College of American Pathologists
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  President’s Desk Column


cap today

Shedding the cobwebs

March 2003
Paul A. Raslavicus, MD

Sometimes life gets ahead of you. There is the unread book, the out-of-style clothes. There is not a flat-screen TV anywhere in sight. The practice, the family, the community—these responsibilities often take precedence.

To once more "become organized," I decide to dust the cobwebs off the old file cabinets that I had not opened for several years. In weeding out the past, I come across a folder labeled "The Future." The future of medicine and pathology, in fact. The future is here, so I open the folder eagerly to see how close to—or far from—the mark were we yesterday in predicting the present.

Economists, sociologists, and other soothsayers have for centuries predicted doomsday, events spinning out of control, and a scarcity of resources. Twenty-five years ago we heard much about the unsustainable growth in health care expenditures. Spending was accelerating; it more than tripled in the ’70s and exceeded half a trillion dollars by 1990. We had regional planning councils, Certificate of Need programs, and optimum care committees to oversee (read "ration") care. In the early ’90s, as a solution to our woes, the Jackson Hole Group proposed a managed competition plan with government-controlled regionalization and a dozen national "supermeds" serving the entire country. The Clinton health care reform movement morphed it into the managed care system that made the insurance company the watchdog for the patient, and the patient, in the words of Mitch Rabkin, the well-known health administrator, became "little more than a rectangle of exposed skin surrounded by sterile drapes." Like the assembly-line blue-collar worker of the scientific management era, what physicians gained in productivity we lost in the spirit of our profession.

Slightly constrained by managed care, costs have continued to rise and now represent $1.5 trillion. Expressed another way, health care costs represented 4.5 percent of the Gross National Product in 1961 and 13.3 percent of the GNP in 2001. While these expenses may be greater than the whole budget of France, I marvel at how well our country absorbed, even prospered under, this burden. We have nurtured an abundance of innovative technology, built mega academic medical centers, and employed millions in the health care sector. We know we have system inefficiency problems and that there is an abundance of opportunity to improve. But we also know our efforts have resulted in great victories over many maladies, from neonatal mortality and childhood leukemia to acute coronary disease. These achievements have enhanced the health and quality of life of our citizenry beyond the imagination of anyone of a quarter century ago.

We in laboratory medicine participated in the growth of costs and in an abundance of technologic and scientific change as well. We managed to reduce costs on a per-test basis, but despite great productivity improvements, increase in test use negated our wins. The underlying problem of malutilization was identified in those papers of a quarter century past. The tremendous opportunity for pathologists to use their professional skills to help develop best clinical testing practices has not diminished with time.

The CAP Foundation ran its think tank Dearborn Conferences 20 years ago, the Association of Pathology Chairs engaged the future at the 1990 Black Point Retreat, and the original American Society of Clinical Pathologists tackled future needs and strategies in Colorado Springs. Predictions of calamity came from various directions, with advancing and transforming technology seen as the biggest threat. There were conflicting reports about whether there would be a pathologist glut or a dire shortage. Academics feared the latter; many in the community foresaw the rise of the unemployed and unemployable pathologist. The supply of new pathologists did reach an excess in the mid-’90s; only now does it seem to have reached better market balance. In the process, we have gained a new generation of highly trained and subspecialty-educated young pathologists.

The predicted technological changes in how we serve patients are, to a great extent, the reality of today. Raymond Gambino, MD, foresaw in 1983 the development of home and bedside testing. Ronald Weinstein, MD, predicted in 1987 the development of telepathology and the networking of pathology diagnostic services. The late Perry Lambird, MD, predicted 15 years ago that unless pathologists and their organizations embraced change, the future could be grim. He rejected his own Sayonara hypothesis in which advancing technology and government interference crippled the specialty, and in which the average pathologist’s work routine became "devoid of challenge and intellectual charm." He also rejected the possibility of a "soft landing," insisting that the course of pathology would be determined by how well our leadership and we, the practicing pathologists, capture the spirit of the future and adapt ourselves to be leaders of pathology and laboratory technology of our present time.

How have we done in this regard? We certainly have not become vaporware. We have been highly successful in pursuing some technologies; in others we have failed to fully grasp the opportunities that came our way. The possibilities of medical informatics, as expounded by Ralph Korpman, MD, and others in the ’80s, have not resulted in a contemporaneous prediction by William Hartmann, MD, that there would be a "pathoinformology" subspecialty. We do have the Association for Pathology Informatics and a core group of leaders, but many more of us need to be involved.

Likewise, William Gardner, MD, 15 years ago presciently predicted a day in which "tissue diagnosis would not be derived from a collection of pink and blue artifacts to which we are so remuneratively attached, but from computer recognition of specific biochemical and genetic fingerprints." This same theme arose in a recent seminal editorial by Donald Henson, MD, in which he reminds us that in a period of some 150 years, we evolved from being physicians who observe gross disease at autopsy, to microscopic diagnosticians of myriad pathologic changes. Now, having reached great capabilities in microscopic diagnosis, we are entering the era of molecular diagnosis and molecular imaging.

Microscopic diagnosis will remain a foundation of pathology practice, but we will not be shackled to the past. As long as the doomsayers do not destroy our spirit, we will go forward to an abundance of new territories to expand our boundaries in molecular medicine, new technologies of cancer diagnosis, tissue banking, genomics, and even genetic counseling.

To all of us, at whatever stage we are in our careers, the College offers its help to shed the cobwebs of the past. Our CAP ’03 Annual Meeting in San Diego Sept. 10-14 promises to be such a transformational experience. Become immersed in molecular pathology. Be in the vanguard of cancer diagnosis. Exchange insights and solutions with colleagues. Participate in immediately useful practical education. Register by the early registration date of April 15 and you will save $75.

That, by the way, is enough for a down payment on that flat-screen TV. I think I will do it.