There isn’t a clean answer to your question, but we can offer some things to consider.

Setting up a routine reminder that should be considered in the wake of abnormal troponin results seems reasonable on first reading. Your letter seems to anticipate the possibility that the next step would be routine reminders for any reportable quality data required as part of the United States Centers for Medicare & Medicaid Services’ (CMS) Reporting Hospital Quality Data for Annual Payment Update program, and that concern also doesn’t seem unreasonable. Putting the two together, however, does create, in your words, a slippery slope. Most notably, can it be good medicine to make routine advisories on the basis of a payment update requirement, especially when 87% of the laboratory testing involves outpatients? Is it so unreasonable to think that reminders for reportable quality measures could quickly become routine, and soon thereafter, a busy staff person might neglect to consider treatments that are equally valid but not covered under the reportable measures and therefore not included in the reminder system? Probably not.

With CMS providing a financial incentive to hospitals that successfully comply with the reporting requirement; it makes sense to encourage it. The CMS Web site lists among its reportable quality measures aspirin upon arrival for heart attack symptoms as well as aspirin prescribed at discharge. (For more background on reporting quality measures, go to http://www.cms.hhs.gov/HospitalQualityInits/08_HospitalRHQDAPU.asp.)

So there could be merit in creating a medical staff committee to identify criteria for treatment reminders that could appropriately attach to test results. Subcommittees of appropriate specialists could determine circumstances under which a given treatment reminder would be appropriate. A transformational pathologist would welcome the opportunity to propose and facilitate these subcommittees, and to shepherd resulting recommendations through review by relevant departments and the hospital risk management committee.

It would be wise to think about how these recommendations are presented, so that the nursing staff will not assume that any basic follow-up measures, such as aspirin for abnormal troponin readings, will be indicated with the test results. That aspect will be an important aspect of the risk management committee review.

Making use of test results to encourage closer working relationships with other clinicians in ways that benefit patients would seem to fall well within the activities of a transformational pathologist. If, as is often the case, your colleagues are not accustomed to consulting their pathologists on treatment guidance, either because your department has not initiated these conversations in the past or because they have never thought to come to you for advice, an initiative like this one could change that. A project to develop hospital-wide criteria for treatment flags tied to test results could make a big difference in how your colleagues think of your role in clinical care. It might even encourage them to come to you for consultation on other indicated treatments that typically relate to certain test results.

A thoughtful collaboration that draws in physicians from various hospital departments to develop tailored treatment recommendations tied to specific test results for patients who meet clearly identified criteria (one of which may be “inpatient”), would build bridges.

Dear Dr. Wilson,
A number of government initiatives are improving the ability of laboratories to obtain real-time data on emerging infectious diseases. Here is a short list:

• The Centers for Disease Control and Prevention (CDC), through its National Center for Public Health Informatics, has launched an initiative to integrate laboratory information systems within CDC and its partners in outside laboratories.
• The Public Health Information Network, facilitated by the CDC, is a national initiative to improve the capacity to exchange information electronically through the promotion of standards for reporting as well as for technical requirements.
• The National Electronic Disease Surveillance System is an Internet-based system of interoperable systems for public health surveillance data exchange developed by the CDC.
• The American Health Information Community (AHIC), a federal advisory body of the federal Department of Health and Human Services, is working (in conjunction with the CDC) toward Development and adoption of standards-based healthcare information systems for public health reporting. AHIC is creating interoperability specification standards that promote the exchange of biosurveillance information across organizational and jurisdictional boundaries. The adoption of these interoperable laboratory specifications, on both national and international levels, will provide the tools necessary for reporting emerging infectious diseases as well as environmental and bioterrorism outbreaks to the CDC. Interoperable laboratory specifications will also allow pathology laboratories to receive pertinent information regarding possible outbreaks.
• Persons interested in prevention of health-care-acquired infections and antimicrobial resistance may go to http://www2a.cdc.gov/ncidod/hip/rns/hip_rns_subscribe.html and request a no-charge subscription to the noninteractive CDC Rapid Notification System for Healthcare Professionals. The RNS provides periodic time-sensitive e-mail messages about important healthcare events such as disease outbreaks and product recalls, and also notifies subscribers about available publications, such as new healthcare guidelines. This listserv is sponsored by the CDC Division of Healthcare Quality Promotion, formerly known as the Hospital Infections Program.

The College already participates in a number of these projects through its Diagnostic Intelligence and Health Information Technology (DIHIT) initiative. The DIHIT seeks to ensure that members remain knowledgeable about developments in this area by offering both educational and participatory management opportunities.

Pathologists have a leadership role in the creation of standards necessary for real-time reporting of emerging infectious diseases. To that end, working through the DIHIT, the CAP will:

• Offer Web-based presentations on many of these national initiatives to publicize current standards proposed and developed for disease surveillance and
• Encourage and assist members who are interested in taking active leadership roles in developing these interoperable specifications.

As your question wisely implies, Dr Wilson, there is always more that proactive individual pathologists can do to ensure effective biosurveillance. One resource to that end is ProMED-mail (Program for Monitoring Emerging Diseases), a free international infectious disease surveillance and outbreak e-mail alert system with more than 22,000 users. This Internet-based system, sponsored by the Gates Foundation, Rockefeller Foundation, Oracle Corporation, Nuclear Threat Initiative, and many individual donors, allows any e-mail user to upload disease alerts and receive near real-time disease-warning information from around the world. While the College does not currently have a position on this site, we encourage physicians to take advantage of all available disease surveillance alert systems.

More information on ProMed-mail is available at: http://www.promedmail.org/pls/otn/f?p=2400:1950:3386837377382496::NO
The enrollment link is as follows: http://www.isid.org/promedmail/subscribe.lasso.

Thank you for writing, Dr Wilson. As you point out, this is a transformational issue, one that becomes more relevant as health care concerns become more and more global in nature.

The College collaborates with many other specialty societies and advocacy groups; our professional network enriches nearly everything we do. It is impossible to imagine the CAP without the advice and support of residency program directors, academic centers, pathology chairs, and other pathology organizations. Of course, those are the groups most close to home; they don’t begin to cover the extended CAP network. Perhaps the best way to respond to your letter is to share examples. They’re random, but representative.

• Two years ago, in partnership with the American Society of Clinical Oncology (ASCO), the College developed guidelines for laboratory testing for HER2 positivity. That led to another important CAP/ASCO effort now underway to write a guideline for estrogen receptor testing.
• We collaborate with the American College of Medical Genetics and the Association of Molecular Pathology, both organizations on the cutting edge of research directly tied to our mission.
• We work with the American Health Information Community, the Healthcare Information Technology Standards Panel, the Certification Commission for Healthcare Information, and other groups that support quality health informatics.
• We collaborate with the National Comprehensive Cancer Network, an alliance of 21 of the world’s leading cancer centers working to develop treatment guidelines for most cancers and to support research to improve the quality, effectiveness and efficiency of cancer care.

Liaison relationships are one of the most effective ways to strengthen ties with other specialties and health advocacy organizations.

• We appoint or host liaisons, for example, with committees of the American Academy for Clinical Chemistry, the National Association of Medical Examiners, the Association for Genetic Technologists, and the American Association of Blood Banks.
• Through liaison relationships, we keep communication flowing with the Joint Commission on Accreditation of Healthcare Organizations, the American College of Surgeons Commission on Cancer, American College of Radiology, and American Medical Association.
• And of course, we work with countless governmental and regulatory agencies.

Those were random lists that don’t begin to cover the waterfront, but you get the idea. The College would never have the hubris to suggest that we could transform the specialty on our own! Transformational pathology will have no meaning if it is restricted to our own specialty. Transformation is about far more than how we see ourselves; it is also about how others perceive us.

As fundamental to our mission as it may be, 17,000 pathologists thinking differently about how they approach their professional lives is not enough. But several hundred thousand other physicians, patients, and health care professionals thinking differently about our place on the patient care team would be a good start. If that is to happen, we must demonstrate that we are not only diagnosticians but physicians who integrate information from a variety of instrumental and clinical sources. We must take our rightful place on the clinical team, advising colleagues on treatment alternatives and monitoring patient progress once a therapeutic regimen has begun.

So, Dr Rimm, you’ve hit the nail on the head. It is critical that we transform our relationships with clinicians who need our services. Our campaign to encourage transformative thinking about pathology will be judged most successful in those places where we close the feedback loop by partnering with other physicians as advocates for both classic and innovative tools and techniques to improve patient safety and health care quality.

Transformation is about encouraging innovative and integrated use of clinical skill, laboratory tests, new technologies, and other resources (including human resources!). Changing how we think about our role on the medical team is only half the task. Changing how others think about our role on the medical team is where we close the loop.

Before we get into some of the more philosophical aspects of your letter, I would like to address your urgent concern about continuing education to ensure that the technical laboratory staff remains competent in an era of high pressure and rapid change. For that purpose, I would like to recommend the CAP competency assessment program.

The competency assessment program is a new, systematic, online approach to CLIA-mandated competency assessment in the laboratory. It offers courses with customized training and continuing education (CE) credit, reassessment tools, and a continually evolving library of stand-alone courses. Checklists for specific instruments are included, as is software that enables managers to track progress of individuals. Each laboratory team can collaborate to select courses and build a curriculum that meets their needs. The system will also track and record each participant’s earned credit, including that earned from non-CAP courses.

The College also supports technical staff education by providing speakers for meetings of professional groups, such as the Clinical Laboratory Managers Association. And those laboratories that subscribe to Surveys have the benefit of free online educational activities tied to specific proficiency testing products.

The CAP competency assessment program is subscription-based, and you mention an absence of institutional support for CE funding. It may be helpful to advocate for that funding in the context of staff adaptation to rapid technological change across medicine. Motivating administrators to respond to changes in greater health care delivery environment is an important responsibility of the transformational pathologist, and it may be possible to see this as an opportunity to step up to that task.

As for the philosophical aspects of your letter, if this were a graduate course in logic, your argument would earn an A+. But you wouldn’t have written if we were operating in a controlled system governed by rational choices.

The amazing rush of new diagnostics and technologies popping up like kudzu may deny anything resembling methodical staff training in new technologies, but there are worse problems. And while heavy emphasis on outreach creates complications of its own, it beats the alternative.

Most pathologists have a healthy respect for proper training and education; we know that a slower, stepwise plan to implement new technologies would be ideal. But methodical isn’t going to happen. In its absence, as you point out, continuing education and training for the technical staff is critical.

Changing our way of thinking about change is an important part of what the transformation is all about. We didn’t invent this brave new world, we didn’t set out to evolve overnight as the integrator, prognosticator, and advisor to the clinical team, but a golden opportunity has fallen to pathology and we would be fools to let it pass us by. And that could happen if we insist upon imposing logic upon a system in productive chaos. If it seems that we are rowing with one oar—which is to say, going around in circles—then we need to reach out to new rowing partners or risk drowning in a whirlpool of our own making.

So we go with the next best alternative—to juggle as fast as we can, keeping all the balls in the air with the help of the College and the support of our fellow pathologists. Many of our clinical colleagues have not yet grasped the strength of the tsunami that is personalized medicine. Because pathologists work with all specialists and all patients, we are uniquely positioned to appreciate the enormous potential of the powerful emerging tools.

And it is good that we do, because one of our most important tasks will be introduce new challenges in the laboratory, where our technical staff will be expected to function more independently than ever in this brave new world. As you clearly recognize, they will need to learn to use new tools with precision and speed. They will need to sustain the necessary energy and commitment to meet the challenge of rapid adaption. They, too, will need to transform.

Finally, you ask about our ability to ensure an adequate number of highly skilled technical staff to support the increased demand for sophisticated laboratory tests that new technologies will create. This, too, is a philosophical question. It is extremely difficult to predict what will happen in terms of technical workforce demographics and trends over the next decade. But regardless of how many people go into health care professions, our society has to figure out how we are going to provide health care to our citizens. What are the options? One is figuring out a way to increase the number of people who go into health care professions in general, not just pathology or medical technology. A second is thinking through how we can leverage technology to identify where gaps in workforce may create opportunities health care professionals. It will be feast or famine in the short run; at any given time we might have an abundance of one type of technical staff or another, and at any given time a new technological breakthrough may increase the need for technical staff. We may or may not need as many personnel; it is impossible to predict. This is something that we as a society need to address.

You are entirely correct in observing that ultrasound-guided fine-needle aspiration is a topic of great interest within the CAP community. In fact, we are in the initial states of developing education to support a certificate program in this area that is scheduled to launch in the third quarter of 2009.

The CAP education department is working with several content experts for the UGFNA certificate program; at this point, we are not planning to add additional content experts to the team. Although our content experts have not yet identified all of the requirements for the UGFNA certificate program, we expect that the primary focus will be on the thyroid.

As the various certificate content teams moved forward, some may want to seek pilot feedback. It is too soon to know whether our UGFNA team will be looking for feedback experts; that decision will be made down the road a bit.

If you would like to become more involved with the College, either as a pilot feedback expert or in any other role, please access the committee appointments information on cap.org.

The College has many committees and opportunities for our members to volunteer their expertise. Sometimes there are more candidates than available committee positions; in that event, not all candidates can be placed on a committee right away. However, the College keeps the names of those not appointed on file for immediate reference should midyear openings occur, and all applications remain on file for 3 years.

Your interest in the certificate programs is most welcome, thank you for writing. Your letter reflects kind of initiative, energy, and attitude that will drive the success of our transformation.

The forensic pathologist will have several leadership roles in the transformation. First, your colleagues will turn to you as a mentor and role model. Forensic pathology requires interpersonal skills and agility in functioning outside the medical comfort zone. Daily interaction with persons in the legal and criminal justice systems keeps the forensic pathologist flexible, fosters perspective-taking, and yields important insights into how non-medical professionals think and interact. The forensic pathologist is called upon to exercise a level of versatility rarely seen in any field of medicine. He or she has chosen to live “outside the box,” and that is what the transformation is all about.

Despite all the talk about new tools and techniques, transformation is, at its heart, about personal growth. As physicians who put themselves in uncomfortable situations that they cannot change, forensic pathologists take on tasks that many people would go some lengths to avoid. Transformation is very much about learning to function well outside your comfort zone and forensic pathologists are natural leaders in this regard.

Finally, transformational pathology conjures an ability to embrace new technologies. Forensic pathologists have already experienced the benefits of an outstanding new tool: the virtual autopsy. This innovation has enabled the staff at Dover Air Force Base to provide a complete and timely postmortem report to the family of every American soldier and contractor killed in Afghanistan or Iraq. CAP leaders who visited the Dover Air Force Base in October of 2007 found that the military is employing the virtual autopsy in an extremely touching and dignified environment. An important gesture of respect for our soldiers, the virtual autopsy procedure at Dover was made possible, in part, by innovative thinkers at the General Electric Company, who converted an older model CT scanner for this purpose.

Virtual autopsy is a complementary technology, meaning that it makes use of a current tool, the CT scanner, for a new purpose. Complementary technology, which signals sensitivity to limited resources, is expected to be a hallmark of transformational pathology. As our specialty evolves, pathologists will not only study new technologies and teach others to use them, but will explore and evaluate new ways to adapt current tools for new purposes. (To learn more about virtual autopsy, visit www.virtopsy.com, where cutting-edge work in this field is taking place.)

In sum, the forensic pathologist has several extremely important roles in the transformation. As role models and innovators, they will be among those who will bring the transformation home.

CME is a vital part of what we’re setting out to do, but transformation is not an overstatement. The difference between CME and transformation is the difference between staying current and reinvention. This is more than a matter of degree; it’s a substantial change in how we see ourselves and how others see us. CME increases the knowledge base; transformation changes behavior. CME is about maintaining competence; transformational pathology is lifelong learning on steroids.

New technologies are not only for new pathologists! CAP Institute coursework will enhance your ability to relate to your clinical colleagues and bring your practice-based knowledge to the conversation. For many pathologists, leadership on the clinical team will be a new experience. For most, it will be a very good experience. Seasoned pathologists who understand the new tools are needed to guide younger colleagues in their use and put new knowledge in context for other specialists on the clinical team. If you are an experienced pathologist, that job has your name on it.

The Institute and the Center are strategies to protect quality and patient safety in an era of great volatility and promise. Transformation is more than education; it’s evolution. Just as the CAP Institute is about more than CME, transformational pathology is about more than new tools. The CAP Institute and the CAP Center will house and nourish essential developmental changes in our specialty. Pathologists are a population at risk; if we do not evolve we will not survive. The CAP Institute and CAP Center are frivolous investments only if you think that investing in our survival is less than prudent.

Those who say that “this is not our job” are right. We do not have a job; we have a mission.

New technologies are emerging rapidly from a host of sources; there is a void to be filled in monitoring quality and protecting patient safety. All of medicine is in transformation. As we move from a curative to a preventive model, everyone is looking to find a footing. Transformational pathology requires a monumental shift in our collective thinking. To ensure that scientific progress continues to occur with all deliberate speed but also without risk to patient safety, physicians must regroup and specialists must work more closely with one another. Pathologists, who work with all specialists and see all the evidence, are uniquely positioned to understand why and drive that message home to our clinical partners.