Path. Res. Pract. 180, 107-111 (1985) Palh()l()g~ ill lu['opc

Pathology at the Crossroads

Jan Vincents Johannessen Director of The Norwegian Radium Hospital and Institute for Cancer Research, Montebello, Oslo 3, Norway - Professor of Pathology, Col/ege of Physicians and Surgeons of Columbia University, New York, N. Y. - President of the European Society of Pathology

The specialty of pathology is at a complex crossroads. Like other medical specialties, it is undergoing a healthy process of introspection, examining where it has been and attempting to decide where it should be going? We who practise it must now choose the right direction or else we will not be in the mainstream of medicine by the year 2000. What is then the right direction for routine pathol­ogy, research pathology and teaching pathology? This article does not pretend to provide any patent solutions, but puts forward some personal views and some collea­gues' views that I share. In the following I use the word pathology to cover morbid anatomy, histopathology, cytology and experimental pathology, and not in the sense it is used in the United Kingdom where it also includes medical microbiology, hematology, chemical pathology, immunology, and forensic pathology3.

Routine Pathology

Pathologists have been too eager to present their special­ity as a service discipline. It is therefore not surprising that Renato Baserga in 1973 raised the question: "Patholo­gists: Servants or Colleagues?"S

Pathology is a service discipline, and the pathologist is a servant, but to the patient. In this respect, surgery is also a service discipline and the surgeon a servant as well.

In the United States, and this is important to us too, since bad American habits are usually imported into Europe after a time, pathology represents one of the few departments where search committees feel free to choose chairmen from other disciplines. Thus internists, hematologists, pediatricians and immunologists have all been chairmen of pathology in medical schools, although most of them have been the failures one would expect. Pathologists must guard their speciality, and should not accept such experiments from universities or hospitals until the same authorities appoint a pharmacologist to the chair of surgery or a microbiologist to the chair of psychiatry.

© 1985 by Gustav Fischer Verlag, Stuttgart

The problems in routine diagnostic pathology are, how­ever, not solved by the appointment of pathologists to chair positions in pathology.

In some countries whole areas of diagnostic pathology are scaling off from the departments of pathology. Society through its elected representatives is asking: What do pathologists do? Why does it cost so much? Can't some­one (or something) do the same thing at less expense? Thus, it is increasingly incumbent upon pathologists not to lose sight of those unique services that require clinical expertise; the alternative is to risk losing a significant amount of their responsibilities to commercial laboratories or nonpathologists . Gynecologists read their own cervical smears and specialists of internal medicine evaluate the fine needle biopsies. In 1975, Dr. Stein wrote: "The grow­ing numbers and roles of physician assistants and associ­ates and the training of the parapathologists to screen tis­sue sections guarantee further erosion of the pathologist's professional morphologic duties,,19. I feel, however, that parapathologists can and should do much of the routine work that is today done by pathologists, but that the pathologists should decide the scope of parapathologists work. The cytotechnicians who screen cell smears are cer­tainly not a threat to the cytopathologist.

Today, almost all tissues removed by the surgeon are subject to light microscopy examination and in about 80 or 90% of these cases the diagnosis may already be known to the clinician before the histopathological exami­nation, and these specimens usually present no problems to the pathologist either. These examinations mayor may not be markedly reduced in number when economy in the health sector tightens. This may depend upon whether the hospitals may then lose protection against lawsuits for medical malpractice.

Modern investigative methods like electron microscopy and immunohistochemistry are expensive, but are they unacceptably expensive? First of all the examination of a specimen from a human being is not more expensive than the examination of a specimen from a mouse-and may in fact be just as important. This, however, is not a valid

0344-0338/8510180-0107$3.5010

108 . J . V. Johannessen

argument when the mouse examination and the human biopsy interpretation are usually paid for from different sources. If only very difficult diagnostic cases are subjected to immunohistochemistry or electron microscopic exami­nation, which is usually the case in most laboratories, the cost per specimen will be rather high. The benefit will however be great too.

To put it briefly: when calculating the cost/benefit ratio, one should be aware of what this ratio means, - it cer­tainly differs from the cost per specimen figure.

At a round table discussion some years ago, Dr. Layton said: "Pathology has gone through 4 periods:

The oh and ah period when tissue sections were cut and stained and people looked at the pretty colours and went either ooh or ah when they looked at the slides.

The second period was the grind and find period where you put everything into a mortar and pestle or Waring blender and ground it up and tried to get some reaction from the mixture.

The third stage was the black and white era when elec­tron microscopy was to be the answer to all of pathology, and osmium tetroxide and the other substances which let us see black and white were to solve it all.

Now we are in the all or nothing period in which all kinds of methods from a variety of disciplines are being used. This too shall pass but we do not know where the future is going to be."

I do not think the all or nothing period will pass, but that the word "all" will continually change its meaning. I do feel, however, that the period will pass in which all researchers look at all the different aspects of a particular problem. It is not necessary to make the same diagnosis by 10 different techniques. "The overutilization of laboratory tests by clinicians, so customary in recent years, may abate as a result of economic pressures. Physicians can be careful of economics if the situation dictates it,,20.

Will automated image analysis be the answer for those who want a fast, objective, reliable histopathology diag­nosis at low cost? Will it be possible to replace the pathologist by a silicon chip in the year 2000? Only a decade ago, microscope image analysis systems were operating at a rate of 15 to 60 measurements per second. Capabilities to convert the data to numerical values in these instruments were limited to about 1,000 to 10,000 values per second. Today, image digitizing systems capable of recording up to several hundred million image points per second and digitizing them at the same rate are in development18

• This represents a gain in speed by a factor of several tens of millions within ten years, and at virtually no increase in cost. As impressive as all of these capabilities are, they provide a necessary, but by far not sufficient, condition for any computerized diagnostic sys­tem. The information is now available, picture point by picture point, in digitized form. The computer system at this point has gained access to the information. Its present diagnostic capability is, however, less than that of an abso­lute layman looking into a microscope for the first time. Human visual perception is superb at seeing a pictorial scene as a whole, where different components form an

arrangement or a placement pattern, and the characteris­tics of a particular placement pattern can be judged with great reliability whether or not it constitutes what is expected in a certain diagnostic situation4

•

It is therefore very unlikely that the pathologist will be replaced by a silicon chip in the year 2000; I doubt even that this will happen by the year 2050.

As pathologists we have to accept that pathology is the study of disease and that every one can participale in this study. We shave the light microscope, the fluorescence microscope, the electron microscope, and other instru­ments with a large number of disciplines. Pathologists were not even the first to use these instruments, but annexed them later on, often much later on. Our strength as pathologists compared with basic scientists is a solid knowledge of morphological expressions of human dis­ease, not of special instruments or techniques. We have a unique opportunity to evaluate modern methods in a clini­cal setting and should in this context be leaders rather than followers. This is the only way to remain colleagues rather than servants. We must always strive to become better and remember that he who stops being better, stops being good.

Pathology will persist in being one of the remaining "generalist" areas of medicine. Nothing can be more fun­damental in medicine than the study and diagnosis of dis­ease. An understanding of disease still remains the basis of sound medical care and therapeutics.

Should the pathologist confine himself to morphology in the year 2000? I agree with Dr. Townsend that "For those who have a tendency to seek refuge behind the "par­affin curtain", they should open their doors and join the mainstream of medicine. For example, anatomic patholo­gists should become adept at the performance of diagnos­tic procedures such as needle biopsies and not have to rely entirely upon the radiologist or surgeon to obtain a speci­men. This, again, highlights the need for clinical compe­tence as well as clinical confidence on the part of patholo­gists,,20. A good example of what I mean is the develop­ment of fine needle aspiration biopsies, pioneered in Swe­den by Sixten Franzen, Nils Soderstrom, Josef Zajcek and Thorsten Lowhagen, - two of them in fact clinicians. This is a very simple, efficient and reliable method of tissue diagnosis performed in the clinical ward, often in the out­patient clinic or in the patient reception area, by a pathologist, and often before most other techniques like X-rays, ultrasound, computed tomography, etc. The diag­nostic procedures to follow depend in fact upon the result of the examination of the fine needle aspiration biopsy. The method carries only a very minute risk of complica­tions and is almost painless. It can be repeated throughout the patient's clinical history, for example to assess a tumor's response to treatment, and it can be combined with techniques like flow cytometry and immunohis­tochemical staining with polyclonal or monoclonal anti­bodies. In the area of anatomic pathology, the pathologist must be willing and able to go into the ward and operating room to consult with his fellow physicians. He must keep abreast of such discoveries as those allowing gene identifi­cation and recombinant DNA technology that permits

manipulation of gene expression15 • Furthermore, he must be aware of the identification of oncogenes in human tumors and the role such identification may play in the future diagnosis of cancers. Monoclonal antibodies and specific host's responses to specific antigens offer further hope of diagnostic tests as well as potential vehicles to guide therapeutic agents to target cells"zo.

In many countries, including my own, too much credit has been given for experimental research papers compared to diagnostic skills, even when positions in pure diagnostic pathology are filled. I feel too that those pathologists who are interested in teaching and research should have at least full preliminary training in "service" pathology. Regard­less of research interests, an academic teacher of pathology or of clinical subjects for that matter should be able to practise what he teaches. I agree with Alvin Foraker that an academic pathologist unable to practise his speciality is as much of an anomaly as a professor of surgery who cannot perform an appendectomy9.

This certainly does not mean that the pathology profes­sor or chairman has to be the best diagnostician, the best teacher and the best researcher in the department - but that he should be acceptably well educated in all of these fields so that he can stimulate and perhaps even more important, appreciate the skills of his coworkers whatever field they work in. An intelligent man can perhaps be best in anything, but not in everything. Unfortunately, many pathology chairmen prefer to duplicate subordinates rather than rivals. If a chairman is good in one of the three fields mentioned he will, if he is sensible, attract good people to cover the others. This is only possible if he appreciates the strengths of his coworkers and also accepts their weaknesses. There is unfortunately a widening gap in many laboratories between those who do so-called basic or experimental research and those who do clinical service work. I agree with Donald West King that the terms basic and clinical never should have been allowed to have good and bad connotations13

•

In an article entitled "Pathology and probabilities: a new approach to interpreting and reporting biopsies" in the New England Journal of Medicine, Schwartz and col­leagues!7 suggest that the clinician should assess probabil­ity on clinical grounds and that the pathologist should assess it solely on morphological grounds. Later in the paper they suggest that the pathologist may also be con­cerned with the clinical evidence.

I am very disquieted by thoughts which I feel originate in mathematical rather than biological minds. It is crucial that we receive all the available information about the patient and view the morphological expression of disease against that background. A morphological appearance which may be very worrisome in one organ or in one age group may be quite innocuous in another. Diagnostic pathology is a matter of very great importance to the patient, not an academic game where the numbers of "hits" are compared with those made by another special­ity. If we do our work in the dark we will not be keeping the welfare of the patients foremost but may end up as some kind of "bingo pathologists".

Pathology at the Crossroads . 109

Research

The trend of current research at the cellular level, whether it be called cellular pathology, cell biology, or genetics, or endocrinology, or cellular chemistry or what­ever, is the province not only of many persons, but many disciplines. The tragedy is that at this time we see a scarcity of physicians participating in these areas of biologic inves­tigation. Since the physician still remains the responsible "captain of the ship" of medicine, his particular expertise and philosophy is desirable as an important part of the total medical research effortZo.

As mentioned earlier, the strength of the pathologist is his solid and broad knowledge of how disease is reflected in the morphology of cells and tissues. As Szent Gyorgi said a long time ago: "Morphology and function are two sides of the same coin". I once met a world renowned capacity on macrophage research who did not recognize macrophages in tissue sections put before him, and an international authority on experimental breast cancer who did not recognize a run of the mill human breast car­cmoma.

Pathology researchers should be problem oriented and not method oriented. Pathologists must however be mea­sured with the same quality yardstick as other researchers. There is no special league for pathology research, not even a league for national research.

I do not think that pathologists should use new and sophisticated techniques just because they are new and sophisticated. You may then end up, as a large number of researchers already have, with the "Emperor's new clothes" syndrome. You should always ask yourselves which problems that particular method may be able to answer.

I agree with Grisham that "The pathologist of the 1980s and 90s needs intensive training in the investigation and interpretation of pathological processes, including their causes and consequences, be they in hospitalized patients or experimental models. He or she must be educated to cope with and intelligently utilize the high technology of the diagnostic and/or research laboratory without being perverted by it"lO.

Teaching

Teaching and teaching abilities have unfortunately not been sufficiently appreciated in the past. If you apply for a chair of pathology the search committee puts less weight on your ability as a teacher than on your ability as an experimental researcher. This discourages people from spending more than a minimum time on teaching, and the quality of teaching will greatly influence the recruitment to pathology.

I feel that the departments of pathology who have teach­ing talents with charisma will have to show their apprecia­tion of these persons much more and cultivate their talents further, in the same way as they cultivate a research talent. A more active approach offering an elective curriculum of pathology at Duke University was very rewarding. Under

110 . J. V. Johannessen

the traditional curriculum, an average of 1.5% of each Duke graduating class entered pathology, under the elec­tive structure the comparable figure was 6.8 per cent14.

There have been strong arguments about the best way of teaching. Should we use conventional lecture approach, self-instruction methods, integrated teaching, or all of them together?

I do not have a patent answer to this. I do not think there even is one. Each medical faculty and department of pathology will have to tailor the different methods to suit their particular situation. The contact between an inspired teacher and the students is of utmost importance, while a well made self-instruction program is certainly far superior to a dull and uninspired teacher.

The effectiveness of the conventional teaching method and the self-instruction method seem to be equal, but the results are even better when the two methods are com­bined12

•

The measure used is however only the quantifiable amount of knowledge the students have acquired. This kind of measurement may be treacherous. The danger of education today is that it develops the memory at the expense of imagination. We should remember the famous teacher who taught his students "to take from the altar of knowledge the fire rather than the ashes". Education means developing the mind, not cramming the memory. Or to use John M. Mason's words: "The aim of education should be to convert the mind into a living fountain, and not a reservoir. That which is filled by merely pumping in, will be emptied by pumping out".

Quite a number of colleagues seem to think that all problems would be solved if pathology were taught in one of the last semesters of the medical curriculum, as pathol­ogy is one of the disciplines which the students find most interesting under the present circumstances. We should however recognize the fact that most students enter medi­cal school with the intention of becoming a doctor. Pathol­ogy is in fact often the first discipline which brings him into contact with human disease. It is therefore not sur­prising that he will often prefer our specialty to those which present him frog's legs or formulas of steroid hor­mones. At a later stage in the curriculum we will have to compete with intensive care medicine and fascinating clini­cal personalities who transplant hearts and livers.

The fact that pathology is often taught together with basic medicine may however give the doctor-to-be a wrong impression of our specialty. He may think that we live in a world where we are only indirectly involved with patient care through research and the performance of autopsies.

Residents responding to the U. S. Joint Manpower Sur­vey listed the following factors as important reasons for selecting a career in pathology: 1) regulation of own hours, 2) opportunity to practice medicine without exten­sive patient involvement, 3) enjoyment of laboratory work, 4) research or scientific challenge, 5) pathologists known, 6) opportunities for teaching, 7) opportunities for research, 8) interactions with a professor of pathology, 9) freedom from competitive features of private practice and 10) patient related challenge16.

I have visited a number of European countries where they claim to have no recruitment problems since all posi­tions in pathology are filled. I think this is a dangerous way of reasoning. To ensure a high standard of pathology in Europe the important point is not to fill all positions but to fill them with the right people.

Dr. Butler wrote in 1978: "Our specialty has in recent years attracted a large number of physicians who dislike or think they dislike dealing with clinical illness ... j in addi­tion other trainees have chosen pathology for reasons of life-style. There are worrisome developments and should be addressed and limited,,6.

I feel that the practice of pathology should become more patient oriented, and agree that directors of training pro­grams and chairmen owe it to prospective applicants who dislike dealing with clinical illness to discourage them from entering service pathology2.

Conclusion

Alvin Toffler tells us in "Future Shock" that change is inevitable and that successful adaptation by individuals, or groups of individuals, depends in a large measure on their capacity to manage change to their best advantagell•

We pathologists should bear this in mind. If we want to be in the mainstream of medicine by the year 2000 and not in some backwater, we will have to pull the paraffin cur­tain aside and become more flexible and clinically oriented than most of us are today. We have all the possibilities to be leaders rather than followers.

Or to express it in the words of Rudyard Kipling, "We have forty million reasons for failure, but not a single excuse".

References

1 Anderson RE, Hill RB, Conn RB Jr, Benson ES (1977) The need for increased clinical responsibility in pathology training programs. Hum Pathol 8: 597-599

2 Anderson RE (1980) Goals of residency training in pathol­ogy. Hum Patholll (suppl): 493-498

Baron DN (1979) Medical careers in pathology. J clin Pathol 32: 11-15

4 Bartels PH, Wied GL (1981) Automated image analysis in clinical pathology. Am J Clin Pathol 75 (suppl): 489-493

5 Baserga R (1973) Pathologists: servants or colleagues? New Enfl J Med 289: 483

Butler C II (1978) Clinical responsibilities for pathology resi­dents. In: Report on the Second Conference for Pathology Resi­dency Program Directors, September 18, 1978. American Society of Clinical Pathologists, p. 32

7 Conn RB, Anderson RE, Benson ES, Hill RB Jr, Straumfjord JV Jr (1979) Training pathologists for the 1980s and 90s. Hum Patholl0: 493-495

8 Corper HJ (1932) Prospect and retrospect, Presidential address read before Eleventh Annual Convention of the Ameri­can Society of Clinical Pathologists, New Orleans, Louisiana, May 6-9, 1932. Am J Clin Pathol 2: 361-370

9 Foraker AG (1959) The chairless one-armed pathologist. Am J Clin Pathol31: 345-347

10 Grisham JW (1978) The pathologist-scientist-educator. In: Report on the Second Conference for Pathology Residency Pro­gram Directors, September 18, 1978. American Society of Clini­cal Pathologists, p. 18

11 Hill RB, Anderson RE (1977) Change and clinical respon­sibilities in pathology. Arch Pathol Lab Med 101: 621-622

12 Kao YS, Beller MF, Strong JP (1978) Comparison of the conventional lecture method and the self-instruction method for teaching clinical pathology. Am J Clin Pathol 70: 847-850

13 King DW (1974) Patient care, education and research in pathology. Hum Pathol5: 380-386

14 Kinney TD, Bradford WD (1977) The impact of an elective curriculum in pathology. Hum Pathol 8: 329-339

Received November 8, 1984· Accepted November 12, 1984

Pathology at the Crossroads . 111

15 Rabson AB, Rabson AS (1983) Recombinant DNA technol­ogy and laboratory medicine. Arch Pathol Lab Med 107: 505-509

16 Report of the ASCP/CAP/APC Joint Task Force on Pathol­o~ Manpower (1979) Am J Clin Pathol 71: 615-623

7 Schwartz WB, Wolfe HJ, Pauker SG (1981) Pathology and probabilities: a new approach to interpreting and reporting biop­sies. N Eng! J Med 305: 917-923

18 Shack R, Baker R, Bochroeder R et al (1979) Ultrafast laser scanner microscope. J Histochem Cytochem 27: 153-159

19 Stein AA (1975) Is pathology a viable discipline? Hum Pathol 6: 525-521

20 Townsend FM (1984) Pathology at a crossroads (Ward Bur­dick Award Lecture). Am J Clin Pathol 81: 419-423

Key words: Future aspects - Research - Teaching - Specialisation - Routine

Jan Vincents Johannessen, Director of the Norwegian Radium Hospital and Institute for Cancer Research, Montebello, Oslo 3, Norway