The Death of the General (Surgical) Pathologist
Here is a piece I recently wrote for Advance for Administrators of the Laboratory on what I consider is an important, albeit, not a new issue by any means, and will become more significant in the future for the practice of pathology – the death of the general (surgical) pathologist:
An older pathology colleague recently recounted some stories about when he entered practice in 1980. He mentioned that in addition to general surgical pathology sign-out, everyone in the group also had duties related to clinical pathology, i.e., microbiology, clinical chemistry, toxicology, blood bank and/or transfusion services. This pathologist would perform infectious disease consults given his expertise in clinical microbiology, interests in the clinical management of such patients and a defined need within his hospital given only one other infectious disease consultant charged with covering two hospital systems.
As a medical student/intern/resident in the early to mid-1990s, most of the pathologists I was exposed to in a university/medical center setting were pathologists who were-first and primarily-general pathologists, general surgical pathologists and clinical pathologists. Again, everyone did everything in terms of surgical pathology subspecialties, with a few notable exceptions (bone marrow examinations and liver biopsies, depending on the nature of the case and the particular pathologist assigned the case). In addition, the staff pathologists I worked with also covered some area of the clinical laboratory and were responsible for any issues referred from house staff during evening and weekend call.
‘Everyone Did Everything’
While everyone did everything, everyone also had their thing. Many had official boards, were grandfathered and/or had recognized interests and expertise in a particular area of surgical pathology. We had hematopathology, dermatopathology, neuropathology, gastrointestinal, hepatic, cytology and pediatric subspecialists. Still, everyone did everything and referred cases of concern to the sign-out pathologist to the appropriate subspecialty consultant.
Our resident program strived to teach and train competent anatomic and clinical pathologists who could sign-out nearly anything that came across their microscope, refer cases when necessary to a subspecialty consultant and have the skill sets to manage a laboratory. The attending pathologists that trained us all had a similar practice, about 90% general surgical pathology, 10% subspecialty and oversight and/or medical directorship of a part of the clinical laboratory. Sign-out sessions consisted of a wide gamut of specimen sources and part types periodically interrupted by calls related to microbiology, chemistry or toxicology and the like.
Valuable lessons were learned about laboratory management, human resources and time management. Multi-tasking and problem solving were taught and learned skills.
Narrowing Practice
Pathology has become increasingly specialized. The days of the general anatomic and clinical pathologist, outside of a group of perhaps fewer than six pathologists in small urban or rural areas, are gone.
A group of any size in a metropolitan area likely has some degree of subspecialization among its pathologists and clinical PhDs with responsibilities for the clinical labs. General surgeons, radiologists, pathologists and oncologists treating, for instance, breast cancer, have been supplanted by breast surgeons, breast imaging experts, breast pathologists and breast oncologists.
One of the side effects of this trend has become an increasing number of highly trained, subspecialized pathologists who no longer can do everything, but can do one thing. What is worse, in my opinion, is that folks in training are increasingly interested in limiting their practice before they actually start practicing. They specialize in hematopathology with no or little interest in, say, gynecologic pathology and the prospect of signing out endocervical, cervical or endometrial biopsies or surgical excisions as part of their practice is a foreign concept.
Limited Silos of Care
While there has been a trend toward “centers of excellence” and dedicated “cancer centers” or “cancer institutes,” there may not be a single department of pathology, but rather siloed departments based on organ system or disease processes. Perhaps I would be in the “gastrointestinal center of disease study” while my colleagues with interests in genitourinary pathology would work within the “urologic disease center” with their respective surgical, imaging and medicine colleagues, much as I would be with my counterparts with expertise in diseases of the gastrointestinal tract.
This could be split out even further with, for instance, medical diseases versus surgical diseases. I could limit my practice to “endoscopic luminal biopsies of the gastrointestinal tract” and not concern myself with liver biopsies, pancreatic cytology or neoplastic resections, let alone prostate, bladder or skin biopsies.
