CAP TODAY Pathology/Laboratory Medicine/Laboratory Management
Stanley J. Robboy, MD
January 2013—CAP secretary-treasurer Paul Valenstein, MD, remarked that pathologists’ varied reactions to our new eBook, New Paths…New Choices: Pathology in an Era of Advancing Science and Disruptive Health Economics, reminded him of “Rashomon.”
In “Rashomon,” which won the 1950 Academy Award for best foreign film, four witnesses to a crime give radically different accounts of what they have seen. Each believes himself or herself to be the killer, and nobody is lying.
There’s what is real, and there’s what each of us thinks is real, and the two are not always congruent. When good-faith versions of present-day reality differ, it’s not ordinarily because someone is right and someone is wrong. It can be because each of us brings our history and temperament to contemporary experiences, affecting how we perceive them.
The idea behind the eBook is to share what we are learning and establish a dialogue around what pathologists across the country are doing as our specialty evolves along with the greater environment. Because the medium is always part of the message, we chose to step out of our professional comfort zone—evidence-based study, measurement, evaluation, academic publication—and tell our story as we are experiencing it. Our eBook, which can be updated and augmented, creates a context for continuing dialogue around the same opportunities we are talking about in our practices and in CAP Peer2Peer meetings—stories about what we think we need to succeed and the challenges that concern us most. We hope the eBook will stimulate new thinking, prompt us to make new connections, and perhaps encourage long-distance mentoring.
We agreed to navigate those shoals by way of the journalistic method, which takes the position that well-informed, good-faith points of view have value and should be shared. The book is constructed around interviews with authoritative sources and shares their thinking in a conversational way. For that purpose, we brought in two highly regarded science writers—Howard Wolinsky and Mark Bloom—who come to the story as clear-eyed observers, neither skeptics nor advocates.
Dr. Valenstein and our CEO, Charles Roussel, advocated passionately for a journalistic approach, one that told our story in ways relatable, balanced, true, and complete—but not always congruent. John Olsen, MD, senior director and acting VP for the CAP Transformation Program Office, kept everyone on track. I talked to the writers nine or 10 times, helping them connect with experts.
We had the benefit of pathologists in current and emerging practice niches who agreed to be interviewed. Some also helped by vetting early drafts. We stayed with it until everyone could agree we had examined and revealed as many facets of the practice landscape as we could accommodate in an engaging “big picture” treatment.
The eBook will be released in the first quarter of this year—14 chapters online and video interviews with some of the experts. This is not theory; it’s evidence from the field. Chapters cover everything from the latest in digital pathology and in vivo diagnostics to the evidence-based work of Eleanor Herriman, MD, MBA, which describes business-supported scenarios useful for our specialty—what the CAP calls Promising Practice Pathways. There’s a chapter on educating colleagues about our value in the collaborative care setting. We can now demonstrate that pathology and laboratory medicine, which account for only three percent of health care costs, can deliver 30 percent of the value in coordinated care systems by reducing the number of adverse events and unnecessary tests while improving outcomes. The eBook discusses the pathologist’s role in genomic analysis, second-generation and exome sequencing. The reader meets molecular pathologists and informatics experts who provide support for electronic physician ordering, specimen tracking, data mining, and error reduction. And after some debate, we included a chapter on the autopsy because rumors of its demise have been exaggerated.
Coordinated care creates a mandate for pathology, to better coordinate our services with the work of other providers, and an opportunity, to leverage our knowledge and traditions to coordinate care across a network. We have to come together in new ways. Our future is not in establishing unanimity but in communicating the multitude of ideas that creative pathologists are putting forth to address system issues that will arise from health care reform.
We took an open-ended approach, in part because we were aware that all of us will encounter many challenges but that those challenges will vary, as will potential alternatives and solutions. So while we did give much thought to what our pioneering colleagues are and will be doing in the emerging era, the eBook is written with the full membership in mind. John Olsen reminded me that pathology today is a big tent; we will no longer be constricted by fee-for-service and there will be space for far more choices. Coordinated care and pay-for-performance will accommodate a wide range of interests and a wealth of possibilities.
Pathologists understand disease at the molecular level. This is one of the most important ways in which we are unique. We can advise on treatment protocols for patients and patient populations because we have a global perspective and are honest brokers with no reason—other than the patient’s best interest—to favor one treatment approach over another.
We will meet the challenges of our times as professionals whose choices will control our professional and economic destinies. The goals of transformational pathology need to align with the goals of health care reform: to create the greatest good for the greatest number. Some on our team will continue to cover anatomic and clinical pathology, which will always be essential responsibilities and core competencies of our specialty (though some cutting-edge roles may be more highly valued in the future). Some will pursue genomics, molecular pathology, in vivo diagnostics, and informatics. Some will lead multispecialty teams.
Our members will contribute to this wonderful specialty by making the choices that suit them best and supporting one another through ongoing dialogue that recognizes we are in this together even as we choose different paths. And the College will continue to create tools like the eBook to help all of us succeed professionally and economically while keeping our patients’ best interests front and center. Each of us will experience differently the dynamic environment in which we find ourselves. Like the characters in “Rashomon,” we will each have our own stories to tell.
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Dr. Robboy welcomes communication from CAP members. Send your letters to him at president@cap.org.