent error without the support of well-maintained quality assurance systems. It would be extremely unwise to suggest that something similar could never happen in the United States. It is true that we have the benefit of robust quality assurance mechanisms that Canada had lacked until now, and that we do not suffer from their workforce shortages. But quality improvement will always be a journey; as long as we are human, we will make mis?takes. As the sad front-page stories in the Canadian newspapers illustrated all too clearly, everything that happens in a laboratory affects a real person, every test is a patient encounter, and every quality compromise is a threat to patient safety. The Canadian experience was a valuable reminder that leadership in the laboratory is everyone’s job. When an error hurts a patient, it doesn’t matter why it happened and it doesn’t matter if it’s an isolated event. When a patient is hurt, there is no such thing as a good excuse.

Patient safety in an environment of dizzying new tools and techniques calls for an aggressive campaign to bring everyone up to speed. In an environment of rapid change, those who fail to adapt do not survive. Successful evolution is the survivor’s response to environmental change. The process of evolution will be transformative, and it will require continuing teamwork. By collaborating with other pathologists and other specialists, pathologists will experience not just education, but evolution, and not just growth, but transformation.

Some pathologists will embrace transformation, pursue new roles in the workplace, and step up gladly to partnership on the clinical care team. For others, these new skills will not come so easily. But if we are to survive, we must adapt. So if a colleague would benefit from a particular course, say so. If you believe he should check out a self-assessment module, tell him. If you think she is too overwhelmed to take time to build new skills, find a way to help.

When everyone is working hard to keep up, knowledge gaps may not be readily apparent. The College will develop tools to help pathologists close those gaps and come up to speed, but not everyone will recognize the need to retool. Awkward or not, if we see performance gaps, we need to say so. We are all on the same team, and we must hold ourselves accountable for the performance of that team.

Individual pathologists will continue to transform, driving the evolution of our specialty beyond survival and toward preeminence in medicine. Transformational pathology is going to be terrific for us, for our clinical colleagues, and most of all for our patients. Next month, I will share more about plans to bring that reality into focus.


Dr. Schwartz welcomes communication from CAP members.
Write to him at president@cap.org.