Training Pathologists to Be Better Clinicians: What Exactly Does This Mean?

Although I use the term clinician frequently in this blog, I discovered that I had some difficulty finding a definition for it that satisfied me. I finally hit on the following definition for clinical, which can also be used to define clinician: Pertaining to [the direct] observation and treatment of patients. In the light of this as well as my previous inclinations, I will resist the temptation to classify pathologists and radiologists as clinicians but rather classify them as diagnosticians who act as consultants to clinicians. It is these latter physicians who provide the direct care to patients.

It is often said by some that pathologists are, or need to be, better clinicians. I personally believe that pathologists need to receive more clinical training in order to fully understand the processes used by clinicians to arrive at diagnoses, a critical step prior to launching treatment of patients. However, I don't believe that they should, or could, become clinicians in the most precise sense of the word. Most of their professional efforts are devoted to generating the surgical and clinical pathology reports used by the clinicians to help them diagnose disease.

In recent notes, I have commented on so-called insourced pathology services whereby pathologists serve as in-house consultants embedded within GI and GU practices, diagnosing the tissues biopsies obtained by the clinicians practicing within the group (see: Continuing Discussion: Insourcing of Pathology Specimens by Specialty Groups; Consideration of the Underlying Forces that Promote Pathology Insourcing; The Importance of Integration of Insourced Pathology Services). Subsequent to posting these notes, I have learned from one colleague, an astute observer of our field, that these pathologists are actually becoming clinician-like. For example, those working in a GU practice and specializing in the interpretation of GU biopsies work so closely with their urologist colleagues that they are starting to identify more closely with this specialty than with pathology. Put another way, they are more becoming more closely integrated with a clinical specialty than with pathology.

It is quite possible that these "insourcing" pathologists working in specialty practices may, in general, deliver higher quality diagnostic services than general pathologists embedded in pathology groups who do not confine themselves to one type of specimens. Does their ultra-specialization cause any problems and, if so, for whom? I believe that the answer to this question is that they cause no more problems than a radiologist who can only interpret images of the body from above the diaphragm or a hand surgeon who can't take out an appendix. However, as the number of ultra-specialist physicians increases, who is then available to perform the "general duty" functions -- to triage the patients initially and refer them to the various specialists who can only operate in a very specialized niche?

Comments

[L Needham]

It also brings into question and possible concern (depending on one's point of view) the constraints on the greater field of pathology. In most of the scenarios currently referenced (GI, GU, even Derm to a differing degree), the pathologist, by working with only one type of specimen and much more intimately with the treating physician, becomes more adept at this area...but loses out on other previous skills. Currently, most 'surgical' pathologists are also trained/certified in 'clinical' pathology, however, their skills/bulk of work is surgical with specific assignments to covering an area of clinical pathology for the larger group...but I think most would agree that the moniker is somewhat ill-placed after several years of practice. If 'they' were to truly have to tend to the clinical laboratory, many would be found wanting. The same can be said of the specialists. if the specializing pathologist, particularly in those fields like GI/GU who are not subspecialty certified (unavailable) were to decide at a later point to depart the lab/area of employment and desire to return to the 'general' surgical pathology practice...they too, though board 'certified' in all areas, would likely be both far behind on advances in these areas since they had last practiced/trained and ill-prepared to practice in such a manner. What then? How to approach? With the stakes as high as they are in pathology (life/health), the euphemism of 'just like riding a bike' leaves more wanting than most pathologists or patients would feel comfortable.