College of American Pathologists
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  President’s Desk


CAP Today



May 2008
Feature Story

Blue-ocean thinking on subspecialization

Jared N. Schwartz, MD, PhD

The Blue Ocean Strategy is a fine little book in which authors W. Chan Kim and Renée Mauborgne divide the world in two—a red and a blue ocean. Almost everybody, they say, dwells in the red ocean and spends most of their time fighting over the same stuff. It’s crowded and combative. The blue ocean is much roomier and decidedly more peaceful. It’s the home of those who have come up with a service or commodity that nobody else is equipped to provide, something truly unique.

Something, I thought, like pathology.

Pathologists are blue-ocean dwellers because we have no home turf to defend. When we make a diagnosis, we’re not invested in one form of treatment or another. As the patient’s advocate, we evaluate therapeutic alternatives without professional bias. Our place in medicine will be secure so long as we remember what it is: to work with all physicians, to be knowledgeable about all diseases, and to advocate for our patients in terms of the entirety of their well-being.

So pathology training is a tall order, but fortunately, we have some extraordinarily wise and hard-working program directors, department chairs, and teaching faculty. In my travels as president, I enjoy opportunities to talk with many of them—along with their residents and fellows—about trends in our specialty. When I do, it seems that we often circle back to the increasing prevalence of subspecialization and the increasingly common expectation that those who plan to subspecialize should apply for fellowships in the second year of training.

Subspecialization is neither good nor bad; we need both generalists and subspecialists and people should follow their muse. There is room for diversity within pathology because we practice in a blue ocean of incomparable scope and depth.

I bring this up because while it appears that early subspecialty choice is a given, none of this occurs in a vacuum and we should be thinking about its implications. John T. Fallon, MD, PhD, codirector of the pathology residency program at the Mount Sinai School of Medicine in New York, says that he will endorse early subspecialization when the choice is driven by a bona fide passion. However, he warns his residents against early commitment for any other reason. “Pathology is so many things these days,” he says. “There are so many choices in this field.” Those residents who do not yet know what they really want to do are encouraged to keep their options open.

Graduate medical education continues the process of learning to think like a doctor. This means clearly relating information involving complex technologies and explaining what it all means in the vocabulary of medicine—the equivalent of street smarts within the medical culture. Our residents need training that incorporates clinical experience if they are to share the right information in context, recognize the broader implications of their findings, entertain appropriate therapeutic alternatives, read and evaluate the results of screening tests, and monitor treatment regimens. Because the patient-care lexicon involves so much that cannot be learned from books, to talk the talk, they must first walk the walk.

Christopher N. Otis, MD, of the Baystate Medical Center in Springfield, Mass., tells residents that they are to master “core and more.” Clinical experience in residency, he says, confers expertise in the etiquette of pathology practice, which takes longer to learn than one might think. Residents cannot afford to compromise on clinical exposure, because while medical school should provide an understanding of disease processes (the “core”), it is residency that builds on that knowledge and extends it to specific applications.

Residents who are thinking about whether or not to subspecialize and how to identify their next steps need mentors. Our specialty is growing quickly and changing rapidly; opportunities are fluid. What is the future of pathology? We’re still writing it. As CAP Council on Education chair William F. Hickey, MD, senior associate dean at Dartmouth Medical School and past pathology chair, likes to say, you can publish until the cows come home, but all the white papers in the world won’t get the same traction with residents as perceptions validated by word of mouth. So one role for the College is to investigate ways to share information and connect residents with visionaries, pragmatists, educators, and hiring pathologists who can act as mentors.

I tell residents that the best fellowship programs have a decidedly clinical, as opposed to a procedural, orientation. GI fellows should be doing a good number of intestinal biopsies, no doubt about that, but they should also be learning to recognize coagulation problems, effects of various GI diseases on blood chemistry, and signs of the infections associated with GI disease in other organs. They should realize that a patient with Crohn’s disease may be on steroids and know how to recognize the side effects of steroid use. They should know how to interpret optical or CT colonoscopies, PET scans, and MRIs. They should know the clinical consequences of all possible diagnoses associated with the findings before them, and the appropriateness of each therapeutic alternative. And they should be able to talk about all of these possibilities with the other physicians who are responsible for the care of their patient.

Because residency no longer includes a clinical year, it falls to mentors, educators, and colleagues to see that residents and fellows get abundant hands-on experience. This means encouraging them, including them, and inventing ways to enrich their training. New technologies are terrific, but the triumph or demise of pathology will rest not on the tools we use but on our ability to cultivate in the next generation the attitudes and capabilities of true physicians. It is our great good fortune to find ourselves in a wide-open blue ocean. Sink or swim, the quality of pathology training will be our doing or our undoing. The outcome rests in nobody’s hands but our own.

Dr. Schwartz welcomes communication from CAP members.
Write to him at