CAP's Transforming Pathologist

[pathstudent]

I got a survey today and found it curious. I had seen the "transforming pathologists" logo on the cap website when reading about the CAP certifed pathologist certificates.

But their survey makes it seem like it will be of much greater scope.

Why do we need to be transformed if we just got out of residency in the last few years? Why does pathology need to be transformed. Are we going to get left in the dust if we don't? Is this a way for CAP to charge us a bunch of money to be labeled TRANSFORMED?

Anyone know what is going on?

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[raider]

Bullsh-t!!! Thats whats going on.

Same sh-t, new method (How much time rounding with other clinicians? Is this meant to be a joke?).

Instead of doing something really transformational, like:

Improving the job market (Using dermatology job market as the benchmark to strive for) = Surgical pathologists recognized as the gods of today's medicine.

 

[pathstudent]

Well from the questions they were asking it seems they want to make sure pathologists don't get left in the dust by molecular pathology. They want us to be the facilitators and communicators of results of esoteric molecular tests. It also seems like we should be more knowledgable about therapy and dosing of drugs.

Another side of me thinks...Great now we need to jump through the MOC hoops and pay for all the extra CME/SAMs and now CAP is going to be hitting us up so that we can be "Gi certified", "breast certified", "transformed", etc... I doubt any of this is going to be cheap.

 

[raider]

Instead of pathologists rounding with clinicians (which is really stupid and a total waste of time), the clinicians should be rounding with pathologists as we sign-out.

 

[Enkidu]

Well from the questions they were asking it seems they want to make sure pathologists don't get left in the dust by molecular pathology.

Maybe this is a dumb question, but does molecular pathology threaten pathologists?

 

[raider]

Not at all.
But may become an additional valuable stream of income because of pharma and onc docs pushing for targeted therapies.

I keep getting invitations to these nonsense dinners from pharmas like the following from clarinet

"The dinner will focus on the major advances in research and technology that are allowing for the identification of new and novel biomarkers that are being increasingly used in clinical practice to qualify patients for targeted therapies in breast, colon, and lung cancer. Join us to learn how pathologists can help the oncology community to better qualify patients that may benefit from individualized therapies."

Big money=Big hype.

However, I do invest in biotech because in matters of life and death, people will even buy snake oil as long as there is a good marketing strategy.

 

[pathstudent]

Maybe this is a dumb question, but does molecular pathology threaten pathologists?

It doesn't, per se. We just want to make sure pathologists are driving the bus.

It is true. The questionaire asked how often do you round on the patients with the clinicians. Now if that means tumor boards, that would be all the time. If it met going to bedside, that would basically never for 99% of pathologists.

 

[BU Pathology]

Maybe this is a dumb question, but does molecular pathology threaten pathologists?

Molecular pathology has the potential to seriously threaten pathologists from a number of perspectives.

First, who controls the tests? Pathologists believe, with strong support from objective measures, that we understand how to ensure that laboratory tests are accurately done and the appropriate results sent out. Molecular testing should be done in CLIA certified labs to provide the best quality.

Second, who controls the patents on which tests may be done, or at a deeper level, who even "owns" the rights on genetic testing. These issues have being argued in the courts and have important implications for the delivery of healthcare.

Third, will molecular pathology threaten the beloved microscopic diagnosis of disease? This is an evolving issue. Currently, it is difficult to beat the cost and accuracy of a glass slide and a well trained pathologist. But there are cases where molecular pathology may provide added value. In the future, some cases will almost certainly have a more definitive diagnosis provide by molecular pathology.

CAP and other organizations are watching these issues closely, and their advocacy website has additional details.

Pathology wants to ensure that every patient gets the right diagnosis. Keeping molecular pathology testing under our control is the best way to acheive this goal. The primary driving force is to get the right diagnosis, not to make sure that we get the most money.

 

[raider]

Molecular pathology is just an ancillary diagnostic technique for surgical pathology. Before it there was electron microscopy, then immunohistochemistry and flow cytometry and so on and so forth.

Consider a new immunostain which comes out with a promise of near perfect specificity and sensitivity. What do you think happens a few years down the road as more data is accrued?

Every claim of the so called "perfect genetic test for tumor diagnosis" has only shown its limitations as more and more cases have been studied.

Consider clonality (a genetic marker of neoplasia?) in reactive skin conditions. Upto 30% of certain reactive skin conditions show clones on a molecular level.

Consider UDH in breast pathology. It shows some of the same chromosomal aberrations as ADH.

The list goes on and on and on.

In cancer diagnostics, the best tool is and will always be a "well trained mind". In time, the "few" molecular tests that stand the test of time will be added to the arsenal at the disposal of that master diagnostician and physician exemplar "the surgical pathologist."

The only real threat to you as a surgical pathologist is that you end up with an "untrained mind".

 

[2121115]

Molecular pathology is just an ancillary diagnostic technique for surgical pathology. Before it there was electron microscopy, then immunohistochemistry and flow cytometry and so on and so forth.

Consider a new immunostain which comes out with a promise of near perfect specificity and sensitivity. What do you think happens a few years down the road as more data is accrued?

Every claim of the so called "perfect genetic test for tumor diagnosis" has only shown its limitations as more and more cases have been studied.

Consider clonality (a genetic marker of neoplasia?) in reactive skin conditions. Upto 30% of certain reactive skin conditions show clones on a molecular level.

Consider UDH in breast pathology. It shows some of the same chromosomal aberrations as ADH.

The list goes on and on and on.

In cancer diagnostics, the best tool is and will always be a "well trained mind". In time, the "few" molecular tests that stand the test of time will be added to the arsenal at the disposal of that master diagnostician and physician exemplar "the surgical pathologist."

The only real threat to you as a surgical pathologist is that you end up with an "untrained mind".

Agree 100%.

 

[yaah]

OK, but well trained minds are working on molecular tests that have the potential to replace traditional diagnostic methods. You can believe this or not, but it will likely start happening. I suspect at some point in the future there will be machines that spit out diagnoses for thyroid FNAs while bypassing the morphology stage. And pap smears are already being marginalized somewhat by HPV testing. The well trained mind would be wise to consider that traditional morphology has many strengths but also has limitations.

Personally, I suspect that most of the inroads of molecular testing will be in conjunction with existing methods - such as using molecular methods to refine prognosis or treatment strategies, things that are already happening with lung cancer, breast cancer, and many hemepath diagnoses. But that doesn't mean a machine that clinicians can put at the bedside and spits out results within 30 minutes based on gene chips and algorithms is not a potential replacement for traditional diagnostic methods.

Treating molecular testing with this attitude is done at your own risk. Molecular tests and methods in some cases may prove not helpful, but others will. Gene sequencing is becoming cheaper and faster every year. It is only a matter of time before a tumor can be completely sequenced and compared to others, and morphology becomes the ancillary test. That might be in 100 years or it might be sooner. It's like surgery - it's probably only a matter of time before surgeons are replaced by highly competent and efficient robots. But it might not happen for many many decades.

 

[pathstudent]

Well put yeah. One of my mentors who is a major alpha uber
Academic diagnostician, says that the who fiefdoms surgery is dying and that we are almost at the point where patients will just go to an out patient center, get a biopsy, which will be analyzed by molecular methods and the patient will go get their chemo. No surgery no pathology. Just oncology and molEcular test.


Yaah is right. Polcythemia Vera can be diagnosed without pathology. Simple blood tests can tell the story. A hgb of 19 and a positive jak2 is all you need.

OK, but well trained minds are working on molecular tests that have the potential to replace traditional diagnostic methods. You can believe this or not, but it will likely start happening. I suspect at some point in the future there will be machines that spit out diagnoses for thyroid FNAs while bypassing the morphology stage. And pap smears are already being marginalized somewhat by HPV testing. The well trained mind would be wise to consider that traditional morphology has many strengths but also has limitations.

Personally, I suspect that most of the inroads of molecular testing will be in conjunction with existing methods - such as using molecular methods to refine prognosis or treatment strategies, things that are already happening with lung cancer, breast cancer, and many hemepath diagnoses. But that doesn't mean a machine that clinicians can put at the bedside and spits out results within 30 minutes based on gene chips and algorithms is not a potential replacement for traditional diagnostic methods.

Treating molecular testing with this attitude is done at your own risk. Molecular tests and methods in some cases may prove not helpful, but others will. Gene sequencing is becoming cheaper and faster every year. It is only a matter of time before a tumor can be completely sequenced and compared to others, and morphology becomes the ancillary test. That might be in 100 years or it might be sooner. It's like surgery - it's probably only a matter of time before surgeons are replaced by highly competent and efficient robots. But it might not happen for many many decades.

 

[raider]

As I said before, as an ancillary diagnostic modality molecular pathology provides and will continue to provide useful information in a "small percentage of diseases" such as MPD, some sarcomas etc. It will also provide useful information for feasibility of targeted therapies (this is where I see the real role of molecular pathology and I strongly believe that pathologists should be trained in it as we are currently trained in IHC).

However, in the vast majority of diseases H & E will remain the diagnostic modality of choice because:

1. It is very cost effective.

3. It has great accuracy in the right hands.

2. It provides more information than any "single test".


HPV DNA testing for cervical neoplasia was mentioned , I think that is an excellent example in favor of my argument. Find the answer to why even in the era of "HPV DNA testing" we continue to have PAP smears read instead of just circumventing the morphologic evaluation and going right ahead with the "molecular test"?

All this aside, we should firmly and aggressively lobby for pathologist-MD run molecular pathology labs. We should strive to keep this modality in our realm and support legislature to bar non-pathologists from running these set ups.

Another way to think about this issue is, to consider radiologists. They have kept on adding to their arsenal of diagnostic modalities X-Ray, CT ,MRI, PET and so on. We should be doing likewise. Better still we should foray into procedures such as interventional radiology etc.

 

[KCShaw]

"Rounding" with clinicians I think is more aptly aimed at CP pathologists/certain CP disciplines. While not particularly useful as a daily routine, in limited circumstances I believe it's useful for resident education and in more limited circumstances in actual practice. But less "rounding" and more simply getting out to the wards every now and then, actually reading the file, better understanding patient status, and staying on top of basic ward workflow (tremendously underrated but necessary knowledge for CP administration). And can do wonders for, quite literally, how the pathologist is "seen" in relation to consultation & patient care.

 

[Enkidu]

Better still we should foray into procedures such as interventional radiology

Interesting thought, what role do you envision for an interventional pathologist?

"Rounding" with clinicians I think is more aptly aimed at CP pathologists/certain CP disciplines. While not particularly useful as a daily routine, in limited circumstances I believe it's useful for resident education and in more limited circumstances in actual practice

Could you elaborate a little more on the value of CP rounding? Do you mean that they would influence the labs that are ordered for the patient? I kind of imagined that clinicians were very skilled at ordering and interpreting the appropriate labs.

 

[Enkidu]

Probably a dumb question, but does everybody think that there is no benefit for an anatomic pathologist to talk to the patient? Maybe when the diagnosis may be affected by a particular physical finding or fact in the history that wasn't provided by the clinician. Or in these cases do you just call the clinician and have him talk to the patient?

 

[malchik]

I kind of imagined that clinicians were very skilled at ordering and interpreting the appropriate labs.

You'd be surprised.

 

[Enkidu]

You'd be surprised.

I guess I am surprised. I suppose I don't know too much about laboratory medicine. Can anyone recommend a textbook for me on clinical pathology?

 

[pathstudent]

I guess I am surprised. I suppose I don't know too much about laboratory medicine. Can anyone recommend a textbook for me on clinical pathology?

Henry is the golf standard. The compendium is more than adequate if u just need to pass boards.

 

[KCShaw]

Yeah..Henry's is pretty much the most comprehensive. Not a big fan of golf, though.

Keeping in mind that we're talking about limited utility, "rounding," or perhaps better put, occasionally being active on the clinical wards, can have a positive effect on everything from what tests are being ordered to how they are being interpreted to management issues such as timing of orders vs turnaround time. While the average clinical attending should have a reasonable grasp of what to order in a given situation for the decision they want to make, realistically we have to remember that clinicians are raised in a shotgun climate in which as residents they are constantly asked how many zebras they considered and whether they ruled those zebras out. They generally have been taught to order first and think later.

Beyond that, they are often not really aware of how certain clinical scenarios or sample problems might affect their results -- very high creatinine, hemolysis, lipemia, recent massive transfusion, etc. Transfusion reactions are also not commonly well-understood among clinicians (especially non-heme non-onc's) beyond possibly volume overload and ABO incompatibility. Non-ID's sometimes have problems obtaining useful samples for culture, or waiting for or interpreting culture results.

And a lot of pathologists just don't understand the workflow issues the average clinician faces daily. If certain lab results aren't available by 7 AM rounds, or earlier pre-round data collection junior staff, then draws have to be earlier or turnaround times faster. If certain decisions have to be made by Wednesday on tests that are batched Wednesday late afternoon, then something should probably change.

There are numerous situations in which this combination of simple "good communication" and having an occasional presence on the wards is, I believe, useful in the realm of CP. I'm not advocating daily rounding, no -- just that there is a place for it in limited institution dependent circumstances.

As for the separate question on AP.. this was touched on to some extent in another thread or two recently. While there might be some utility in speaking with or evaluating a patient personally, that role is very well established as being the clinician's realm. It's like an outside radiologist calling a patient to ask if they have any facial droop rather than saying to the clinician hey, I see this little something on the MRI, any chance they have a clinical abnormality? In this case I think the benefit to the patient of going through appropriate channels with the clinician outweighs the possible benefit to the pathologist of direct communication/evaluation of a patient.

 

[BU Pathology]

I have actually rounded with clinicians on an intermittent basis, about 3 or 4 times per year, specifically with the trauma surgeons. Both groups found it very beneficial in my opinion.

For me, it gave me a better understanding of the challenges they face, why they love point of care testing, and how they deal with the constant barage of incoming information (page from the lab about the K+ level, the problem was dealt with 30 minutes ago during the code).

For the clinicians, I could explain how death certificates are filled out, why certain cases are accepted for autopsy by the medical examiner's office, explaining the biopsy results from the patients, and the immunology behind the immunosuppression of traumatic injury.

It was like a grand rounds, but with more direct communication.

It is difficult to quantify the benefit from this exercise, and certainly it did not directly generate additional income. However, it did substantially raise the profile of the Department of Pathology.

 

[pathstudent]

The current issue of Pathology Case Reviews is dedicated to molecular pathology and is really awesome. Definitely read it. It has a graph in the opening salvo by Hopkins's Goerke that sums up where were at!

 

[Enkidu]

So do most of you see a shrinking role for pathologists as molecular testing improves? I suppose if pathology controls these tests their contribution will also be primarily managerial... Which I'll count as a shrunken role.

Is there any other area where the role for pathology is growing, rather than possibly shrinking? Or is pathology simply becoming... antiquated?

How should medical students factor this into their decision to enter the field?