Laboratory medicine as a specialty

HUMAN PATHOLOGY-VOLUME

6, NUMBER 6

THE HAIRY CELL

November 1975

LABORATORY MEDICINE AS A SPECIALTY

T o TilE EDITOR: T o "FILE EI)ITOR: .

In a Letter to the Editor [tlum. l'ath., 6: 262, 1975] Doctors Schnitzer and l l a m m a c k show a scanning electron micrograph of a hairy cell covered b ) n u m e r o u s villous processes to ilhlstrate their finding that "In all [their] cases [of hairy cell leukemia] the neoplastic cells had the a p p e a r a n c e of B lymphocytes." A h h o u g h l'olliack et al. t believed that B a n d "F lymphocytes have different morphologic surf'lce characteristics,

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scanning electron microscopic stud)" has clearl)shown that the presence o f microvilli can no longer be attributed only to B lymphocytes; i.e., there exists a subpopulation o f microvilli-bearing i)'mphoc)tes without surface immunoglobulins. -~ On the othei" hand, in a scamliug electron microscopic study o f h u m a n cancer cells from bod)" cavity fluids, we have found that n u m e r o u s microvilli are a constant featt, re o f the surfaces o f a majority o f cancer cells, regardless o f the site o f origin o f the primary tumor, z N u m e r o u s microvilli are visible on tile surfaces o f cancer cells of gastric, breast, ovary, and lung origin growing in Ihlids. Figure 1 (opposite page), showing a cancer cell of ovnriali origin, is representative o f our findings. Microvilli have also been shown b ) transmission electron microscop)' on tile surfaces o f t u m o r cells in experinleqtal ascites. T h e a p p e a r a n c e and disal)l)earance o f microvilli in experinlental models apparently d e p e n d on several factors, such as transformation by oncogenic viruses, concentration o f cells in cuhure, and metabolic activity (for stunnmry, see reference 3). However, nothing is known about tile factors governing the formation of villi in human cancer cells. Hence, tile presence o f microvilli cannot be cegarded ;is a cimracteristic feature of any one cell type. Instead, the observations cited point out the uncertainty inherent ill attempting to classify the origin o f cells on tile basis of surface architeCtllre. ~ ' E N A N q U S Z ~1. I)OMAGALA, M . D .

Montcfiore Hospital and Medical Center Bronx, New York

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I. Polliack, A., l.ampcn, N., ('larkson, It. ll., I)cttarven, E., l',ent~dch, Z., Sicgal, F. i'., m~tl Kunkel. M. G.: Idemification of human B and "I" I)mphoc)tes b)" scanning electron micr<+scopy. J. Exp. Med., 138:607, 1975. 2..Molday, R. S., Dre)er, W. J.. Rembntlm, A., and Yen, S. P. S.: New immunolatex spheres: visual markers" of antigens on lymphoc)tes for scanning electron microscop). J. Cell Biol., 64:75, 1975. 3. l)omagala, W. M., nnd Wo)ke, S.: Transmission anti scanning electron microscopic studies of cells in effusions. Acta C)tol. In press.

Wllen General Franco's insurgent armies were besieging ,Madrid d u r i n g the Spanish Civil War, the Falangist forces stated that they had four columns attacking the city and a fifth column within the city. T h e fifth column was not m a d e up of evil people, but rather represented those witll narrow parochial i n t e r e s t s - c h u r c h l n e n , the merchant class, and so f o r t h - w h o feared the commnlfiSt associations o f the p o p u l a r fi'ont Loyalist government more than fascism. They got the latter. Recently there have been two proposals f l o m within o u r ranks to remake Americal~ pathok)gy [R. B. Corm: Sllould laboratory medicine become a separate speciahy? Ihlm. i'ath., 6 : 2 - 4 , 1975; and A. Stein: T h e filture o f the practice o f pathology. Pathologist, May 1975]. Dr. Corm, c o n d e n m i n g the hospital pathologist for both venality and incompetence, d e m a n d s the separation o f clinical pathology as a discipline, to provide defense agaiust encroachments by commercial laboratories and superspecialized clinicians into clinical laboratory practice. In lliS eyes, depart'ments encoml)assing both clinical and anatoinical patholog)' pr;Ictice are void o f merit. Dr. Conn's attitude should not surprise tis, since his entire professional career ilas bee,I spent at university centers with separate anatomical and clinical pathology departments, and he Ires devoted continllOilS efforts toward fending off proposals for association or relationship between the two areas. Dr. Stein fears encroachnlent b)" clinical superspecialists into specialized areas o f surgical pathology and already COllnts as lost in New York State (and tllerefore tile w6rld) the fields o f clinical laboratory medicine and cytopathology to nonphysicians. His sohltion? A s)'stem much like the English s)stem, with narrow areas o f l)athology specialization. Dr. Stein's attitude is equall)" predictable, since his professiolml efforts have bccn devoted to a narrow area o f anatomical patholog)'. Dr. Conn's proposal, :it least, has the nierit for pathologists o f allowing most o f us to avoid beconling famil)" practitioners. U n d e r Dr. Stcin's system onl)' the few wllo are n e e d e d to p e r f o r m surgical pathology, o r who could qualify as genuine single-area clinical laboratory superspecialists, cot,ld survive. Neither Dr. Conu n o r I)r. Stein, iu the splendor o f institutional isolation, considers what tile impact o f his proposals would be on the American systenl o f medical care, invoh'ing thousands o f small comnulnity hospitals Sl)l'ead over a huge land mass. 11ow woukl these areas, i71 Dr.

CORRESI'ONDENCE

Figure 1. Scanning electron micrograph of ovarian cancer cell. The entire surface of the cell is covezed by numerous microvilli. (The black bar at the'bottom is 4 p. long.) Conn's brave new world, obtain tile anatomical pathology services they require? If Dr. Corm and a colleague qualified in anatomical pathology were covering a grou I) o f small hoslfitals, would the surgical llathology service be suspended when Dr. Conn's colleague was away? A n d who woukl de;d with a blood banklug or hematologic problem when l)r. Corm went on vacation? Worse, what if tile comnumity could justif)" the services of only a single man? Dr. Stein's new era would be an even greater disaster, because sm,dl hospitals would not be able to support the activities o f a chemical pathologist, lnicrobiologist, hematologist, and surgical pathologist. T h e y wot,ld bc forced by their lack o f clinical laboratory facilities to serve a triage function, as in England, referring major cases to a "nearby" center. But with o u r vast land mass, the lack o f laboratory support ould spell disaster for emergency services. How could we treat tliabetic patients in COllla, severe trauma, meningitis, renal dialysis patients, and gastrointestinal bleeders with only r u d i m e n t a r y laboratory support? No thank )ou, Dr. Conn and l)r. Stein. Pathologists are not p r e p a r e d to accept the fate o f tile passenger pigeon. I h a p p e n to think that, in general, pathologists are far better at r u n n i n g clinical laboratories than nonmedical

specialists, because ;is physicians they understand tile needs o f those taking care of patients. T h e y recognize that relevancy, imnaediac)', and practicality are equal in importance to ln'e cision ill labm'atory medicine, whereas nonmedical laboratories do not. (Witness the writings o f R a y Bartlett and his o p p o n e n t s on this problem hi Clinical Microbiologg'. ) I know that pathologists are superior to other physicians at r u n n i n g laboratories because the operation o f a laboratory is a fidl-time activity that should not bc sandwiched in brielly between olfice hours and ward ronnds. Patlmlogists developed the concept o f laboraior)' qualit)" control. In a recent st,rye)" b)" the American Society for Internal Medicine, onI)' a small percentage of laboratories run b)" physicians other than pathologists emlllo)'ed any method o f qttalit) control whatsoever. I am also unimpressed b) clinical superspecialists turned anatomical pathologists. At the major acadclnic centers where I have worked, I know that such people like to examine slides, but that is a far cry fiom knowing what they are looking at. In general, nephrologists are poor nephrol)athologists; hepatologists are p o o r hepatopathologists; and gynecologists are p o o r c y t o p a t h o l o g i s t s - f o r the same reasons that laboratories run Ii)' nonllathologists are poorly run. Skillful interpreta-

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HUMAN PATHOLOGY-VOI.UME

6, NUMBER 6

tion of lnorphologic change in tissues is anactivity that should cousuine much of one's time and interest and slmuld not be an avocation. Furtherlnore, disease has a nasty habit o f i n v o M n g more than one organ system. T h e twin Cassandras may be correct in forecasting the doom o f p:uhology as it is constituted, but if our fiekl dies, it will not be because the system does not work. It works quite well. In fact, we have succeeded in developing the most highly sophisticated system o f clinical laboratory diagnosis in the world, and extending it to an u n p r e c e d e n t e d proportion o f the popuhuioil, wlfile siinultaneously reducing the cost of the service. How many other products have d r o p p e d in dollar price in the last 25 )ears? Nor need we defend the fact that advances have been achieved to a large d e g r e e through the research o f basic scientists and engineers, any more than need pediatricians, internists, and cardiac surgeons in their fields.. No, if pathology dies as a professional specialty, it will be througl~ the actions o f powerfill forces in business and g o v e r n m e n t that desire to COlm'ol o r manipulate it, or, more likely, through autogenocide resuhing from the proposals o f o u r Corms and Steins. Two al,horisms, one somewhat time worn, the other more contemporary, are pertinent to tiffs discussion. T h e first applies to o u r fifth and sixth columns, the second to their proposals for reform: (1) With such friends, who needs enemies? (2) We had to destroy the village in o r d e r to save it. HERBERT BRAUNSTEIN, M.D. San Bernardino County Medical Center San Bernardino, California

THE PATHOLOGIST VERSUS THE CLINICIAN T o TIlE EDITOR: It is disappointing and disheartening to read an account o f pathology as presented in a recent editorial by Dr. Emannel Rubin, I who himself has made significant contributions to his chosen field o f medicine. Dr. Rubin's narrow perception o f the history of pathology and o f lmthology o f the present is even more striking when assessed in the light o f his particular setting as a successor to two giants, I'aul Kle,nperer and I lans Popper. Surely he is not serious when he states that the study of morphology has never been considered by pathologists as an end in itself. I'athology has

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always been and will relnain a study o f Imman disease in its clinical setting. Anyoue who as a practitioner of" pathology is not interested in the liviug patient has missed his calling ahogether. I would also like to express my disagreement with Dr. Rubin's statement that "Few pathologists are in tim forefront o f I'esearch in the diagnosis and pathogenesis o f h u m a n disease," and I could cite many examples to prove him wrong. T h e fact that only one senior contributor to Dr. Rubin's symposium is a pathologist and the r e m a i n d e r clinicians is a most snperficial way o f assessing the status o f pathology: T h e matter can be interpreted in exactly the opposite way, namely, tlmt in the study o f h u m a n disease the clinicians have become interested in pathology, as they should be, a n d are devoting increasing time and attention to the correlation o f clinical disease with structural changes. An)' field o f knowledge that is so desirable to others cannot be dead or dying. I f there is, as claimed, a shortage o f "academic" pathologists, the fault may lie precisely with the fact mentioned in the editorial, namely, that so ninny chairmen o f academic d e p a r t m e n t s know so little about human disease and are lntlcll more interested in training molecnlar biologists or virologists than pathologists. T h e vacunm that thns occurs is filled by clinicians who ifi the setting o f many a medical school cannot find competent help in the d e p a r t m e n t s of pathology. T h e r e is nothing wrong with Dr. Rubin's idea o f specialization, b u t against what backgromld? A f t e r all, internists and surgeons first get several )'ears o f basic training before specialization. Should not the same sound principle apply to pathology? T h e question is: who is going to train the pathologists if the chairmen o f major d e p a r t m e n t s are not interested in h u m a n l~atholog)'? A n d who is going to run the laboratories and help patients in smaller hospitals if, as suggested, the training in pathology is to be confined to subspecialists? No doubt the clinicians would take over pathology because they will need it for patient care.

This note would become a sylnposiuln in itself if all the argtunents o f historical and scientific nature were to be cited in s u p p o r t o f this writer's continuing haplfiness with pathology. Most importantly, this letter addresses itself to the young physicians who nmy wish to become pathologists because o f their interest in h u m a n disease: T a k e heart, the bell for pathology has not tolled yet. T h e field is filled with promise and excitement, just as it was when Virchow first identified leukemia some 125 )'ears ago. With new tools and new tech-