Current Topics
The Pathologist-Scientist and the PathologistTechnologist: The Need for Scientific Attitudes Toward Professional Goals and Responsibilities JOE W. GRISHAM,MD "We . . . have built an impressive technology only to find that as we embrace this lechnolog}4, we lose an irreplaceable part o f our profession . . . The specialist physician is metamorphosing into a technocrat a n d businessman. The physician retreats behind the machine a n d becomes an extension of the machine. "1
oratory data to solve problems, but rather passes the data on to someone else for interpretation and application. T h e pathologist-technologist is enamored of techniques and machines, more concerned with them than with their scientific bases and applications or the principles o f abnormal biology that they may elucidate. T h e pathologist-scientist is distinguished from the pathologist-technologist by the attitudes displayed toward his or her professional work, not by the arena in which it is performed. T h e pathologist-technologist is by no means limited to the diagnostic laboratory or to the community hospital. He or she can be found in any setting in which pathologists work. This point is well illustrated by reference to the groves of academe, the work environment with which I am most familiar. Being located in an academic setting does not cause a pathologist to take a scientific approach to his or her work (conversely, being in a nonacademic environment does not prevent the pathologist from being scientific). F u r t h e r m o r e , a narrow technologic approach is not confined to the diagnostic pathologist; the researcher and the teacher can also follow such an approach. During my several years in leading an academic pathology department, perhaps my.most painful and professionally embarrassing experience involved a complaint from a clinical colleague that a senior surgical pathologist, had refused to discuss the interpretation of the histologic pattern of an open lung biopsy, with the rejoinder that it was the pathologist's j o b only to make a diagnosis, not to interpret it in terms of a patient. This response epitomizes the technologic approach at its most extreme! T h e pathologist-technologist may also be found in the research laboratory; this r e s e a r c h e r is m o r e concerned with having, for example, the latest model electron microscope coupled with sophisticated computerized image analysis systems than with what can Received from the Department of Pathology University of North Carolina School of Medicine, Chapel-Hill, NC 27514. Acbe learned about fundamental processes of abnormal cepted for publication March 15, 1984. cell biology with this apparatus. An investigator with Address correspondence and reprint requests to Dr. Grisham. such a technologic orientation may study a pathologic * As used here, the word technologist does not pertain to the process merely to justify the machine, not because of medical technologist, an essential"participant in the arena of the a burning interest to elucidate some mechanism of clinical laboratory. 802 T h e appropriate professional roles of pathologists have been discussed intensively in recent years, as has, as might be expected, the training required to prepare future pathologists to function well in the work roles imagined for them. My purpose is to emphasize that a scientific approach is required if the c o n t e m p o r a r y pathologist is to function appropriately in any o f the possible professional roles that might be encountered and that, as a consequence, future pathologists must be trained as scientists. In discussing this issue, I contrast the attitudes and training o f the pathologist-scientist with those of the pathologist-technologist, trace the historic divergehce o f the science and technology of pathology and the atrophy o f the scientific approach to pathology, outline the dangers of this situation, and emphasize the necessity to reorient our residency programs to emphasize the training of scientists rather than of technologists. I believe that some of the major challenges facing the profession of pathology today have arisen because we have allowed our discipline to become "overtechnologized" and "underscienced." The term scientist epitomizes to me the best that contemporary pathology has to offer in the areas of diagnosis, teaching, and research. The pathologistscientist solves problems by the application and interpretation o f laboratory data. T h e pathologist-scientist is above all an investigator o f abnormal biology, a student of disease, whether he or she works in the research laboratory, the diagnostic laboratory, or the classroom. T h e pathologist-technologist (used here in the sense defined by Ellul 2 to include other technocrats, such as the pathologist-administrator and the pathologist-systems analyst) generates and manipulates laboratory data but does not interpret these data.* T h e pathologist-technologist does not use lab-
THE PATHOLOGIST-SCIENTIST(Grisham)
abnormal biology. I purposefully used the electron microscope to illustrate the pathologist-technologist researcher, because the picture is familiar to most of us who have experienced academic pathology during the past 20 years; most o f us can recall fellow faculty members who have become excellent "electron microscopists" but who have failed to make much of a mark as experimental pathobiologists because of their technologic bias. T h e t e a c h e r may also overemphasize technology in his or her work. The pathologist-technologist teacher may be more interested in computer-assisted instructional and assessment techniques and instructional uses o f television, for example, than in what the student learns or how well the student can use the information acquired. The technoteacher may be more interested in the form of the instruction than in the content. I do not believe that anything unique in the academic environment stimulates the technologic approach and attitude. However, since this condition is not at all uncommon among academic pathologists, it might be useful.to examine this setting briefly in an attempt to identify etiologic factors. The diversification and expansion of responsibilities of academic d e p a r t m e n t s o f internal medicine have been described and aptly discussed by Petersdorf3; the analogy between internal medicine departments hs he described them and d e p a r t m e n t s o f pathology is close. Academic pathology d e p a r t m e n t s are businesses of considerable size, with total cash flows that may exceed $20 million p e r year and labor and professional forces of more than 250 persons. Academic pathology departments must now be operated like businesses, exqtfisitely responsible to a formidable array of clients and regulatory agencies. Diagnostic laboratories are small factories, containing row upon row o f complex and expensive machines that manipulate samples and stamp out resuhs that are fed into electronic computers for further processing. Lecture halls and teaching laboratories are crowded with literally hundreds of students, whose numbers often overwhelm the available teaching staff. Research laboratories contain complicated, expensive equipment, and the money required to conduct a competitive research program in most areas of cellular pathobiology is formidable. In most institutions the academic pathologist must find his or her own support, including a large portion of salary, to carry out the scholarly studies required for advancement in the academic hierarchy. Acquisition of research funding is a highly competitive, some would say cutthroat, business that involves the academician in environments as diverse as the federal bureaucracy and administrative offices of major industrial concerns. This hectic and frenzied condition is not that of an ivory tower! T h e ivory tower has crumbled. 4 High technology is required to manage the veritable deluge of data, paper, money, and people involved in the new academic setting. The requirements for dealing at muhiple levels with thousands of laboratory procedures, including the rel~orting and storage of data; with inspections o f procedural quality control and 803
employee safety; with assessments o f professional competence; with detailed accounting for the millions of dollars that pass through our hands; with the instruction of hundreds of students; and with ttae acquisition and management of grants and contracts allow little time for meditation and contemplation and require the use of mechanized, businesslike approaches in all activities. The need to mechanize and computerize the operation of a pathology department is partly to blame for our present overemphasis on teclmology. Instead o f using the technologic aids available to help us to practice as physician-scientists, we have become more involved with the machines than with the utilization of tile information they produce. To paraphrase McLuhan, the machine and the technique, rather than the application of what is produced by machine and technique, have become the pathologist's message. 5 Associated with this change in the milieu in which we work, scientific and technologic pathology have diverged. Although the science and technology of pathology were closely intertwined during much of the history of pathology, their separation now appears to b e almost complete. Many underlying forces have caused this separation, and the separation began in academia long before tile ivory tower collapsed. Although the utility of high technology in managing our daily responsibilities has played a central role in its current ascendancy in pathology practice, other factors, some recent and some historic, have assisted powerfully. Possibly the most important factor is the sheer breadth of pathology: it is impossible to be truly expert in more than a small fraction of the knowledge that undergirds pathology. Even Rokitansky and Virchow, in an era in which the base of knowledge in biomedicine was much shallower than today, did not possess a deep knowledge of the whole of pathology. For the acquisition of intellectual expertise, specialization is necessary, and in recent years one popular area of specialization has been the technology of pathology, including the supporting i n f r a s t r u c t u r e - management, systems analysis, or data handling--as career endpoints. Indeed, as the acquisition of research funding has become more competitive, timeconsuming, and unpleasant, young pathologists have increasingly turned toward technology, applying the Sutton principle to go where the money appears to be most readily available. Market forces have also played a role in our increasing emphasis on technology: efficiently run laboratories stimulate intense competition for highvolume procedures, because they lower procedural unit costs, and allow large net earnings with high volumes. Policies o f regulatory and funding agencies have forced the separation of diagnostic and research operations. Formerly, the diagnostic and research laboratories of a pathology department were unified and housed in the same space and used the same e q u i p m e n t and personnel, allowing immediate "cross-fertilization" between basic and applied areas of pathology. This practice is no longer feasible because of accounting and "good laboratory practice"
HUMAN PATHOLOGY
Volume 15, No. 9 (Seplember 1984)
rules. Tile historic establishment o f laboratories a r o u n d a single focus (e.g., biochemistry, immunology, cytology) that emphasized certain technologies, although it maximized efficiency in data production, has had an important adverse effect on the m a n n e r in which pathologists use laboratory data. In my opinion, this organizational plan has blunted our ability as pathologist-scientists to integrate and interpret all of the data concerning a single patient, focusing our attention, instead, on specific types of analyses. In effect, it has caused us to wear blinders when we view a patient's diagnostic problem, seeing that patient's illness only from the narrow perspective o f a single analytic technology. T h e most important cause o f the demise of scientific pa.thology and the ascent of technologic pathology, however, is the training that developing pathologists now receive; we no longer train pathologists to be scientists. Many residency programs differ little from classes for medical technologists. Methods and machines are emphasized; production, rather than use, of data is taught. Data interpretation has a miniscule role. Patients are not considered as individuals, but rather as part o f a population containing h u n d r e d s or thousands. Learning to troubleshoot machines, manage technicians, balance budgets, and manipulate statistics, while important, does not lead to the ability to make diagnoses and manage patients' illnesses. Scholarly study, w h e t h e r basic laboratory research or the applied evaluation of the natural history of.diseases encountered in practice, receives scant attention in most training programs today. Rarely does a resident learn by precept or practice to evaluate rigorously and interpret the data accumulated in the research laboratory, to apply similar rigor to the evaluation o f a paper in the clinical or research literature, or to select and interpret laboratory studies in the clinical laboratory. It is unfortunate that accrediting agencies signal an astounding lack of interest in fostering such activities. Many, o f course, believe that o u r high technology has greatly benefited the individual patient through improved diagnostic accuracy and precision. That conclusion is demonstrably erroneous with regard to advanced diagnostic technology generally. 6 Even if accuracy and precision have been improved, the tradeoffs for our profession have been immensely adverse. It is possible to quantify the damage to the profession of pathology and to medicine in general caused by the absence of the personal involvement of a thoughtful, creative scientist in the management of individual patients, or the implication of the loss of scientific thinking in the application of tile discoveries of m o d e r n molecular pathobiology to the clinical laboratory? Where will the new diagnostic procedures come f r o m if new scientific insights into cellular pathophysiology are not forthcoming? Is is reasonable to expect, for example, that surgical pathologists will be able to continue to take an invaluable piece of human "flesh, removed with considerable expense and pain for tile patient, and examine it by merely looking at it? Obviously, excised 804
tissues contain far more information about the patient's condition than that obtained by simple evaluation o f the morphologic features. Already available from r e c e n t laboratory discoveries in molecular pathobiology, recombinant DNA technology, and immunochemistry are methods for obtaining new information about disordered function, e.g., we can discern the presence of an quantify specific receptors and other antigens, and we can detect tile activity of specific genes and quantify some of their products. We can be confident that, in the near future, application of other types of analyses will yield information of ever-increasing diagnostic utility. Yet these new techniques will be applicable only if the intensive scientific study of their molecular biologic basis and of their diagnostic and prognostic validation by pathologist-scientists precedes their technologic applications. T h e demise o f scientific pathology, already proclaimed by the Health Care Financing Agency, will ultimately sound the death knell of pathology as a medical diagnostic specialty. Scientific pathology must be shored up if pathology is to regain its former posture as a vigorous and scientifically progressive biomedical science. I believe that the scientific base of pathology can be rescued, but not without great effort and unity of purpose a m o n g the leaders in academic and community pathology, the various professional organizations of pathologists, and individual concerned pathologists, wherever they are located. Pathology is not alone among medical specialties in having to cope with a burgeoning technology or to deal with requirements to control and process massive quantities of data; we can learn from others some o f the ways in which technology must be used to improve, and not to compromise, professional function. 7 T h e high technology o f applied pathology can be useful, but it must be used creatively. I do not advocate that we become pathologic Luddites and attempt to return to a simpler professional lifestyle after r a m p a g i n g through our offices, lecture halls, and laboratories and breaking up our machines. But we must master technology and not be mastered by it. Some of our recent attitudes and practices must be radically.modified: pathologists must think and act as scientists, using laboratory data to solve problems, whether in the research or the diagnostic laboratory. Central to this m u s t b e a fundamental change in the structure of residency programs, such that training in scientific pathology is revitalized and emphasized. Certainly, young pathologists must learn to run laboratories and to understand technical methods, acquiring knowledge of analytic instrumentation and management of personnel and budgets; although these technical insights are necessary, however, they are not sufficient for successful performance as a pathologist-scientist. Training for the scientific pathologists must emphasize the acquisition o f j u d g m e n t a l skills: problem identification, generation o f alternative problem solutions, informed choices among alternatives, interpretation of data, and assessment of the reliability of data. It is my firm opinion that rigorous experience in either diagnostic or research laboratories o f high
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quality can be equally valuable in developing the basic scientific skills. In the context o f the pathologist-scientist, distinctions between experimental and diagnostic pathology disappear. The mind sets, attitudes, work habits, and approaches to solving problems are similar, whether the object of the problem is a research hypothesis or the diagnostic and prognostic dilemmas posed by a sick h u m a n being. Good clinical experience is also valuable. Although a strong clinical base is important for both diagnostic and experimental pathologists, I fear that the proponents o f a year of formal training in internal medicine or surgery, for example, may view the subject of clinical training too simplistically. The basic clinical knowledge required for the pathologist is a sound understanding of the natural history of diseases and their expressions in the living patient. Not all types o f clinical training provide that kind of learning experience, because much clinical training has also become highly technical and immediately relevant only to a particular limited specialty area. Too often, such so-called clinical training does not emphasize the natural history of disease to the understanding of physiologic principles so necessary to the diagnostic pathologist-scientist. It is doubtful that many pathologists will be consulted about abnormal heart sounds or electroencephalographic tracirigs, but they will be consulted about the selection and interpretation of analytic laboratory procedures and the results obtained. In my opinion, it will do no good, indeed it will be harmful, if pathology residents are required to undergo a period of training that has little relevance to their future professional function merely to satisfy a requirement. We must develop more appropriate experiences, clinical and otherwise, within the context o f our pathology training programs. " H i g h - t e c h " requires "high-touch"S; high technology does not replace the need for h u m a n communication and personal interaction, but rather makes them more critical in the maintenance of a functional society. Pathology is not exempt from this requirement. 9 Possibly the most fundamental skill is the ability to c o m m u n i c a t e with colleagues. Computers may be able to improve the flow of data, but they do not always facilitate the receipt and proper interpretation o f data. Pathologists have failed as communicators, and this may well be the ultimate source o f most of our current array of problems. The well-known characterization of the pathologist as a verbally impoverished person who cannot present an oral argument without the visual crutch of a lantern slide is too true to be amusing to many of us. Although we might not wish to admit it, pathology attracts individuals who want to avoid the problems of other h u m a n beings, who want to eschew the need to communicate with them or to help directly in solving their problems, and who believe that-they can accomplish their goal of avoiding personal contact by immersing themselves in the technologic operation of a laboratory. An essential part of any training program in. pathology involves ieacl]ing residents that good communication with colleagues and their patients is essential and instructing them by example and ex-
perience to communicate their interpretations so that they are received and used. In summary, we must vigorously pursue the resurgence of scientific pathology, beginning with the residency programs. In our residency programs we must emphasize the training o f residents who excel at laboratory study and interpretation of abnormal biology (disease); we must help residents to acqtfire competence to use laboratory data to make decisions; and we must teach them to use and cope with technology, but not to be overwhelmed by it. We must teach them that laboratory medicine is more than the mere production o f data and the m a n a g e m e n t o f budgets and people; they must learn that the ability to communicate data and interpretations of data in a form that is received and used cannot be ensured solely by having the most modern computerized information s y s t e m ~ f a c e - t o - f a c e communication between the pathologist and the patient's physician is required. This revolution in training and attitude will require the cooperation o f many groups and individuals, including the American Board of Pathology, the Association o f Pathology Chairmen, the Residency Review Committee, the training program directors, and pathologists in general. I believe that the current discussion o f the roles o f pathologists and o f the t r a i n i n g r e q u i r e d to facilitate professional functioning is necessary and useful, but it must be followed by a coming together with a unified plan of action by all of the parties involved. The time to cooperate and act is now.
Acknowledgments. This paper resulted from the modification and development of talks that I gave on this general topic at the Second (St, Louis, 1978), Third (Las Vegas, 1979), and Sixth (St. Louis, 1983) Conferences for Pathology Program Directors. I want to thank many associates, both at North Carolina and at other institutions, for helping me to clarify some of these ideas. I especially acknowledge Drs. Rolla Hill and Robert Anderson for their continning encouragement and enthusiasm about the future of pathology and for their assistance in converting the ideas expressed in a talk into an essay. I will appreciate receiving the comments of anyone who reads this document. I am certain that a forceful and continuing discussion about the goals of pathology and the strategy for attaining them must be maintained if our specialty is to progress. REFERENCES 1. GrouseLD: Has the machinebecometile physician(editorial)? JAMA 250:1891, 1983 2. Ellul J: The Technological Society. New York, Alfred A Knopf, 1965 3. Petersdorf RG: The evolutionof departments of medicine. N Engl J Med 303:489, 1980 4. Rogers DE, Blendon RJ: The academic medical center: a stressed Americaninstitution. N EnglJ Med 298:940, 1978 5. McLuhanM: UnderstandingMedia. New York, McGrawHill, 1964 6. GoldmanL, Sayson R, Robbins S, et al: The value of the autopsy in three medicaleras. N EnglJ Med 308:1000, 1983 7. Rogers DE: On technologiC: restraint. Arch Intern Med 135:1393, 1975 8. NaisbittJ: Megatrends. New York, Warner Communications, 1983 9. Hill RB: Change and clinical responsibilityin pathology(editorial). Arch Pathol Lal~Med 101:621, 1977. 805