Introduction

What finally moved me to write was a telephone call from a woman on whom I had made a certain diagnosis. "What the hell are you doing with my breast?  Does it take ten days to get a biopsy result out of you?" she yelled. I have tried here to provide an answer to that question, an explanation of what goes on in the trenches of an academic pathology department, sharing a subject that lies within the subterranean vaults of American Medicine.  In discussing this project with friends, I am inevitably asked who is my intended audience, and my response must be anyone, whether medically trained or not, interested in good patient care.  In 2001, Spencer Nadler wrote “The Language of Cells”, a wonderful account of his work as a pathologist and his involvement in the lives of the people whom he met under the microscope.  The L.A. Times called it “sensitive, often charming, always informative…Moments of poignant realization abound.”  Robert Coles wrote of Nadler’s “affecting, knowing, lyrical language.”  I, too, loved the spirit of his book, yet when (in 2001) he remarked “At Einstein, I slowed to the pathologist’s pace”, I infer that he could only be referring to that other, more gracious planet we inhabited in the 1960s. My work stands in sharp contrast to his romanticized idyll.

When I was a waiter, I learned that people ordering food do not care a whit about a restaurant’s kitchen. They don’t give a damn about whether the cook went AWOL or whether the salad ran off with the dressing. The only thing that matters is that a meal appears, as ordered, on time. The meal, the apex of the experience, is the final product and the entire basis for the existence of the restaurant, its staffing and decor. This account is about my kitchen, the meals that people like me serve, and that you, the public, must eat. My recipes, however, are written in human flesh. My final product is not wild salmon on a bed of rice surrounded by fluffy vegetables, but mere words on a piece of paper. That paper, your report, is the reason that my colleagues and I come to work.  It is for the sake of that paper that my workplace is equipped with microscopes, cameras, computers, telephones, laser printers, automated slide sorters, fancy tissue stainers, and last, yet definitely not least, human beings. The latter, with their gadgetry, collaborate to prepare a singular, customized written entrée. My restaurant, however, has a small, yet unique problem: customers cannot be offered a choice of dishes, and must receive whatever is destined for them.  This kitchen, you see, is not McDonald’s, but a hospital laboratory. Many Americans have unfortunately been led to believe that hospital laboratories work like fast food restaurants, and that the quicker the food arrives, the better the meal. A television advertisement proclaims: “No one ever dreams of going slower.” This may be generically true in our modern society, but it is asking for trouble in the world of pathology. The rush for quicker (and cheaper) answers to intrinsically difficult diagnostic problems may force even good pathologists into errors that they would otherwise not make. The relatively low error rate among pathologists is a tribute to the dedication of the people who work in hospital pathology laboratories.
  
I have tried to describe an obscure corner of the medical world, one that intrudes unexpectedly and rudely into the lives of millions of Americans. This is not the reading one might keep for bedtime perusing. It is hard to write a “story” that does not have a beginning, middle or end, without hero or plot. The characters are, by and large, bit players almost never seen, yet who carry a heavy narrative on their shoulders.  Business may be America’s watchword, but its harsh application during recent decades in the realm of Medicine has contributed towards the loss of layers that protect an academic ecosystem in which future pathologists have traditionally been prepared for serving the public.

My first effort was a simple outline of the life cycle of a biopsy sample in a teaching environment, starting when it is taken from a patient until a diagnosis is issued. However, the scope inevitably broadened to a range of matters that includes the making of pathologists and how they learn observational skills; definitions of a biopsy; how specimens migrate through a department; potentials for error; where biopsies get sent; why a result may take a long Time to emerge; frozen sections; talking to pathologists; pre-operative reviews, and second opinions. I was also drawn into the tricky subject of competence, an area that should be of interest to a public increasingly concerned with sources of medical error and what to do about them. It should be evident from what follows that pathologists work in a continuously stressful setting, withstanding extraordinary demands from patients and doctors for ever more rapid results, ducking between bolts of litigation, contending in cramped corners with pressing workloads, and always under the eyes of supervisory agencies, investigating from near and afar.

The walls of academia have crumbled to the point at which the border between what I do as an academician and the activity of my counterparts in private laboratories has become fuzzy, where it seems that what I and others like me offer is, in the minds of patients and many clinical colleagues, of no more value to them than what they can obtain from any large non-teaching corporate enterprise.  Emigration from academic health centers has spread excellent talent into private laboratories that are propelled by the prospect of draining as much profitable human material as overnight delivery systems will allow. Price and speed have, in the minds of many, become the values that stand above all others, shunting aside those who cherish thoughtfulness, reflection and Time. When systems undergo massive and rapid change, it is to be expected that instability and insecurity will prevail for a while. Since we are in the midst of such a period, and because the work to which I refer profoundly affects the treatment of humans with disease, it is legitimate to examine current conditions and to look ahead in search of potential difficulties. One such difficulty is already upon us, spelling trouble for the pride we take in rendering diagnoses as quickly as possible, and that is the appalling shortage of well qualified technologists needed to produce the slides that pathologists examine in order to make their diagnoses. Thus, I write from a position well below the radar of the average columnist, and beyond the discernment of even the average clinician.

The world of surgical pathology fits almost invisibly into the larger scope of American Medicine, and is not free from current socio-political trends. While writing from the narrow perspective of the few things that I know something about, it has still been necessary to acquire some knowledge of how my specialty came to be buffeted by winds sweeping through the rest of the health care establishment. Background reading from two texts (next paragraph) convinces me of the following: the American public and the medical community are staring at each other and need to have bilateral talks about their reciprocal responsibilities. Events of the last twenty-five years have shown that American Medicine does not stand on its own legs, and that it is dependent on financial support and goodwill from the public sphere. The end of the twentieth century witnessed dramatic, if not revolutionary changes in what passes in America for a health care delivery system. Long-simmering fault lines threaten to shift forcefully under tremendous pressure. Although it is impossible, in the midst of this re-alignment, to know what the future will be, we already know what one quarter of a century has wrought. Central to the shake-up is the perennial issue of money and its sources. The high cost of medical care has generated federal and state regulations that affect reimbursement for services and medical education, and has fed the immense growth of managed care. Bob Herbert, New York Times columnist, wrote (10/25/08): "Few Americans have noticed, but a tremendous number of hospitals, from Boston to Los Angeles, are in serious, even dire, financial trouble. A survey of 4,500 hospitals by the New York consulting firm Alvarez & Marsal found that more than half were technically insolvent or at risk of insolvency. The current economic downturn, combined with an anticipated surge in patients without health insurance, will only worsen what is already a crisis."Hospitals, physicians and medical schools will continue to respond in various ways to the crisis of funding, while patients feel bludgeoned by constraints that leave them wondering how their interests will best be served.

The two texts to which I refer are mandatory reading for anyone wishing to examine the medical panorama that gives way to the present.  They are Paul Starr’s The Social Transformation of American Medicine, and Time to Heal by Kenneth Ludmerer. Starr traces the “conversation” that began between medical practitioners and the general public in the 1800s. He shows how organized American Medicine lay relatively dormant until the early 1920s, by which time its embryonic strands had sufficiently united to set the stage for a sovereignty lasting at least half a century. He analyses how societal regard for physicians went from dismal in the 19th century to high in the 20th, because the profession (relying on scientific advances) was able to convince the laity that well trained doctors finally had something worthwhile to offer. Starr describes the onset of what might be called the internal globalization of American Medicine, which began in the latter part of the 19th century with the modernizing of communications and transport, allowing patients to travel ever greater distances to consult medical experts. That process is now in full flood, aided and abetted by newer technologies that (borrowing from New York Times columnist, Tom Friedman) have flattened the world. Ludmerer’s account of “American medical education from the turn of the century to the era of managed care” is a riveting and lucid masterpiece, taking over where Flexner left off.  Abraham Flexner was, of course, the author, in 1910, of a famous critique on medical education in the United States in Canada, leading to many recommendations that influenced the future shape of the medical profession. The reading of parts of Starr and Ludmerer helped me to understand more clearly that the present moment is but a tiny crack in a long medical timeline, preceded and supported by a tapestry of science, and held together by the guidance of exceptional teachers.

The work of surgical pathology is carried out by physicians who enjoy the intellectual challenge of their work, while shouldering specific responsibility for the clinical well being of their patients. I hope that the reader will come to realize how it has become difficult for those who take intrinsic pleasure in teaching the next generation of surgical pathologists to exercise this responsibility and to satisfy the American public. Ludmerer’s point, with regard to the training of clinicians, coincides exactly with my worry:  “…it is important to recognize the fundamental importance to the physician’s work of having sufficient time with patients…good medical care cannot be provided on the fly. Problem solving – figuring out a diagnosis… - requires time for the physician to think and reflect.”  Which brings me, briefly, to a characteristic of industrial systems, namely that they judge their performance by measurable criteria, such as the time that it takes to carry out various tasks. The manufacturing model is geared towards the completion of assignments in as short a time as possible. While time may be measurable, it is an illusion to assume that strictly measured segments of time are always related to quality. In the industrial model, time is more accurately considered a measure of efficiency, which may or may not correlate with quality. The general application in Medicine of an efficiency model, however, feeds impatience with things that take long to accomplish, and discourages the idea that it may be wise and mature to wait.  

What actually happens on a pathologist’s microscope stage and in the mind of a pathologist is necessarily beyond the understanding of most citizens. The processes, however, that surround the making of a diagnosis can to a large degree be demystified, offering non-medical members of the community an opportunity to step behind our walls, into our laboratories, to grasp the context in which an individual diagnosis is made. Notwithstanding automation and scientific progress, surgical pathology is still greatly centered on the laborious dissection of excised human tissue and the interpretation of cellular patterns under the microscope. Our methods are, in many ways, anachronistic, if not archaic, relying on some approaches developed more than a century ago. For example, the most commonly used dye to delineate human tissues was first deployed by Waldeyer in 1863. Formalin, the tissue fixative, came into use in about 1893. The machine for cutting tissue sections, i.e. the microtome, was itself introduced in the late 19th century, and must still be operated by a skilled histotechnologist (“histotech”), one turn of the wheel at a Time.  There remains, in the midst of all the robotics, CT and PET scanning, gene splicing, MRIs, pacemakers, test tube babies, EKGs, and so on, a residuum of the past, a place where no technology has yet been able to supplant the mind’s ability to decipher the human terrain. We have certainly come a long way since the Dutchman, van Leeuwenhoek, developed the microscope in the 17th century, but the ultimate interpretation of a biopsy still depends very heavily, although not exclusively, on the work of a physician trained to use a modern version of the same instrument. It may be that, within ten or fifteen years, these remarks will be largely irrelevant, because the microscope is already yielding in some instances to the century of molecular and genomic pathology.  Image digitization is well under way and is already making a practical impact on the way in which information from slides is analyzed and stored. It will take some time, however, for the trusty microscope to be displaced as a routine diagnostic tool. Until then, we will remain very much dependent on the human eye peering down a tube at a magnified image on a piece of glass.

I have chosen not to write about the autopsy. Its unwarranted decline as a measure of the quality of medical care is a concern, and about which much has already been published. The material upon which I have drawn covers my experience in the academic institutions in which I have worked, and also draws on knowledge about other institutions that one gains from conversations with colleagues and from general reading. The fundamentals of surgical pathology are more or less constant, and the problems facing a single teaching department are approximately the same as those facing all. I have written here an entirely personal statement, as a surgical pathologist engaged for more than 30 years in clinical service, research, and in the training of successive cohorts of pathologists. The picture is a true composite, portraying no individuals or institutions in particular. The opinions herein are mine, and I accept responsibility for errors of fact.  I offer a short trip through a somewhat arcane yet crucial piece of medical landscape onto which the tide of baby boomers is already stumbling.