The People Have Spoken—Are Pathologists Listening? Open Access

As physicians our work begins and ends with our patients. The delivery and organization of health care continues to change both in the community and in academic settings. There is greater emphasis on both personalized medicine and population health. As medical knowledge expands, diverse expertise is required to deliver personalized care. Similarly, expertise is needed to design wellness, monitoring, and chronic care programs for population health. All these demands lead to development of health care teams for effective and efficient delivery of optimal care to individual patients and populations. Pathologists are essential professional members of health care teams, contributing to interdisciplinary² /interprofessional³  teams as experts in diagnostic medicine.

What does a pathologist need to do to be an effective member of a health care team? Let's start with the obvious: we need to be accessible, show respect for team members, and communicate effectively. Pathologists need to use their diagnostic expertise to guide test selection, enabling a definitive diagnosis and thus an optimal treatment plan. Pathologists need to interpret diagnostic results, integrate multiple findings into a nuanced yet coherent report, and communicate a diagnostic opinion clearly and concisely to the health care team, enabling efficient and effective care for our patients. Pathologists need to educate team members on advances in diagnostic medicine and provide leadership in health care teams' developing diagnostic algorithms for screening programs and chronic disease management. We need to be influential team members, guiding processes that minimize preanalytic and postanalytic diagnostic errors.

Is there a call for pathologists to adapt their practices to the changes in health care delivery? The recent report from the Institute of Medicine, Improving Diagnosis in Health Care,⁴ is clearly such a call to all health care workers and it is in particular an opportunity for pathologists. Diagnostic error is defined as “the failure to (1) establish an accurate and timely explanation of the patient's health problem(s) or (2) communicate that explanation to the patient.” Errors can thus occur at every point in the diagnostic process including preanalytic, analytic, and postanalytic phases. Pathologists exercise great care in the analytic process, using quality measures to minimize error. But most errors occur in the preanalytic and postanalytic phases. By working effectively in health care teams, pathologists can help increase coordination and reduce errors in those phases as well. Certainly the advent of competencies for clinical training programs in all specialties of medicine will require all physicians to learn to communicate and interact more effectively.⁵  We are in the early days and it will take time for programs to fully integrate these skills into every aspect of training.

How can we integrate these professional skills more effectively in pathology training programs? Do we need to modify our training programs to produce a pathologist who can practice team-based medicine and thereby provide leadership in improving diagnosis? The article by Post et al⁶  on employer expectations for newly trained pathologists describes the deficiencies in preparing pathology trainees for clinical practice. This study is not the first of its kind, but the findings underscore and add to those in the past. Our residency programs in general emphasize anatomic pathology diagnostic skills, preparing residents well for fellowship training, and fellowship in anatomic pathology yields a higher level of diagnostic skill in a particular area of anatomic pathology. This paradigm, set forth in 1902 to distinguish physicians from charlatans,⁷  yields specialists with more refined but also more narrowly focused skill sets. This young specialist is less likely to be (or to want to be) adaptable and resilient regarding scope of practice. Despite so much time invested in honing diagnostic skills, there is no guarantee the young specialist has devoted formal time to developing advanced communication and interpersonal skills to be effective as a physician member of an adaptable interdisciplinary health care team. A recent small survey of pathology residency program directors indicates that most training programs—though keenly interested and understanding their value—have not embraced health care teams in their training.⁸  If pathologists are to have an impact on improving patient care (personal and population) and in reducing diagnostic errors, we must alter our residency programs to yield expert diagnosticians with excellent interpersonal and communication skills, enabling them to be effective members of health care teams. The training must be an element of the core that provides foundational pathology skills and knowledge (anatomic and clinical), teaching critical thinking/clinical reasoning (decision-making sciences^9,10 ) and quality management, and developing communication skills, in the context of a team environment. One can envision a modern training program with a core lasting 12 to 24 months, intended to produce an individual with a strong grounding in these elements of pathology who can then use these basics over the remaining time in the residency program to develop greater expertise in particular areas of pathology. Because such a core would provide the basic skills for all areas of pathology practice, it would yield professionals who could more readily gain additional areas of expertise after residency training; that is, to fill gaps of pathology need within their health care setting.

What could these first years of pathology training in such a program encompass? They could start with an on-boarding process that refreshes trainees' knowledge of histology and uses case-based teaching to introduce basic principles in laboratory testing. This would enable residents to begin their training with an assured common level of basic skills. The first months could include autopsy training emphasizing the importance of clinical history, building skills in gross examination, handling tissue, and histopathology. The importance of issuing a timely and meaningful preliminary report that integrates clinical history, laboratory, and anatomic findings would instill the organizational and professional skills required for general clinical communication and practice. During the first months, residents should commence a longitudinal informatics/data analytic project that would either assess test utilization for a patient cohort or provide quality management information.¹¹ 

As the first year progresses, integrating surgical pathology with relevant laboratory diagnostics should be straightforward in such areas as hematopathology and medical renal pathology. The challenge would be to cover the essentials of the subject matters required by the American Board of Pathology (ABP) in fewer years, while providing the complementary skills that enable pathologists to function and influence care in a health care team. In addition to diagnostic skills, we would need to teach, by use, data analytics/computational pathology,¹²  interpersonal skills facilitating team work, and communication skills enabling interdisciplinary cooperation, these last 2 built on an empathetic appreciation^13–15  for the roles of all the members of the interdisciplinary health care team. We are challenged as well as enabled regarding communication by the intermediation of the electronic health record and must learn to communicate effectively across the electronic interface, turning our data (results) into information that our patients can understand and our colleagues can use to implement treatment plans. If we ask ourselves whether this degree of change is needed, our answer lies in empathy for our patients, and what we would want in their place.¹⁶ 

Currently, we are afforded moderate flexibility by the ABP to redesign our training programs. In concept, the elements of a core (described above) will give a strong foundation for diagnostic skills together with the much needed skills to practice in an interdisciplinary health care team. An effective core would produce an adaptable, resilient¹⁷  pathologist and allow the resident more time to develop advanced diagnostic skills in particular areas of pathology, thereby reducing the impression that multiple fellowships are needed. Certainly we would need to develop new metrics to assess the effectiveness of any new training programs. In addition, as such programs take hold, the ABP might need to adapt its requirements for certification.

We have the ability and the opportunity to train pathologists for the new world of medicine. Are we listening? Do we have the strength to act?