Shedding the cobwebs
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
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
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.