Today’s pathology residents will be practicing in a very different healthcare delivery and financing environment, where the emphasis is on providing the maximum value for patient outcomes while managing costs. This new generation of pathologists will need to think of their roles as purveyors of knowledge who are critical members of the care team, and will need to expand their skill set to understand new technologies and personalized medicine, ultimately to provide better patient outcomes.
Medical education programs are evolving to better prepare residents to understand molecular medicine, to be conversant with different technology platforms and how to investigate those platforms, and to know how to use informatics to improve patient care. In each of these areas, the opportunities to leverage patient data produced for driving system-wide improvement are enormous.
Twenty years ago, diagnostic testing and the interpretation of results were much less complex than they are today. A classification of non-Hodgkin lymphoma, for example, was deemed good, intermediate, or bad. Any more depth of information was not useful, as there were only a few different ways of treating lymphoma. Now, many different kinds of lymphoma are recognized, and many have fairly specific treatment modalities.
Pathology and laboratory medicine are transitioning from tissue-based diagnostics with a focus on morphologic characteristics, to blended diagnostics, incorporating molecular assays, immunohistochemistry, and genomics. This is occurring throughout the medical profession, which is still in the early stages of personalized medicine: the patient is no longer treated as part of a large cohort, but as a unique individual with unique phenotypes.
Managing the diagnostic process
Today’s pathologist manages the diagnostic process and helps clinicians ask the right questions. That is a very different job than that which pathologists used to perform. As the profession moves toward a system that pays for value, not per volume of tests performed, pathologists are being held accountable; they are being asked to show that they are good stewards of limited resources.
What does this mean for training? Pathology will have to be integrated into caregiving teams, and pathologists will have to understand how to convert the mounds of data that are generated into knowledge to support the diagnostic process from the beginning to the end of the lifespan. This means pathologists must be embedded as part of the clinical care team. It also touches on appropriate test utilization and support in making decisions of therapeutic modalities. Some training programs and traditional academic departments are being organized into multidisciplinary teams, which will enhance communication and streamline care.
As part of their rotation at Yale University School of Medicine, for example, senior residents take part in several programs that help them understand the team approach and where they fit in that team to advance patient care. One of these teams focuses on pathology. Here, the senior residents have graduated responsibilities. They oversee junior residents and help them interpret test results, and talk with clinicians to facilitate the dialogue about the tests they’ve ordered for a patient. They also communicate test results back to the care team.
Another senior rotation, in anatomic pathology, is called the “hot seat.” Here, senior residents are the traffic cops for everything coming into the pathology lab. They review cases, prioritize them, and make calls to the surgeons for more information. They also assist junior residents in prioritizing what needs to be done. At the same time, they act like a junior attending and put in their preliminary diagnosis. When the case is over, they confer with the senior attending on how well they are doing.
Breaking down silos
The Pathology Department at the University of Illinois-Chicago is also working to break down the traditional silos of anatomical and clinical pathology departments or divisions and is embedding pathologists on multidisciplinary teams. Clinicians of other departments are made members of these teams in order to provide clinical relevance in the training program.
Placing pathologists on the multidisciplinary care team takes them out of the basement, so to speak, and requires them not only to serve as consultants, but to take a leadership role in the future care delivery model. Developing strong leadership and interpersonal skills will be critical to their success.
Pathologists need to be trained to work in systems. Medical school curricula often address this under the rubric of management competencies, such as team building and process improvement. Lab Management University, a collaborative initiative of ASCP and the American Pathology Foundation, is building competency in laboratory management through a combination of online courses and live activities.
Going forward, it will be pathologists’ ability to build knowledge structures, more than to transmit data, that will enhance awareness of their importance in the delivery of quality care. Pathologists must be able to demonstrate to a hospital, health system, or medical home, what they are doing to improve a system’s ability to serve patients. The future for pathologists looks bright, but the skill set that they will need will continue to broaden as the profession becomes ever more critical to patient-centered care.