New Paths New Choices

New Paths ...
New Choices
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New Paths ... New Choices
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TABLE OF CONTENTS
12 Relevance, Competency, Consultation 90
13 Promising Practice Pathways™ 99
14 Changing the Course of Pathology 107
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12 Relevance, Competency,
Consultation
Preparing Pathologists for Leadership Roles in
Medicine
Pathology can be an acquired taste. Rather than love at first sight, the journey to a residency in
pathology can twist and turn, winding through the ICU, the OR, or even the primary-care waiting
room. Pathologists may take a while to find their way home.
Future pathologists often have no idea of pursuing the specialty. Then they encounter a eureka
moment in medical school that motivates them toward pathology. It could be seeing a patient
with a rare tumor diagnosed by a pathologist. Or perhaps they are inspired by a pathologist in
the OR giving a surgeon a frozen-section diagnosis that determines surgical treatment.
For the right student, pathology offers an intellectual challenge when other potential specialties come up
short. An example is Nicole D. Riddle, MD, FCAP, who once pictured herself as an orthopedic surgeon, a
form of payback to those who helped her through fibrous dysplasia, the degenerative bone disease.
But Dr. Riddle, who gets around on crutches, found that she didn’t have the stamina to stand for hours
performing surgery. Nevertheless, she wanted to help patients with bone and soft tissue conditions.
A tour of a pathology laboratory at the University of Florida in Gainesville

opened her eyes. She says, “I just really enjoyed it, and I knew I didn’t
want to do orthopedics anymore. I did a rotation in pathology as the
very first elective I could do in fourth year, and I was hooked.”
After her pathology residency, Dr. Riddle completed a one-year fellowship

in bone and soft tissue pathology at the University of Pennsylvania in
Philadelphia in 2012 and joined the faculty at the University of Texas at San
Nicole D. Riddle, MD, FCAP Antonio where she practices surgical pathology and cytology.
Nirali M. Patel, MD, FCAP, had planned to follow in her father’s footsteps and become an
internist. Her father is a solo practitioner in Arcadia, Fla., an hour east of Sarasota.
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Yet she tried a rotation in pathology in medical school at the University

of Miami and found she enjoyed the problem solving in the laboratory. “I
realized I liked figuring out what was wrong with patients and leaving the
management to other people,” she says. “Pathologists interact with all the
other specialists.”
Another pathologist was born, a convert to a career on the leading

edge of diagnostic medicine.
Nirali M. Patel, MD, FCAP
Nirali M. Patel, MD, FCAP, completed a four-year residency in anatomic/
clinical pathology at NorthShore University Healthcare System in Evanston, Ill., and in July she
began a fellowship in molecular pathology at the University of North Carolina in Chapel Hill.
But for many medical students, pathology doesn’t get a second glance. Wesley Y. Naritoku, MD, PhD,
FCAP, program director at Keck USC/LAC+USC Medical Center/VAGLAHS Department of Pathology
and Laboratory Medicine, says some students don’t even realize that pathologists are physicians.
One reason for this, according to Stephen J. Sarewitz, MD, FCAP, of Renton, Wash., may be that
most medical schools no longer give a separate course in pathology. Instead, they integrate
pathology into the study of each organ system.
Obviously, though, some students see the light. For those who complete pathology residencies,
more than half plan to obtain at least one fellowship. In the past three decades, the percentage
of pathologists with American Board of Pathology subspecialty certifications increased from
20% to 50%. The American Society for Clinical Pathology’s 2012 Fellowship & Job Market Surveys
found 60% of residents planned to complete one fellowship while 34% planned to complete two,
primarily to increase their employability. Approximately 80% of respondents to the CAP’s 2011
Practice Characteristics Survey regularly practice in more than one subspecialty.
The society found residents were attracted to traditional fellowship programs, with surgical
pathology, cytopathology, and hematopathology
topping the popularity list while molecular genetic
GME and CME must pathology came in ninth, just ahead of forensic
fundamentally change to pathology. (See Chapter 11.) According to the
equip pathologists with American Board of Medical Specialties (AMBS),
skills and experiences there was a 5.8% growth in molecular genetic
pathology certifications from 2001 to 2009. In the
that add new value in
same time period, forensic pathology certifications
the evolving health care decreased by 0.2%.
ecosystem.
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Among those doing fellowships, about 10% choose molecular medicine and perhaps 1% choose
informatics. These two state-of-the-art fields and others have been cited by the College of
American Pathologists (CAP) as representing the future of the specialty.
So the CAP notes that pathology education, both GME and CME, must fundamentally change
in order to equip pathologists with the skills and experiences necessary to add new value in the
evolving health care ecosystem.
The CAP warns that changes in pathologist skills, such as molecular and digital, will occur faster
than the increase in supply of pathologists. Working together, the CAP and other pathology
organizations, including the Association of Pathology Chairs, can influence GME to ensure the
curriculum is relevant to pathologists’ future scope of practice and CME to help ameliorate the
impending skills shortages.
In one critical area, says Gail H. Vance, MD, FCAP, a professor of medical and molecular
genetics and director of the cytogenetics division at Indiana University School of Medicine in
Indianapolis, the board exam is starting to ask about molecular medicine. But resident trainees
have a low bar: “Their residency expectations are they will learn enough to pass the board
certification exams by the American Board of Pathology so they can then go out and start their
professional career,” she says.
Dr. Vance, a former member of the CAP Board of Governors and chair of the CAP’s Council on
Education, says there are no incentives for trainees to seek fellowships in emerging subspecialties
such as molecular medicine or informatics “other than if they have a desire to do so. So in my
opinion and in the College’s opinion, we have to change the traditional models of training.”
Dr. Vance tells of spending a week with pathology residents to get them acquainted with new
concepts, such as genome-wide association studies. “I just wanted them to hear the language,
to understand what is going on, and so forth. When I got the evaluation, the residents said
advanced genetics was unimportant, a waste of their time, and didn’t pertain to the boards.
This is the kind of battle we have. To their credit, the transformation and the College are
marching forward.”
There is a demonstrated need to prepare pathologists to use and be leaders in emerging

technologies, including genomics, in vivo microscopy, informatics, and digital pathology. (See
Chapter 8. See Chapter 4. See Chapter 9. See Chapter 7.)
Pathology educators are concerned about the readiness of medical students for pathology
residencies. Many have been trained on digital slides and don’t know how to operate an optical
microscope; many programs hold boot camps to prepare the young doctors for pathology
residencies.
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Educators also are concerned about residents’ readiness for the job market. The American
Society for Clinical Pathology survey notes: “Tellingly, fewer than 20% of senior residents sign out
frozen sections on their own.”
These concerns are leading to dramatic changes in residency training for pathologists as well
as other physicians. Medicine, after years of discussion, is moving toward competency-based
training to replace time-based residency training. The Accreditation Council for Graduate Medical
Education’s (ACGME) Milestone Project is a ramp up to The Next Accreditation System, an
outcomes-based accreditation process through which “future doctors will be measured for their
competency in performing the essential tasks necessary for clinical practice in the 21st century.”
“What we change next is how we educate,” says Jennifer L. Hunt, MD, MEd, FCAP, the chair of
the Department of Pathology and Laboratory Services at the University of Arkansas for Medical
Sciences in Little Rock. “It will be fairly roundabout. The goal of education toward competency
is a really good one, after all that is what you want. You don’t want somebody who passes the
boards. You want somebody who is competent. They’re not necessarily the same thing.”
USC’s Dr. Naritoku is spearheading the Milestone Program for pathology. “Our current
accreditation system is like taking a biopsy every four to five years and then extrapolating from
reading that biopsy to the overall health of the program. It’s not static like a biopsy is,” he says.
“If faculty members change, for instance, or the program director or chair changes, there can
be a drastic change.”
He says pathologists like other residents will have to demonstrate their competencies. He says
the milestones look at competencies residents should have at various stages in their training,
from the time they enter the program through completion of the program to two years following
residency training, whether they are in a fellowship or working for a commercial laboratory.
Dr. Naritoku points out that new ACGME requirements emphasize teamwork, the involvement
of residents in multidisciplinary teams. For pathology residents, he said, that was somewhat
of a shock. “They’re not accustomed to thinking in terms of teams,” he says. “But when you
talk to them about it, they acknowledge that in the OR there is the surgeon there and the
anesthesiologist and that we help guide them with our diagnosis and consultation. And there
are tumor boards, where we prepare our slides and talk about the pathology and our findings,
and that does change the treatment discussion. So, it takes them a while, but they figure out
that pathologists are a critical part of the overall health care team.”
The CAP has called on pathologists to seek out and take active roles on integrated,
multidisciplinary care teams. (See Chapter 3. See Chapter 6.) The concept needs to begin
during residency.
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Of 521 pathology residencies offered by allopathic hospitals in 2012, US seniors filled just over
half the positions, with international medical graduates bringing the total of filled slots to 89.4%,
according to the National Resident Matching Program’s “Results and Data: 2012 Main Residency
Match.” It was the lowest fill rate for pathology in the past five years. In 2012, 56 pathology
resident positions, more than 10%, were left open. Osteopathic hospitals filled 43 positions.
Robert P. DeCresce, MD, MBA, FCAP, who chairs the Department of Pathology at Rush University
Medical Center in Chicago, says pathology now is somewhat competitive for residents, but over
the years it has had ups and downs. “In the ’90s, the bottom collapsed out of pathology, and
very few people went in it.” He says the desirability of residencies follows the job market, and
that has picked up.
It’s a rare pathologist who has trouble finding a job after residency,
says David Wilkinson, MD, PhD, FCAP, chairman of pathology at Virginia
Commonwealth University in Richmond.
The demand is expected to increase in the face of a predicted

shortage of pathologists as well as other physicians. (See Chapter
10.) But at the same time, storm clouds are gathering over graduate
medical education. As of 2012, there was a threat that the main source
David Wilkinson, MD, PhD, FCAP of funding for residents could be severely curtailed or eliminated. That
funding is from Medicare Part A, which covers salaries for most residents.
The Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency

established by the Balanced Budget Act of 1997, says that approximately half of the Medicare
funding is not “empirically justified” on the basis of current costs of teaching hospitals intended
to be covered by that reimbursement. To that pronouncement, Congress cocked an ear.
In the fall of 2011, the ACGME asked residency and fellowship officials how they would respond
to varying levels of reduction in funding. The 306 respondents represented more than two-thirds
of accredited programs in academia in 2011.
Thomas J. Nasca, MD, chief executive officer of ACGME, and colleagues concluded: “Under the
worst case, 50% reduction, we estimate that 2,551 programs would close, and 33,023 positions
(29.2% of all GME positions) would be lost.” The impact would be stark across the board. It might
be particularly hard on pathology residency programs because pathologists are not considered
primary care providers.
It’s a Catch-22 situation, says Dr. Vance. She adds, “Medical schools are trying to increase the
number of slots overall because of predicted shortages of all types of physicians, including
pathologists. On one hand the government supports a report that says there is going to be a
shortage of physicians, particularly in rural areas.
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It funds increased training slots for medical students, and then it pulls the funding for residency programs. And
you can’t have a physician practice without training—residency, postmedical school training.”
Dr. Hunt echoes this concern. “The big question to me is whether the money will go to primary care,
meaning that the pathology money will be cut. I suspect that will happen. I think that because pathology
is not direct patient care in many people’s eyes—and it’s certainly not primary care—pathology training
money could be dramatically cut. Are we going to double the size of the family practice residency, double
the size of internal medicine, and quarter the size of the pathology residency?”
The federal government may aim to save and at the same time create more demand for medical
services as patients get care through the Patient Protection and Affordable Care Act, notes Dr. Hunt.
“We’re going to actually need more doctors, not fewer. And you can’t propose having more doctors
without training more doctors, and you can’t propose increased training by cutting the dollars to train.
The cycle will not work,” she says.
Dr. Vance says a shortage of slots for pathology residencies will be felt more acutely because of the
impending “retirement cliff” in pathology in particular. (See Chapter 10.)
Dr. Hunt’s program, which has 20 residents and a handful of fellows, already has cut the proportion
of its funding from Medicare, tapping profits from its faculty practice to help pay resident salaries that
otherwise would flow into the general fund at the university. She estimates that 60% to 70% of trainee
funding comes from this source.
“Everybody would prefer to have the Medicare GME money paying for trainees, but our department
has traditionally done well and had a good margin, and many other departments don’t,” she says.
ACGME says the majority of respondents to its survey would fight to save their residency programs by
seeking private funding followed by community or other hospital support and faculty practice support,
such as it occurs in Dr. Hunt’s program, to replace or augment any cuts in federal support for GME.
“We’re in a plateau state in terms of the number of pathologists needed,” says Michael B.
Prystowsky, MD, PhD, FCAP, chairman of pathology at Montefiore
Medical Center in New York and a member of the CAP Board of
Governors. “But as we go out in five to 10 years with population growth
and people retiring, we’re going to need more pathologists unless
everything is just reorganized in a way that we don’t know about yet.
The forecast is that more pathologists are going to be needed. And if

we start at the level we’re training now and that if in fact we reduce the
number of pathologists being trained, then there is going to be a more
significant shortage.”
Michael B. Prystowsky, MD, PhD, FCAP
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Yet Dr. Sarewitz says it is possible that the anticipated shortage will be ameliorated by factors that
leverage pathologists’ activities: pathologist extenders, and new technology (digital image analysis,
molecular diagnosis, telepathology with whole slide digital imaging); and by further laboratory and
pathology practice consolidation.
Dr. Wilkinson says social media has crept into decision making for students who are on the fence about
the choice of residencies. “The ability of a few people who have an axe to grind can go viral and spread
myths and actually influence people,” he says. “Medical students rely on Facebook and even though the
information that is on the social media is not in any way scientific or statistically validated, it sways them a lot
because that’s how they live their lives now. And a myth that’s out there is that jobs are scarce in pathology.”
He related the story of a young man a few years ago who was active in the CAP’s Residents Forum who
posted about how terrible the job market was for pathologists. It turns out the critic knew there were lots
of good jobs but not necessarily where he wanted to live. Therefore, his feeling: “If I can’t get a job where
I want it, the job market is crappy.” Rejoins Dr. Wilkinson: “The reality is that our residents all get jobs, and
nearly all have jobs lined up long before they finish their last year of training.”
If residency slots are cut back by funding issues, residency programs for generalists and other specialties
better known to medical students will be competing more fiercely with pathology residency programs.
“It’s not hip to be a pathologist by any means,” says Dr. Vance. “It’s not great cocktail conversation.”
Yet pathology’s image problems make it harder to attract residents. She says an 89% match success
may sound good but some specialties match 100%.
Salaries, availability of positions, student debt, and job satisfaction all play a role in a medical student’s
decision to enter a specialty.
Pathology has been described as a “lifestyle specialty,” which offers good hours with few night calls
and decent pay. The CAP’s 2011 Practice Characteristics Survey Report found respondents worked an
average of 50.4 hours per week in 2010, slightly higher than the average 49.7 hours reported in 2007.
The CAP survey found average base salary for respondents with one to 10 years of experience
is $201,775 per year. Pathologists with 11 to 20 years earned an average base salary of $260,119.
Respondents with the highest base salaries are those with more than 30 years of experience
($279,011) and those with 21 to 30 years of professional experience ($274,886).
Dr. Riddle says she anticipates falling pay in pathology and other specialties as health reform is implemented.
“The public thinks all doctors are rolling in money. And it’s not true. A lot of pathologists are making
$150,000 to $200,000. I’m not saying it’s not good money, but it’s certainly not ridiculous like
some specialties where they’re making a lot more while some specialties like pediatrics or family
practice are barely making $100,000.
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Making that little, it’s hard to pay off your loans and rear a family and if you wanted to run your
own clinic—that’s basically impossible to pay your overhead and your nursing staff.”
Dr. DeCresce says, “I always like to say, divide the income by the hours required. That’s the
happiness factor. I don’t think pathology is that easy of a specialty. I get here at 7:00 or 8:00
every morning, and I leave here 6:00 or 7:00 every day. Everyone else around here does that.
You don’t have to work weekends. You don’t have to work nights. That’s more the lifestyle part
of it.”
He says his goal as chairman is to prepare his residents for the job market: “That’s what I think my
job is. I can’t find them a job, but I want them to be prepared for the job market.”
He says if graduates are willing to move, they will find jobs. But he notes that many want to work
in a major metro area, which increasingly could be a problem.
Dr. DeCresce says this situation is pushing more graduates into employed positions for
commercial labs, such as Quest Diagnostics and LabCorp. “I think that’s changing the specialty
a lot. They’re not hospital based and when you go to work for a place like that, it’s more like
factory work. I’m not criticizing it. What I mean is you’re a cog in a big manufacturing plant,
and the manufacturing plant is producing pathology services and you get hired for X-hundreds
of thousands of dollars a year—good salary. Your job is to produce 60 or 70 cases a day. It’s a
production mentality. And that’s what you do. You come in at 9:00. You leave at 3:30 or 6:00,
whatever it takes you to knock off the work. You don’t generally work with other physicians. You
tend to be working in an office park. Maybe you work with a couple other pathologists, but you
don’t work with other specialties. You don’t go to tumor boards.
“They’re knocking out slides and the issues of a pathologist are different for people like that than
they would be for people working at a hospital. That’s where most of the new jobs have been
created—the new ones. So over time I think that will change the way things are.”
On balance, says Dr. DeCresce, most people going into pathology envision themselves looking
at slides through a microscope all day long. “It’s an intellectual exercise, and a lot of people
envision that as their career. I have a very hard time here getting our residents interested in
things that are not anatomic pathology. It’s hard to get them interested in molecular pathology.
They don’t see that as a major part of what they do. The molecular pathologist doesn’t get paid
for being a molecular pathologist. People get paid for looking at slides all day long. You can
train someone to be a molecular diagnostician and do all these molecular tests. But right now,
that’s not the job.”
The CAP’s vision for the future of the specialty is that pathologists need more contact with
patients and their clinical colleagues. (See Chapter 5. See Chapter 6.)
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Dr. DeCresce agrees with the CAP’s overall goal for pathologists to get more involved beyond
reading slides. “I think the College is right because you need a big organization to look ahead
with strategic planning. It’s good that the College is looking forward and asking, ‘What do we
need to do?’ Well, the action is going to be closer to the patient. You need to prove yourself
as a value. You need to be a valuable member of the patient care team. I do my best as a
pathologist. I was president of the medical staff here. I got myself involved in medical center
activities all the time. I’m head of their fundraising campaign, different kind of things to be an
active participant in the medical center’s activities.”
Dr. Vance says debt levels carried by medical graduates and potential earnings in specialties
can influence the residents’ specialty choices, though this is not the only factor.
“Residents are attracted to specialties where they are valued, have autonomy and garner
respect, have choices and make a decent salary. The later is more important for recent graduates
because of very high debt levels,” she says. “Medical students see pathologists as hospital bound,
not in control of their environment and with few choices about practice models.”
She says that pathology will become more attractive to medical graduates once the specialty
highlights new models, such as the Thyroids R Us practice with close contact with patients,
(See Chapter 5.), cutting-edge technologies such as in vivo microscopy (See Chapter 4.), and
genomic analysis (See Chapter 8.) and demonstrates that pathologists play a role on treatment
teams (See Chapter 3.).
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13 Promising Practice
Pathways™
Roads to the Future
Imagine pathologists and radiologists dancing to a samba beat to produce an integrated report
on a malignant tumor. So it goes in Brazil at the Fleury Group’s Diagnostic Centers in São Paulo,
Rio de Janeiro, and elsewhere in the country.
This collaborative diagnostic model with radiologists is one of four overall career concepts for
American pathologists who dare to think outside the box. They were outlined in a report by L. Eleanor
J. Herriman, MD, MBA, that was commissioned by the College of American Pathologists (CAP) as
part of its transformation project.
These Promising Practice Pathways™, as the CAP calls them, were selected as examples of
service models for pathologists as reimbursement shifts away from fee for service toward value-
based payment. The pathways also involve opportunities that focus on oncology, clinician
diagnosis, and population health management.
Dr. Herriman, a pathologist, is managing director, advisory services for G2 Intelligence, which
has provided critical information for the clinical diagnostic laboratory and anatomic pathology
sectors since 1979. Dr. Herriman’s guiding principle is that for pathologists amenable to change,
there is a world of opportunity. She is supplying four signposts among a myriad.
Dr. Herriman says there are a number of industry analysts and investors who believe that the next
decade will bring on “a golden age of diagnostics.” For example, with the growth of genomics,
she expects there will be a relative power shift from therapeutics to diagnostics.
Pathologists should follow the power shift—and

the money, she says. Nowhere is this truer than in
A number of industry
oncology, she adds. Dr. Herriman calls this “high-
analysts believe that the performance pathology for high-value oncology.”
next decade will bring In this pathway, pathologists will be working closely
on “a golden age of with oncologists, using genomics combined with
diagnostics.” Pathologists traditional pathology tools to not only diagnose
tumors but also help select personalized therapy.
should follow the power
shift.
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In another pathway, pathologists can use information technology tools and team with clinicians
to attack the “under-appreciated epidemic” of clinician diagnostic errors. Clinician errors due to
physician shortcomings in knowledge, communication, synthesis, interpretation, and management
of diagnostic testing are as high as 15%, and they contribute to 15% to 20% of all adverse events,
says Dr. Herriman. This is a full three-fold higher than diagnostic errors by pathologists.
That 15% error rate translates to between 40,000 to 80,000 preventable deaths annually in US
hospitals alone. “Given the rising complexity of clinical care and clinical testing, an aging
baby boomer population with multiple chronic conditions, and the shortage of primary care
physicians, the error rate is likely to increase,” she adds.
With the boom in genomics and molecular medicine, Dr. Herriman believes that potentially even
more clinical diagnostic errors could occur. She sees this as a market opportunity for pathologists
who can “generate value by elevating diagnostic accuracy through ‘high-performance’ pre-
and post-laboratory testing services.” Pathologists can get involved to decrease errors and
introduce advances to improve diagnostic accuracy.
“So, what’s the payoff for practices?” she asks. “Because diagnostic errors
are in the top three of the most costly adverse events, lowering them
could improve a wide variety of quality performance measures such
as readmissions, complications, and mortality rates. High-quality scores
in categories like these are integral to the value-based compensation
programs being rolled out by hospitals, accountable care organizations
(ACOs), Medicare, and other payers. So our ultimate payoff is a share of
this value-based compensation.” Pathologists could increase quality and
L. Eleanor J. Herriman, MD, MBA decrease costs.
Finally, as ACOs become increasingly common, Dr. Herriman envisions that pathologists will play a major
role with population health management to help ACOs reduce costs while improving the care of patient
populations. (See Chapter 3. See Chapter 6.) And in this, she sees a role for pathologists.
“As pathologists, we have informatics applications for identifying patterns of risk, managing
performance, and informing the creation of guidelines that can systematize care across
populations,” she says. “We call this our ‘top-down’ data analytics advantage.
“But we also have our ‘ground-up,’ personalized medicine testing advantage that complements
that top-down approach beautifully. Our molecular and biomarker testing expertise can
individualize ACO guidelines at the point of care, giving practitioners the freedom to practice
both the art and science of medicine.”
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Trying to help CAP members cope with revolutions in health care finance, organization, and technology,
the College views these four pathways as prime business models to help transform the specialty and
enhance pathologist incomes in the next few years. Oncology attracted the most attention.
Paul N. Valenstein, MD, FCAP, secretary-treasurer of the CAP and leader of Pathology and Laboratory
Management Associates, a 16-pathologist group in Ann Arbor, Mich., makes a clear distinction
between new roles for pathologists and new business models in which pathologists operate. “A new
role requires that an individual acquire new skills, knowledge, and competencies,” says Dr. Valenstein.
“A new business model requires a strategic arrangement of parts (pathologists being one of them) to
distinctively serve a customer and to extract some of the value created by that relationship.”
Dr. Herriman, he notes, has envisioned four distinct business models that while not particularly
attractive in the old economic setting show promise in the new economic environment.
Pathologists, he adds, are apt to think about the types of skills they should acquire and activities
they should do, but not spend much time to think whether their employer is appropriately
configured to support these activities in a competitive environment.
Stephen J. Sarewitz, MD, FCAP, a CAP governor, who is a staff pathologist at Valley Medical Center
in Renton, Wash., views oncology as a “clear pathway” for pathologists. “The oncology pathway is a
compelling one in terms of being something that’s logical for pathologists to proceed with,” he says.
He points out that pathologists are already involved in oncology and have a comfort zone in this area.
“It’s this very fact that makes it a logical pathway where pathologists can extend their services,” he says.
Dr. Sarewitz adds: “There are lots of tests and products the oncologists are using that are outside of the
particular pathology practice that’s servicing them. The oncology pathway would bring all that into the
pathologists’ purview. It would have the pathologist be specialists to the same extent as the oncologists,
so the oncologists wouldn’t feel the need to go outside the pathology group to get consultations or to
get certain types of testing. They would go through the pathology group, period, because that would be
their total resource for oncology in the vast majority of situations. That’s the goal.”
In this pathway, says Dr. Sarewitz, community hospital pathologists will become more like academic
pathologists in offering a comprehensive menu of pathology service and specialties to oncologists.
Dr. Valenstein says the synthesis of oncology and pathology is an attractive practice pathway
because pathologists already have a stake in cancer diagnostics. “Pathologists diagnose almost
all cancers today, and we already employ a battery of markers to assess prognosis and guide
therapy,” he notes.
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So pathologists should be attracted to pathways

If the only thing
that create value while playing to their strengths.
“We know a lot about cancer diagnostics. If
pathologists do is sit and
we can figure out how to combine our existing look at slides, that’s fine,
diagnostic skill with new services in a cost-conscious But unless they transform,
manner, we can create an interesting business,” he pathologists will not be
says.
thought of as MDs or
“Today, a pathologist is likely to be the first person
critical to the patient care
to know a patient has cancer. And what do we do team.
with this information? We give it to the person who
performed the biopsy for the price of a CPT code, and that person steers the patient where he
wants and most of what happens subsequently plays out without a great deal of pathologist
involvement,” he says.
Perhaps pathologists should not be satisfied with a biopsy as the input and a diagnosis as the
end product, Dr. Valenstein adds. “Instead, we can move upstream to propose a diagnostic
plan for a patient with a lump, and downstream to provide a management plan along with our
diagnosis. All of a sudden we’re triaging the patients.
“In a fragmented delivery system where surgeons and oncologists chose their pathologists
and don’t want to hand over workup and management responsibilities, this type of integrated
business doesn’t work very well. But with bundled payments and a demand for more
economical treatment, it might be an attractive proposition.” Dr. Valenstein says.
Gene N. Herbek, MD, FCAP, president-elect of the CAP, is a surgical pathologist at The Pathology
Center at Methodist Hospital in Omaha, Neb. One day recently he diagnosed a colon cancer in
the morning and a lung cancer in a lymph node in the afternoon. “This is what pathologists do day
to day,” he says, adding that a strong pathway to pathologist practices’ future is concentrating on
genomic and molecular pathology. (See Chapter 8.) The high-level oncology pathway will offer
things all pathologists can learn as they diagnose cancer, working with oncologists and surgeons,
acting as consultants, giving information as far as what molecular tests they should be ordering,
using guidelines, making sure the cancer protocols and data points are filled out, and we pay
attention to it while we examine all of the surgical resection specimens.”
Dr. Herbek says high-performance pathology for high-value oncology will involve higher visibility
for pathologists to patients, with pathologists being encouraged to speak with patients to
explain the diagnosis and the therapeutic options.
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Dr. Herriman also views high-performance pathology for high-value oncology as quite promising
for pathologists, creating “significant compensation...as pathologists can be compensated
on value rather than as a vendor.” The pathway includes technologies and services for initial
diagnosis, tumor test panels to direct therapies in oncology, informatics and algorithms for
predicting risk and avoiding complications, and tools for clinical trial decisions. Advanced
academic centers are starting to develop this pathway, but Dr. Herriman thinks it can be
deployed in the community setting as well. “This oncology diagnostic services opportunity is
[pathologists’] to lose,” she says.
Charles Roussel, the CAP’s CEO, thinks that high-performance pathology in oncology will offer
much to pathologists willing to evolve: “Over time what you’ll see is some of our members
acquiring the skills to be able to counsel the woman on her breast cancer. You will see others
who become supremely good at being the physician’s physician. You will have others who do
neither, who simply sit and process tissue, or process fluids with whatever new technologies are
available. That’s perfectly legitimate, but you will see that these different roles are assigned
different levels of value and commensurate pay.”
In other words, he says, “If the only thing pathologists do is sit and look at slides, that’s fine. But unless
they transform, pathologists will not be thought of as MDs or critical to the patient care team.”
Dr. Herriman has been examining another model that she feels holds great potential: diagnostic patient
centers in which transformed pathologists and laboratories work closely with radiologists. One diagnostic
center model that has gained international attention is the Fleury Group’s Diagnostic Centers in Brazil.
Gastão Fleury da Silveira, MD, bought a small clinical laboratory in the center of São Paulo
in 1926. This laboratory grew to become a larger multispecialty diagnostic center, where
pathologists, radiologists, cardiologists, endocrinologists, nuclear medicine specialists, and others
focus on diagnostics. Over the years, Fleury Group, with 1,500 physicians on staff, has evolved
to offer a concierge-style one-stop shop for affluent Brazilians, featuring collaboration between
pathologists and radiologists and integrated reports.
Take a patient with a colorectal tumor. “We do the analysis of oncology and also the results
of radiology or endoscopy. What we are trying to do is an integrated analysis of two very
specialized physicians,” says cardiologist Jeane Tsutsui, MD, chief medical officer of the Fleury
Group.
Pathologist Celso Granato, MD, clinical director of Fleury Group and the medical adviser for
infectious diseases, says the combination of the specialties saves time and diagnostic resources.
“Patients profit the most from the agility with which the final diagnosis is achieved,” says Dr.
Granato, one of 30 Fleury staff pathologists. On rare occasions, he says, primary care physicians
view the integrated approach as interference.
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“For primary care physicians, integrating radiology

evaluation with microbiology and molecular biology
results speeds up the diagnostic process and avoids
unnecessary requests for additional tests and
inadequate antibiotics prescriptions,” he says.
Mr. Roussel comments: “Diagnostic patient

centers such as Fleury bring together the relevant
diagnosticians as part of the full-service-care model.
Oncology Pathway
The implicit logic is the diagnosis, irrespective of the
technology, is highly consequential to the course of
Webinar
treatment and therefore, why not do whatever you Coordinated Population
can as a matter of convenience for patients but
Care
also as a matter of economic reality? Why don’t you
bring that diagnostic expertise as tightly into care
delivery as possible? It works in Brazil. Conceptually, it makes a whole lot of sense for the US.”
Dr. Sarewitz says pathologists and radiologists have a natural affinity in diagnosing disease. But
he argues that there is not a clear pathway for pathologists: “Radiologists and pathologists have
a little different way of organizing things,” he says.
Bruce A. Friedman, MD, FCAP, professor emeritus at the University of Michigan in Ann Arbor and
a pathology futurist, likes what he has seen at Fleury, which he has visited. But he is skeptical
about the Fleury model taking hold in the US.
“The reason why the Fleury model won’t work well is that in Brazil, this is a very high-end,
multispecialty clinic competing for the very, very wealthy patients. They’re very smart business
people. They have valet parking, coffee lounges. The very wealthy in Brazil are used to being
catered to. It’s a business model, for profit, catering to the very wealthy. I love the basic
concept—integrated diagnostic centers and I’m waiting for that to happen here—but I think the
Fleury model except in rarified environments is not going to work well here.”
Dr. Friedman, a founder of pathology informatics, also sees rough sledding for integrated
records in the US for collaborations between radiology and pathology. He says radiologists and
pathologists already are “happy in their silos” and reluctant to integrate their records.
Still, Dr. Herriman maintains that the Fleury model resonates with health care reform in the US with
an emphasis on ambulatory care to decrease costs and the potential for increased accuracy of
diagnostics from a collaboration of laboratory medicine, pathologists, and radiologists.
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“Everything is moving into the ambulatory world, even hospitals are investing in the ambulatory
world because services are basically less expensive there, and it’s reaching out to patients
where things are more convenient,” she says. “With Fleury, operations are lean and efficient.
“When you have laboratory, pathology, and radiology all integrated together, you have all sorts
of accuracy advantages, especially when you are streamlining operations.
“Diagnostic patient centers have a strong patient experience and customer service value
proposition, which is completely lacking in today’s health care system for diagnostic services.
Right now, our services are not ready for the consumer market, because there are no
considerations for patient conveniences.”
She adds, “Over the past decade or so, employers have shifted health care costs to the point that
employees now pay a greater out-of-pocket total for their health care than do their employers. Think
about it—that means that what we think of as commercial payers are ultimately, mostly consumers.”
She says some US community hospitals have ambulatory integrated breast cancer screening
clinics. “It seems like a smart business opportunity to me. The rest of the world is really supportive
of this model. Somebody will try this in the US,” she says.
Dr. Herriman’s Promising Pathology Pathways that focuses on preventing the rash of clinical
diagnostic errors offers pathologists and laboratory medicine a new role.
She explains that clinical or medical diagnostic errors involve cases where the clinician makes a
misdiagnosis, misses the diagnosis, or where there is a clinically significant delay in rendering a diagnosis.
Dr. Herriman sees this as a market opportunity for pathologists. “This is a way to get into value-
based compensation. So we start with fee for services being phased out. It will take a while, but
it’s going away—though never completely. How do you get compensated based on value? This
is the logic: Pathologists who get compensated based on value have to increase quality and
decrease avoidable costs,” she says.
She says pathologists could make the case for being compensated based on error reduction to
hospitals, ACOs, and third-party payers.
Dr. Sarewitz views this model as a real, albeit small, opportunity, one that fits best in larger
pathology practices. He says larger practices potentially could add an expert focusing on error
prevention.
He also says pathologists would have to fight for this role: “I don’t think that pathologists have
a monopoly in the expertise for this area to the same extent as they do in other areas in lab
medicine.”
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Finally, with population health management, Dr. Herriman notes that to improve quality and
reduce costs of care, ACOs need to segment their populations and predict risks to direct
interventions, improve health, and avoid preventable illnesses and complications. “Information
technology systems and robust, thorough clinical data are critical components in this new
model. But beyond IT solutions, ACOs are looking for guidelines, order sets, and other electronic
medical record (EMR) applications for which pathology knowledge is a necessity,” she says.
Pathologists have their finger on the pulse of the patient’s health with the steady flow of
laboratory data—said to represent 70% of EMR information—while also providing the powerful
predictive tools of molecular diagnostics and biomarkers and potentially more from genomics
and related areas. Therefore, pathology and laboratory medicine have an opportunity to
develop services and tools and expertise, moving beyond providing laboratory results, she says.
Dr. Herriman says ACOs can use pathologists working with laboratory test informatics to imbed
individualized medicine into routine care, including guidelines, order sets, and EMR applications.
Catholic Medical Partners in Buffalo, N.Y., already is taking this sort of approach in developing
guidelines for troponin, for example, for suspected MI. (See Chapter 3.)
Dr. Sarewitz says pathologists to some degree have been involved and could become more
involved in this sort of informatics and guideline development. “But pathologists are not
leading. We’re seeing other groups coming out with things like tests not to order, suggesting test
algorithms. We’re seeing other medical organizations coming out with that stuff, not pathology.
It’s going to be harder. Pathologists aren’t going to be alone in trying to grab that kind of
function; but certainly especially as we get to more ACO-type organizations and large practices
that are interested in the most efficient way of testing and care, it will be an opportunity. But
pathologists will need to be aggressive in pushing their way into it. I don’t think it’s as big an
opportunity as something like the oncology pathway or genomics,” he says.
Of the four pathways, Mr. Roussel says, “You can debate whether this is the right list. I’m less
worried about that right now. If we have to offer a couple more pathways next year, we will.
What I am worried about is ensuring that the CAP has something relevant to say to pathology
practice leaders about how to evolve today’s businesses.”
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14 Changing the Course of

Pathology
Be Visible. Be Ready. Be Competitive.
Several years ago the College of American Pathologists (CAP) leadership looked at the future of
pathology and found it perilous, unacceptably laden with dangerous shoals. So the organization
viewed the horizon and started to consider ways to help pathologists and pathology practices
make a gradual but significant shift in their professional courses.
Consequently, the transformation initiative was introduced to seek new roles for pathology and
pathologists. It was designed to enable them to thrive in a medical landscape with a vanishing
fee-for-service system, a new emphasis on accountable value for performance, and to provide
new areas where the physician role as a pathologist brings unique value.
“There is a window of opportunity for pathology to take control of its economic and professional
destiny,” says Charles Roussel, the CEO of the CAP and the guiding spirit of transformation. “The
CAP is here to help.”
Assistance is the watchword in transformation, which is well under way. The CAP Board of
Governors has approved a 19-page action plan entitled “A Strategy for Helping Transform
Pathology.” With three broad categories and more than 30 specific programs in its quiver, the
action plan outlines a generational shift to help pathologists find their way in the changing
economic and technologic environment.
Foremost in its action plan, the CAP would help spur a significant increase in the visibility of
pathologists in the environment of coordinated care. It is encouraging its members to step up
with their diagnostic advice and sound off with their evidence-based case-management views.
This is viewed as particularly vital in light of the recent
research revealing that pathologists create 10 times
There is a window the value of their cost, a finding that pathologists
can parlay into greater income.
of opportunity for
pathology to take control Points out Mr. Roussel, pathology and laboratory
of its economic and services may represent only 3% of costs but
professional destiny. The pathologists can lead the creation of more than 30%
CAP is here to help. of the value in coordinated care systems.
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These data emerged from research

by L. Eleanor J. Herriman, MD, MBA, the
pathologist futurist at G2 Intelligence. Her
work was commissioned by the CAP. It
gave pathologists an evidence-based
wedge in negotiations for a proper share
of the accountable care pie.
Value is defined in this context as

potentially avoidable costs related
to gaps in care as quantified through
Medicare. These include US Centers
for Medicare & Medicaid Services’ Pathology Transformation Strategy, CAP
hospital-acquired conditions, 30-day
readmissions, patient-safety indicators, and
ambulatory-care-sensitive hospitalizations.
“We must show that we can generate cost savings through the value of our services so that
someone else doesn’t try to create value by cutting our services,” Mr. Roussel said at the CAP
’12 annual meeting. “You cannot continue to be the best-kept secret in medicine.”
At the same time, says the action plan, “We intend to showcase new roles that deliver this value and to
provide pathways for our members to enhance their scope of practice to capture more value over time.”
Through the promotion of Promising Practice Pathways™ research by Dr. Herriman, the CAP is
offering guideposts for pathologists who want to lead the way into the new future. (See Chapter
13.) This CAP-funded research involves the structures in which pathologists practice and identifies
promising markets and business models for those who are ready to adapt their practices.
Moreover, says the action plan, “The CAP will promote the adoption of science, scientific standards,
and diagnostic and information technologies in ways that improve patient outcomes and showcase
the distinctive value that pathologists add to the application of those technologies. We intend to
carve out marquis value areas in genomic medicine and informatics, where pathology is seen as the
natural incumbent and where we can sustain a strong competitive position.”
Specifically, the CAP is considering more than 30 initiatives to implement the transformation of
pathology and pathologists. The CAP is promoting such efforts as policy research and positions,
a revision of the graduate medical education curriculum, learning opportunities for enhanced
roles for pathologists, more business planning materials for new practice pathways, guidance for
an integrated pathology report, interpretation of next-generation genomic sequencing data,
models for data mining, and others.
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The toolkit, says Stanley J. Robboy, MD,

FCAP, vice chair for diagnostic pathology
at Duke University Medical Center, in
Durham, N.C., and president of the CAP,
is “the combination of the education, the
tactical experience, and the discussions
we’re having at the College so people
understand what will be needed and
how to plan.”
The action plan also calls for:

Pathology’s Evolution, CAP
• Learning opportunities for enhanced
roles outlined in the Promising Practice
Pathways (G2) program
• “Role guides” to facilitate implementation of critical Promising Practice Pathways roles
• Promising Practice Pathways business planning materials, spinning off of Dr. Herriman’s
research, to extend the learning contained within the research reports
• A true electronic member engagement network
• Support to pathologists and practices in self-advocacy within coordinated care settings
• A modest start to long-term brand-building activities to enhance perceptions of pathologists
• Revising the GME curriculum
Fundamental elements of the College’s efforts include:
The CAP Pathology and Laboratory Quality Center will continue to focus on evidence-based
guidelines to address gaps in pathology practice and assimilate best practice insights and other
resources required for enhanced pathology roles, especially clinically oriented ones.
The CAP will encourage the integration of clinical, diagnostic, and therapeutic information in
pathology reporting to help pathologists demonstrate their value to clinicians and patients.
Pathologists know The CAP will leverage its expertise in quality

that their expertise is assurance to provide tools that ensure high-quality
results and patient safety in the performance of
indispensable. Now they
clinical roles.
have to make others
believe it, too, and The CAP will help strengthen pathologists’ ability to
demonstrate how they engage in data mining, biostatistical analysis, and
can add even more value population-based medicine.
in the new landscape.
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The CAP will try to bolster pathologists’ ability to lead

in the clinical application of genomic medicine.
The CAP considers its
At the same time, advocacy efforts in Washington role more facilitative
and at the state level are being designed to than prescriptive… it has
bridge advocacy and policy gaps. Apparently, this developed a broad three-
approach is already paying dividends. Massachusetts pronged strategy to help
pathologists contend that the CAP’s advocacy
pathologists find their way
paid off with legislation signed by their governor in
2012, ensuring that pathologists through their role as in the changing economic
medical directors of laboratories are represented and technologic
within accountable care organizations (ACOs). environment.
In some respects, this ebook reflects the CAP call to action. It
suggests new practice pathways for pathologists. It describes the major economic, scientific, and technological
changes looming before pathologists. The very culture of pathologists themselves is up for grabs, such as their
relationships with clinical colleagues and patients.
In a nutshell, it lays out ways that pathologists can control their own destinies. It suggests ways
that pathology practices can create greater value, especially in embedding new genomics and
informatics capabilities in their work, and be paid for this—in the context of coordinated care.
Pathologists know that their expertise is indispensable. Now they have to make others believe it,
too, and demonstrate how they can add even more value in the new landscape.
That’s easier said than done for pathologists, who don’t naturally toot their own horn. But no one will do it for
them. So helping pathologists cross that cultural divide is part of the transformation process. Pathologists are
being encouraged to engage more with the medical environment around them—having more face-to-
face contact with patients and other clinicians, for instance, and having a greater willingness to share their
view of therapeutic implications of a diagnosis. Transformation may also involve acquiring new medical skills,
such as in vivo microscopy, digital pathology, informatics, molecular pathology, or genomics interpretation.
For many pathologists, transformation, if they pursue it vigorously, represents a challenge. It could mean learning some
new tricks. It means change. It could mean shifting their eyes away from the microscope more than they might like.
To be sure, the term transformation itself is somewhat hyperbolic. No one suggests that all
pathologists everywhere need to interrupt their careers to take up new subspecialties or to introduce
direct patient contact into their practices. Not every pathologist will be expected to make rounds.
And few even consider that pathology would dwindle into insignificance if all tenets of the CAP’s
initiative were not fulfilled. Indeed, some critics say that if there were no transformation project at
all, the market would cure most of pathology’s shortcomings by itself, incrementally and driven by
demand. Others, however, suggest these critics are burying their heads in the sand.
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The CAP has assembled a persuasive case that

with the rise of accountable care pathologists
have a rare chance to rise in the esteem of
their clinical compatriots by demonstrating
an enhanced special value in diagnosis and With a Pathologist on the Team
therapeutic planning. This would help achieve
the accountable care goal of better care for
less expense, with a commensurate impact
on incomes across the board. And pathologists can buttress the case for their value by
taking a more active role in hospital affairs, laying aside any laissez faire philosophy. Finally,
transformation encourages pathologists to establish themselves to their benefit in emerging
areas such as genomics and informatics. Transformation offers a guide to these efforts with
specific recommendations and points of view.
This ebook narrative serves to elaborate on some of the points of view for change that
CAP members have debated, refined, and, finally, codified. Chapters in the ebook cajole
pathologists to consider new ways of practice, innovative technology applicable to the
specialty, and novel business models, such as the pathways described by G2 Intelligence. Now
the CAP faces the challenge of helping its members implement the transformation philosophy.
How do pathologists, if they so choose, get from here to there?
As an institution, the CAP considers its role more facilitative than prescriptive. It does not consult with
pathologists about their individual practices, but it has developed a broad three-pronged strategy
to help pathologists find their way in the changing economic and technologic environment. Its aim is
to support pathologists in adapting to, and prospering in, the changing health care environment.
Gene N. Herbek, MD, FCAP, of The Pathology Center at Methodist Hospital in Omaha, Neb., and
president-elect of the College, says the transformation development has positioned the CAP
well for helping members deal with the specialty’s thorny issues. “Without this effort, I don’t think
we would understand our challenges as well as we
The CAP aims to help do today,” says Dr. Herbek. “I know we have a much
strengthen pathologists’ better idea of the challenges that are ahead of us.
ability to lead in the We need to get the word out to pathologists.”
clinical application of
He says the CAP won’t be able to implement all of
genomic medicine, data the proposed initiatives at once. The organization will
mining, biostatistical have to set priorities and focus on a couple initiatives
analysis, and population- each year. “The transformation is organized; and
based medicine and act we have something to work from and can measure,
and we can plan and then measure whether or not
as stewards of integrated
we’re successful in the various areas that we choose
medical information. to follow.”
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Indeed, Dr. Robboy urges pathologists themselves to

recognize their need for change and get down in In the convergence
the trenches to assert themselves. They need to be at of coordinated care,
the table in every committee and in every setting to
payment reform, and
have a better chance of surviving and flourishing. With
accountable care, particularly, it’s not business as usual. scientific advances in
genomics and informatics,
“The College will help pathologists adapt to the new we can find a solid
realities in economics and technology in medicine, helping foundation for this next era
them find and develop new roles,” he says. “The College is
in pathology.
going to help with the education, with the public relations,
with the settings and tools for the competitive advantage.
But the pathologists have to get in there and be involved; and if they’re not, they’re toast.”
The CAP aims to help strengthen pathologists’ ability to lead in the clinical application of
genomic medicine, data mining, biostatistical analysis, and
population-based medicine and act as stewards of integrated medical information.
The CAP’s arguments for pathologists to consider change will be compelling to some
members, less so to others, and dismaying to those who are perfectly happy with the status
quo. Realistically, Mr. Roussel estimates that the apprehensive pathologists will outnumber the
audacious. For most members, a bird in hand is worth two in the bush.
But to Mr. Roussel this is not a problem.
Mr. Roussel says his vision of transformation as an “inevitable” process doesn’t require all
pathologists to change. In fact, he figures about one-third are not amenable or willing to
change. “If someone has five years left in practice, we probably don’t have a lot to say to that
person,” he says. “But I would argue that anyone outside of that group has quite a lot invested in
thinking critically about what he or she needs to do to change.”
In 2008, the CAP Board of Governors hired Mr. Roussel to lead the CAP and its transformation
efforts. Mr. Roussel has made a career as an organizational change agent, working with
the consulting firm Accenture and leading change in electronics, high-tech products, and
telecommunications. He served as an executive-level adviser to pharmaceutical and high
technology companies, and led the firm’s research on personal and home health technology.
His work with the CAP is his first aimed at changing an entire industry sector: the specialty of pathology.
Besides the innovators and early adopters, he says the transformation effort is aimed at the
“moveable middle,” the one-third who are open to change when shown a compelling reason
and who will help be the tipping point of a cascade of change.
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He says that transformation is a scope-of-practice issue. “Our overriding goal is to help you take
control of your economic and professional destiny before someone else does,” he told the CAP
’12 audiences.
He says change will be promoted simultaneously at three levels: the individual pathologist,
pathology practices, and the specialty of pathology. He adds that efforts will be broad based
but focused on the moveable middle, initially identified by Ogilvy Public Relations.
Mr. Roussel argues that this formula—with a small group leading the way—has driven major
social change in the US.
“You need to get enough of your members juiced up about something to have it happen,” he
says. “You do not need to have the vast majority.”
In his calculation, he says, “I have 800 members who are actively engaged in the life of the
College every year on councils, committees and another 1,500 involved in the laboratory
accreditation inspection program. They develop our intellectual property. They are the R&D
horsepower of the College. So what I’m looking for in that movable middle is about another
3,000 or 4,000 people. And I am not in any way trivializing the amount of work involved in
appealing successfully to the hearts and minds of those people, but I do think that if you frame
this as a decade-long intervention, change process, then you can actually think about this in a
realistic way.”
Speaking at CAP ’12, Mr. Roussel said: “In the convergence of coordinated care, payment
reform, and scientific advances in genomics and informatics, we can find a solid foundation for
this next era in pathology.”
Not all pathologists buy into the concept that the College needs to take a direct hand in
trying to change the course of the specialty. Some are skeptical that it can be done, believing
the invisible hand will regulate the market. Some see a sense of hubris in the College’s plans.
Others don’t believe the traditional personalities attracted to pathology will want to undergo
personality transplants to fit into a new order.
Edward O. Uthman, MD, FCAP, a clinical and anatomic pathologist in Houston, is a long-time
inspector for the CAP. He considers himself part of the CAP’s “loyal opposition.” He says that in
his popular pathology listserv, PATHO-L, the CAP’s transformation plan is not a hot topic.
“We talk about individual CAP policies and individual changes, but I haven’t heard any buzz
about transformation,” Dr. Uthman says. “I think most people assume that it’s a marketing term,
and we don’t expect any transformation other than the incremental changes. I’ve seen over the
years that the CAP tries to set trends, but ultimately much of what we do is demand driven.” He
disputes the idea that pathologists can save money, for instance, by “correcting” oncologists.
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“For instance, some of these expensive genomic type tests that are done on tumor tissues
now—if the oncologist wants them, we pretty much have to get them done,” he says. “If the
oncologist doesn’t want them, then it’s stupid of us to insist that they be sent. A lot of it depends
on what our oncologists demand.” Dr. Uthman argues that pathologists don’t sell well.
One of the ideas in the transformation is for pathologists to become closer to patients, not only
diagnosing disease such as cancer but also explaining it to patients and helping their direct
care. This will be a flashpoint of resistance to the transformation, says Robert P. DeCresce, MD,
FCAP, chairperson of pathology at Rush University Medical Center in Chicago, who has been in
practice 33 years.
“Many people go into pathology because the last thing they want to do is to take care of a
patient,” he says. “People are attracted to pathology because there’s no medical or surgical
internship. They graduate from medical school, and they come here; and then they never have
to see another patient again.
“It’s just personality. Nothing wrong with it. I don’t want to see patients either. I like what I’m
doing. It’s more interesting. Radiology is the same. It’s an intellectual pursuit. I like what I’m doing
and what I do doesn’t involve me seeing the patient. What should I do? Go to the patient’s
room and knock on the door and say, ‘Hi. I just read your biopsy and you’ve got cancer. Don’t
worry about it. Dr. Smith, your surgeon, is going to take care of you.’ I guess I could do that, but is
that what we need?”
Yet Mr. Roussel says pathologists may do well to reexamine this prejudice against direct patient
contact. He feels it could only benefit pathologists to become more hands on and known to
their clinical colleagues and the patients.
Mr. Roussel says, “Whenever I give a speech, I have a couple of pathologists who come up to
me and say, ‘You’re not getting this. I never, ever want to touch a patient. I literally never, unless
it’s a deconstruction or a fluid of a patient or a sample of tissue from a patient, want to see a live
patient.’
“I think that is extraordinarily dangerous and becomes a little bit of a self-fulfilling prophecy. Part
of why I go and say what I say at the CAP and other meetings is a bit of a pep rally to say, ‘Look,
we’re not saying you all have to be all lovey-dovey and nurturing to patients, but you better be
relevant to the patient’s needs. Patients want to know that we care—it’s part of the service they
expect. How are we demonstrating that we care in a way patients can see and understand?
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“And that means that your diagnosis is instrumental to the therapeutic course that follows.
Some subset of you may want to sit and counsel a woman who has been diagnosed by you
with breast cancer. Others of you may simply be the physician’s physician. When we started
this whole transformation effort, we had a bunch of people in the early days saying we don’t
want to be the physician’s physician anymore because this puts us back in this derived demand
model where somebody else determines the demand for our services.’
“Well, that’s true, but frankly that’s true of any subspecialty. You’re going to be in this derived
demand model. So why not be a really good physician’s physician? I think over time what you’ll
see are some of our members acquiring the skills to be able to counsel the woman on her breast
cancer. You will see others who become supremely good at being the physician’s physician.
You will have others who do neither. They will simply sit and process tissue, sit and process fluids
with whatever new technologies are available, and that’s perfectly legitimate, but they will see
commensurate levels of value and pay.”
Even with no transformation, Mr. Roussel says that many pathologists will continue to make a
decent living following traditional paths. But he is calling for generational change and that
could involve attracting different types of people to the field. He has been discussing this with
pathology chairs at medical schools.
“We can reinstitute Thursday night pizza parties at medical schools to attract potentially a
different kind of profile to pathology,” he says. “Get them while they’re young. Make it cool and
sexy. Make them aware of genetics and molecular pathology. That’s just one subspecialty area.
Think consciously about the kind of people you want to attract into that environment and then
make sure you hold on to them through the residency process. I think that’s fertile ground.”
Mr. Roussel views this as an evolutionary rather than a revolutionary change because the move
toward a fee-for-performance model will take time.
He adds two points:
• Change should be facilitative rather than directive. We cannot make anyone change. We
will encourage and enable.
• Change should be promoted and enabled at the lowest levels possible. The diffusion of
innovation happens best through interpersonal
networks of those who can shape the opinions of
Change should be
their peers.
facilitative rather than
directive. We cannot Gail H. Vance, MD, FCAP, a former CAP governor
make anyone change. and a pathology professor at Indiana University
We will encourage and in Indianapolis, notes that the CAP already has
transformation programs underway.
enable.
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“We don’t have limitless resources, but the College

is trying to do a lot right now,” she told attendees at
Change happens. And
CAP ’12.
then it happens again.
Dr. Vance says: “For example, we felt that one of
the best upfront investments we could make would
be to help practices grow and evolve and become more relevant in relation to coordinated
care.”
She notes that the College already sponsors peer-to-peer discussions “to facilitate pathologists
talking with one another, learning from one another, and supporting one another.”
“We have also developed the ACO Network, spoken to members, advocated for members, and
educated members. Under the framework of the Policy Roundtable, a white paper was written
to address issues of pathology and coordinated care. Even a website has been created as a
go-to platform for questions and answers,” she notes. (See Chapter 3.) “Over the next several
years, the promising practice models will drive a lot of our tools, communication, and peer-
based learning work.”
Dr. Vance says teams now are developing plans to promote G2’s Promising Practice Pathways
work and help these happen through peer networking and learning opportunities.
The CAP’s advocacy staff will engage more to support local advocacy efforts and to mobilize
state societies in our national advocacy work.
The CAP plans to double down on member engagement online.
Dr. Vance adds, “Driving changes in graduate and continuing medical education will require
the Council on Education to work with its committees, the Academic Caucus, and APC/PRODS
(Association of Pathology Chairman/ Program Directors Section) in reviewing resident curricula
and reforming it so that our newly minted pathologists are prepared for the environment they will
find themselves in.”
She says all members need to collaborate to map out how the CAP’s transformation goals can
be accomplished. For example, the Council on Education has an initiative to build out CME
offerings to help pathologists prepare for roles in genomic medicine.
Personalized health care (PHC) webinars will also be used to provide community pathologists at
small hospitals with knowledge and techniques, such as in molecular markers, genomics, and
pharmicogenomics, that they will need as they take on emerging new roles. The CAP has a free
non-CME credit webinar series on new techniques, such as the business argument for genomic
testing using a sequencing platform, the legal status of laboratory tests, and the use of biomarkers.
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There are also CAP Advanced Practical Pathology Programs (AP3s) that offer pathologists the
opportunity to develop, demonstrate, and become recognized for knowledge and skills in areas
the American Board of Pathology does not currently address. The AP3 course on ultrasound-
guided fine-needle aspiration teaches entirely new skills and enables pathologists to perform
ultrasound examinations, such as for thyroid masses and cysts, and at the same sitting, perform
the fine-needle aspiration.
The two top-elected leaders of the CAP are both self-confessed transformed pathologists.
Granted, though, neither are the proverbial quiet, uninvolved practitioners who write reports and
go home, the stereotypical pathologist the CAP might like to galvanize for change.
Nine years ago, Dr. Herbek worked in a five-pathologist group in a small hospital in Sioux City,
Iowa. But most surgeons in the Missouri River town invested in an outpatient surgery center and
then built a specialty hospital. Dr. Herbek’s group had handled 75% of the surgical pathology
cases in town up to then. The new center and specialty hospital siphoned away that business.
“We still had plenty to do. But it was clear we were never going to be involved with pathology
services with the new hospital or health care organization,” he recalls. Meanwhile, his group was
asked to fill in with another practice in Iowa and South Dakota.
Change happens. You can adjust and even thrive—or fall by the wayside.
Dr. Herbek opted to move on from the group in which he had practiced for 25 years and join a
12-pathologist practice, The Pathology Center at Methodist Hospital in Omaha.
Change happens. And then it happens again.
Methodist, like many hospitals, concluded it was overusing blood. And the pathology
group, with the support of the administration, the medical staff, the laboratory, and nursing,
volunteered to tackle the problem with a blood conservation program. Dr. Herbek was named
medical director of the program, which showcases how pathologists need to get involved. “You
can’t be a wallflower,” he emphasizes.
He notes, “We have improved patient care because patients who do not receive blood they
don’t need get out of the hospital sooner, get out of intensive care units sooner, and recover
more quickly from surgery. And in the end it ends up costing the hospital and health system less.
So everybody’s happy. It does exactly what you want to do. It improves patient care and saves
money at the same time, so it’s a great example. Improvement and savings can both occur at
the same time. There is no need for the two to be in opposition. We’re probably spending a half
million dollars less each year now just on blood costs to the laboratory and to the hospital from
the American Red Cross, with overall care improved.”
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Now he and his practice are preparing to tackle a new role building a full-service coagulation
consultation service at Methodist Hospital at the request of the medical staff leadership.
“It will be patient centered using the laboratory and the pathologist-clinician, rather than being
pharmacy centered or hematology centered. It’s an opportunity we said we would like to
do if offered, understanding that like all specialties it takes practice and time to grow into the
position. When asked, we said yes, we would do it. We didn’t say maybe. Pathologists have to
be involved and step up.”
Change is inevitable.
Despite being in practice for more than 30 years, Dr. Herbek had transformed himself in the face
of changing economic and practice conditions.
A half dozen years ago, as a member of the Board of Governors of the CAP, he adopted
the mantra of transformation for the specialty, which itself has been facing economic and
technologic change and uncertainty. Dr. Herbek, who becomes CAP president in 2013,
preaches transformation to the profession—as someone who knows whereof he speaks.
“Pathologists must be more aware, more flexible, and more willing to act as physician
consultants rather than traditional pathologists who stay in an office and produce reports and
then go home,” he says. “Actually, I’ve always been out and about and involved in the clinical
side, in hematology, blood banking, coagulation, getting bone marrows, and being a more
active consultant in cytopathology, interpreting fine-needle biopsies of liver, lung, and thyroid.”
Dr. Robboy says his 42-year career has been marked throughout with change: “I’ve always
transformed and been consistently transformed. What strikes me is that about every 15 years,
and maybe it’s increasingly now in speed, our whole field completely changes.”
When he entered pathology in the mid-1960s, the focus was shifting to surgical pathology as
autopsies were declining as pathologists’ bread and butter. “I needed to learn an entirely new
area. What did I do? I focused on a relatively unexplored subspecialty area called gynecologic
pathology. There was relatively little written, with only a single textbook. I had a good mentor
and jumped into the area,” he says. “The rest is history, including the description of many new
tumors, definitive articles, and a major textbook in the field.”
He also developed the first comprehensive computer system for anatomic pathology at
Massachusetts General Hospital in the early 1970s because of problems he and his colleagues
had encountered tracking biopsies. Dr. Robboy says, “That was four years before PCs had even
come on the market. I saw a problem and had a vision to fix it. No one said I would transform
pathology and that certainly was not my intent. I wanted to fix a problem and make my life
easier. But I saw benefits where others did not. Our system, as a spinoff, was able to tell the
hospital’s cancer registry of new cases or, for known patients, provided follow-up about survival.
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Our system, as a spinoff, was able to tell the hospital’s cancer registry of new cases or, for known
patients, provided follow-up about survival. Our system also gave radiologists feedback on
their readings from up to three months ago. Imagine how this transformed radiology when the
radiologist learned that an earlier reading of pneumonia actually harbored a cancer discovered
during the subsequent thoracotomy. What feedback! This is what transformation is all about,
then and now.”
Mr. Roussel told the CAP ’12 audience that the bottomline for pathologists is to be optimistic.
“There are two tectonic plates in motion: one scientific (fueled by genomics and informatics);
the other economic (fueled by health care reform and coordinated care),” he said. “We’re
fortunate. In the convergence of these two massive shifts, at the fault line, there is sustainable
advantage for pathology.”
He says pathology’s future advantages can be leveraged from its strong legacy: “Our
advantage comes from historic strengths in analyzing data and understanding disease at the
molecular level. Pathology can drive value in ways that few other specialties can; we are only
3% of the cost, but can help drive ten-fold this in value in coordinated care.
“In driving this value, we can maximize the ways in which we help society and patients and, in
addition, achieve economic stability as individuals and as a specialty.”
Mr. Roussel cited the philosophy espoused in the economics department at the University of
Chicago, calling on pathologists to invoke rational factors while doing good: “Consider the costs
and benefits of change and decide to change because it makes sense to do so.
“The good news is that you can maximize your individual utility and that of your practice while
also doing the right thing for patients and society. Not every specialty will be able to say this, but
pathology will. You’ll be able to do good, while also doing well.”
TM
New Paths…New Choices

College of American Pathologists
February 2013
119

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New Paths ...

A tour of a pathology laboratory at the University of Florida in Gainesville

After her pathology residency, Dr. Riddle completed a one-year fellowship

Yet she tried a rotation in pathology in medical school at the University

Another pathologist was born, a convert to a career on the leading

There is a demonstrated need to prepare pathologists to use and be leaders in emerging

The demand is expected to increase in the face of a predicted

The Medicare Payment Advisory Commission (MedPAC), an independent Congressional agency

The forecast is that more pathologists are going to be needed. And if

Pathologists should follow the power shift—and

So pathologists should be attracted to pathways

“For primary care physicians, integrating radiology

Mr. Roussel comments: “Diagnostic patient

14 Changing the Course of

These data emerged from research

Value is defined in this context as

The toolkit, says Stanley J. Robboy, MD,

The action plan also calls for:

Fundamental elements of the College’s efforts include:

Pathologists know The CAP will leverage its expertise in quality

in the new landscape.

The CAP will try to bolster pathologists’ ability to lead

The CAP has assembled a persuasive case that

Indeed, Dr. Robboy urges pathologists themselves to

But to Mr. Roussel this is not a problem.

“We don’t have limitless resources, but the College

The CAP plans to double down on member engagement online.

Change happens. And then it happens again.

New Paths…New Choices

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