Where Have all the Informaticists Gone?

On a boat on one or more likely all three of the rivers that course through Pittsburgh, circa 1997, as a medical intern I met several folks who were the recognized leaders in pathology informatics. In the years that followed, between other “APIII” meetings as they were then called – “Anatomic Pathology Informatics, Imaging and the Internet” – along with CAP and USCAP meetings, I met other established pathology informaticians and folks who one could predict were rising stars.

Many of these folks have gone on to become Directors of Pathology Informatics, Professors of Pathology and Vice-Chairs at large academic medical departments in leading medical institutions. Their reach stretches from coast to coast and from north to south. Several have gone on to work within industry, in addition to their clinical and academic pursuits.

And several fellowships have grown to train additional informaticians.

But where are they now?

It seems in the decades since then, the field has not grown significantly. The folks who were leaders 20 years ago remain so today, without passing the torch to the many classes of residents that have completed training in the intervening years.

A relatively small group of individuals are still responsible for the majority of content at national meetings, in publications and through industry collaboration, a role they have carried for the past 2 decades.

I don’t know all the specifics of how many pathology informatics fellowships there are, or of how many complete the programs. Of those, I’m uncertain how many stay in academics compared with those who perhaps go on to other pursuits including fulltime nonclinical research endeavors or go into industry.

According to data recently presented at the Association of Pathology Chairs meeting, 97% of graduating residents complete at least 1 fellowship and 50% complete at least 2 fellowships. This is an entirely different topic for another post, but if someone does, say, a hematopathology or a molecular pathology fellowship along with an informatics fellowship, their skills related to hemepath or molecular may be more desirable to a potential employer, be it a pathology group, department or laboratory. Perhaps they are recruited for their surgical pathology or dermpath skills and are also recognized as the “computer guy” or “computer girl” among their colleagues.

Perhaps a group is looking towards a new LIS, making systems more interoperable, evaluating digital pathology or considering increased automation in their clinical laboratory and they are recruited primarily for a subspecialty, such as breast pathology, with added interest and expertise in informatics.

Here comes the push and pull between clinical service needs/requirements and “projects” that are not seen as immediate revenue generators – potentially significant cost centers – with a longer ROI than a surgical pathologist with a microscope and a telephone.

In my opinion, while this no doubt may help specific groups, departments or laboratories, the overall impact to the field has been less significant in terms of changes within the field of pathology informatics.

Does pathology informatics belong to anatomic pathology (AP) or clinical pathology (CP) or both? Surely both. Perhaps more work is being done in CP (to which I am somewhat less attuned) and there are more “clinical pathology informaticians” moving the needle, making some of my observations flawed.

Or it could be that “hard core” anatomic pathologists are publishing in informatics and my opinions are way off? 20 years ago, there seemed to be a mix of AP and CP folks interested in informatics, within their respective broad subspecialties. Perhaps there are more pathology informaticians than I know of and I am way off base.

Or it could be, as I surmise, that today’s leaders in this field are the same folks that were leaders (or soon-to-be leaders) 20 years ago.

In 2005, on the day the Base Realignment and Closure (BRAC) list was released and the Armed Forces Institute of Pathology (AFIP) was slated for closure, a mentor of mine – an experienced Army pathologist for many years – made the point that the AFIP, as a model to maintain its position as a worldwide referral center, suffered from not focusing on what he called the “3 Ms”; money, molecular and mentorship. As a business, it is widely known there were several issues concerning the fiscal activities at AFIP, which properly managed, with appropriate billing, collections and audits, could have been a very profitable laboratory with a workforce cost far below its civilian competitors. The AFIP also suffered from a lack of scaling in their clinical molecular laboratories, where it had expertise but lacked vision to commercialize. But, money and molecular aside, I think the AFIP suffered most from a lack of mentorship. A generation had passed within several branches where the torch was not passed to train the experts of tomorrow. There wasn’t a mechanism within the institution to consistently recruit and retain staff, to provide significant depth of younger staff in many departments.

By the time the AFIP closing was announced, many experts and their ability to train future experts, was gone. Retirement parties and funerals were more common than Under 40 or Young Investigator Awards.

Overall, I don’t think we have a systemic mentorship problem in pathology.  A new crop of breast, genitourinary, lung, gastrointestinal and other subspecialty pathologists appear to have succession plans in place. Younger faculty are assuming leadership roles and are being recognized for contributions to their respective fields – but I do not see this happening in pathology informatics.

Perhaps it never will.  With increased competition from fellowships in other areas that are more marketable, it may be hard to “sell” the field of informatics to graduating residents. Perhaps it has taken this long to build some capacity within residency programs and fellowships, collaborate with other organizations, grow meetings and societies, and even see the genesis of the Journal of Pathology Informatics, since that boat ride in Pittsburgh began planting the seeds to grow this field.

Warren Buffett has been quoted as saying “Someone is sitting in the shade today because someone else planted a tree long ago.”.

Perhaps we just need to keep watering those seeds and trees we’ve been planting.