CURRENT TOPICS specimens interferes with tim Gietnsa a n d I.eder stains, wifich are useful for the recognition of "blasts" a n d n e u t r o p h i l i c granules. "s's Since the Itistologic e x a n t i n a t i o n of tile b o n e m a r r o w adds so m u c h i n f o r m a t i o n to tile study o f smears, a n d since it can be acc o m p l i s h e d without any additional discontfort to tile patient, there is no excuse for o m i t t i n g this i m p o r t a n t step in the evaluation o f b o n e marrow. Pathologists should be stinmlated to become proficient at processing a n d i n t e r p r e t i n g histologic sections o f aspirated b o n e m a r r o w or that o b t a i n e d by biopsy. A m e a n i n g f u l i n t e r p r e t a t i o n o f b o n e m a r r o w findings based o n histologic a n d cytologic stud)' requires some familiarity with the clinical history a n d laboratory data a n d tiros constitutes a bridge between a n a t o m i c a n d clinical patlmlogy. Also, since histologic study o f b o u e m a r r o w aspirates llas b e e n neglected, it is still relatively easy to find previously n n d e s c r i b e d lesions. T h u s within the last few )'ears we have b e e n able to describe lipid g r a n u l o m a s , the eosinophilic fibrohistiocytic lesion, a n d n o d u l a r l y m p h o i d hyperplasia. 4" 7"s Because of the study o f histologic sections we were able to sllow tlmt tile color o f "sea-blue histiocytes" was caused by cytoplasmic ceroid granules. 9 Many basic problents have yet to be studied. T o n a m e j u s t two: W h a t are tile n o r m a l n u m bers o f various cell types in histologic sections? W h a t is the significance o f n o d u l a r l y m p h o i d hyperplasia (Fig. 1)? Some clinical hematologists are reluctant to s u b m i t m a r r o w for histologic e x a m i n a t i o n for economic reasons. T h e y collect the pathology fee paid by third part)" payors for their i n t e r p r e t a t i o n o f tile b o n e m a r r o w sntears. T h e y fear that third party payors nmy be unwilling to pay two separate fees, o n e to tile clinical hentatologist for r e a d i n g the smears a n d o n e to tim pathologist for p r e p a r i n g a n d i n t e r p r e t i n g the sections. ht o u r institution b o n e l n a r r o w aspirations are p e r f o r m e d by both clinical hematologists a n d pathologists. By a n d large o u r clinical colleagues use o u r teclmique a n d almost always subntit smears with the s p e c i m e n to be processed for histologic sections. "File clinicians appreciate o u r interest in b o n e n t a r r o w m o r p h ology a n d arc eager to look at histologic sections with us. T h i r d party payors scent to have recognized that in some instances two pathology fees arc justified. In s u m n t a r y tile study o f b o n e m a r r o w sections adds a n o t h e r d i i n e n s i o n to the traditional i n t e r p r e t a t i o n o f smears only. It extends tile diagnostic potential o f b o n e m a r r o w e x a m i n a t i o n s b e y o n d the field o f h e m a t o l o ~ ' . It builds a n o t h e r b r i d g e between a n a t o m i c a n d clinical patltology a n d b r i n g s the pathologist
closer to tile patient a n d to clinical medicine. The interpretation of bone marrow preparations constitutes in conjtnlctiot] with liver, kidney, small intestine, a n d muscle biopsies what might be called "medical lmthology, '' which makes u p a n increasing p r o p o r t i o n o f the daily "surgicals" o f the practicing pathologist. References 1. Burkhardt, R.: Farbatlas der Klinischen llismpathnlogie yon Knochenmark und Knochen. Berlin, SptingerVerlag. 1970. 2. Jamshidi, K., and Swaim,W. R.: Bone marrow biopsy with unahered architecture: a new biopsydevlce.J. Lab. Clin. Med., 77:335, 1971. 3. Rysdin, A. M., et al.: A simple technic for the preparation of bone marrow smears and sections.Am.J. Clin. Path., 53:389, 1970. 4. Ry~din,A. M., et al.: Lymphoid nodules of bone marrow: normal and abnormal. Blood, 43:389, 1974. 5. I.una, L. G.: Manual of lllstologic Staining Methods of the Armed Forces Institute of l'athology. Ed. 3. New York, McGraw-tlill Book Company, 1968, p. 119. 6. Leder, L. D.: Uber die selektixe fermentcytochemische Darstellung yon neutrophilen m)eloischen Zellen und Gewebsmastzellen im I'araffinsclmitt- Kiln. Wodlenschr., 43:533, 1964. 7. R],idln, A. M., and Ortega, R. S.: t.ipld granulomas of the bone marrow. Am. ,l. Clin. Path., 57:-157, 1972. 8. Rywlln,A. M., et al.: Eosinophilic fibrohistiocyticlesion of bone marro~': a distinctive new morphologic finding, probably related to drug hypersensitivity. Blood, 40: 464, 1972. 9. Ryxdin, A. M., et al.: Cerold histiocytosisof spleen and marrow in idiopathic thrombocytopenic Imrpura (ITP): a contribution, to the understanding 'of the sea-blue histioc.vte. Blt~)d, 35:587, 11171
IS PATHOLOGY A VIABLE DISCIPLINE? ARTHUR A. STEIN, M.D.*
Rapidly c h a n g i n g economics, new m e t h o d s o f education, a n d tile i n t r o d u c t i o n of accountal)ility have radically c h a n g e d tim role o f tim pathologist in itospital practice d u r i n g the past few )'ears. With c h a n g e s itt the cconomics o f practice we have observed a sldft in n u m p o w e r , training, a n d roles. I n New York State tile shift from p e r c e n t a g e o f gross r e i n t b u r s e m e n t or lease a r r a n g e l n e n t s to full timc salaricd employees is well established. F u r t h e r m o r e , redefinition by law has s t r i p p e d clinical pathology front tim accepted category o f practice of medicine. Tiros, the largest i n c o m e s e g m e n t o f the practice o f pathology is not a professional serwce. Nonpttysician director j o b descriptions for individual clinical laboratories have b e e n *Professor of l'athology, Albany Medic;tl College. Attending Pathologist, Albany.Medical Center ttospital, Albany, New York.
-525
H U M A N I ' A T H O L O G Y - V O L U M E 6, NUMBER 5 September 1975 written, established, and accepted. Only morphologic services, the performance o f the autopsy, cytology, bone marrow evaluation, and surgical pathology remain as professional services. Ah'eady there are groups challenging the medical professional classification of cytologic services. T h e growing numbers and roles of physician assistants and associates and the training of the parapathologist to screen tissue sections guarantee further erosion of the pathologist's professional morphologic duties. Over the past decade there has been decreased interest and acceptance of clinical teaching of morphologic pathology. T h e clinician and house staff rarely attend the necropsy or other pathology teaching sessions unless they are made mandatory by tile chief of service. Even p:micipatory teaching with othcr disciplines is poorly attended. In general, the standard method of presentation has been dubl)ed by students as "aduh show and tell." This response is pmt of a general reaction to classic methods of teaching. Approxilnatel)' two-thirds o f the trainees who take the board examinations in pathology are foreign graduates. Ill the morphologic area, where prose is mandatory, there are difticulties ill generating reports. In the areas of patient or physician contact there are problems o f individual acceptance. In other situations too there may be language or custom barriers. Many times basic research generates laborator)" oriented technology that can be applied to the clinical situation, hnmunoIhtorescence and electronmicroscopy are two such situations. Are there lnore? Certainly emission spectroscopy of cells, tissue culture techniques, analytical q.uantimtive cell sl)eCtl'OSCOp)', pattern recognition programs, and computer data utilization are all around tls. For this immediate future the rectlrring question will again be, "Will the acccptable efforts of clinical medical practice be recognized by our associates and third party payers?" I'robably not! As we move down the structural scale in morphologic obserwttions, we find that wc share tools with many other disciplines. Elcctrolmlicroscopy, microspectroscopy, and microdensitonletry, tot example, are not the exclusive donmin o f the pathologist. In addition, there ;ire many internal divisive moves. Tile pathology service itself is divided I)y subspeciahies, such as neuropathology, ophthahnic pathology, renal pathology, and derlnatopathology. Introduction of new technical apl)lications tends to further support subspccialization, such as tile role o f fluorescent antibody techniques for the nephrologist or the dernmtopathologist. Fractionation ill pathology is also occurring on the basis of discipline procedure rather than organ (e.g., immunopath-
526
ologist, nuclear medicine, molecular pathologist, electronmicroscopist). Still other external divisive forces are in motion. T h e r e is tile revival b)" key strong departments to develop integrated nmltidis, ciplinary nficrosystems. Thus, tile specialist, for example, a surgeon, becomes expert in other basic disciplines, e.g., pathologT, anti thus departments of surger)', gynecology, and ophth;dmology have clinicians competent in a limited area o f pathology service. In retreat, the pathologist has assumed lnanagement duties, inch,ding supervision of l)ersonncl, logistics, finance, marketi,lg, and long range planning, t Iowever, lie is really unprepared to provide professional management to such a large dollar business. T h e n he also becomes an administrator involved with various committees, such as infection control, and medical education coordination. Wc can fight to preserve the status quo or We c;ln particil)ate with an opportunity to create a viable role for the pathologist. I doubt that we can turn the clock back. Therefore, expenditures of dollars and effort to recaptt, re "the way it was" are fruitless. After clearly establishing rcalistic goals that are economically SOtlnd, let tis review otlr resotllCes and establish priorities and a strategic plan of action with both short and long term goals. It shoul(l also I)e un(lerstood that in the philosopl W o f assessment of cost a laboratory fnnction has a two-fold ptirpose. First one nltlSt generate data and second one must evaluate tile data in relation to the specific patient. Tim generation of lllOSt data is not accepted as the practice of medicine. Therefore nonphysician microbiologists, clinical chemists, cytotechnol()gists, and inmnulohematologists can and will direct major laboratories legally and professionally. I believe that we nmst understand that with the growth of third party I)ayntcnts and imminent national health insurance, we will bc paid for tile delivery of a direct patient medical service or the exl)ression of a valued medical jtltlgment based on our training and experience.
I'ROFESSIONAL C L I N I C A L P A T H O L O G Y SERVICES Since data generation is not a professional service by law, why should we be training physicians for this fnnction? T h e fnture must be considered in relation to the professional output of clinical pathology. How? Consider, for example, the practicing physician ill infectious disease, in nuclear medicine, ill metabolic diseases, and in clinical pharmacology.
CURRENT TOPICS I'I;',OFESSIONA L M O R I ' H O L O G I C SERVICES
Cytology Eighty-five to 90 per cent of cytologic specimens are read and reported b)" cytoteclmologists without review by tile pathologist. T h e experience in quality control in New York Ims indicated that many pathologists need retraining in the evaluation of these residual smears. T h e National Cancer Institute and industry are actively supporting studies ill tile mechanization o f processing and diagnosing these cytologic sllecimens by a battery of teclmiques.
Chromosomal Analysis Some morphologically oriented patllologists have grown interested ill the area of chromosmnal analysis and cell genetics. Again this type of clinical service does not require a physician's background 6nless he is prepared to become a practicing geneticist. There are ah'ead)' immediately available COlnputerized systems to generate the necessary data from chronmsonml preparations.
Necropsy Pathology As tile percentage o f deaths that should undergo necropsy is changed by hospital approving groups, there will be redt,ction in the lmmber o f necropsies llerformed. As the ntllnber o f physician associates ill patllolog)" increases, much of the physic|airs physical effort in the performance of the necrops)' will be reduced. Ill the past tile pathologist performed tile necropsy without a direct charge. Now the fee should be seriousl)" cost analyzed. Work|nell'S COmllensation recognizes the value of tile necropsy and has established a reasonable fee. T h e third party carrier must recognize this service as a real quality control cost in the deliver)' of Ilealth care. Ill a similar way private insurance COmllanies have a vested interest ill the results of a necropsy. In forensic services too tile necropsy is |Ill integral p:nt, but their performance requires quality control. Again there is a real need for econolnic review and regional planning for the unifornl availability o1 these services to low density polmlations.
Currently, at tile light microscopic level, there is a need for comllarative pathology ill environmental inedicine, l lowever, 1 feel that tiffs area o f safety evalnation will be a team effort including the veterinary pathologist, the fish pathologist, the plant pathologist, and the clinical pathologist.
Surgical Pathology In surgical pathology we have the only area of agreement on professional pathology services that third party payers, administrators, and even our colleagues recognize, t lowever, these services lnUSt be re-evaluated from a cost basis, including the n u m b e r of special stains and related services like immunofhxorcscence a n d trallsnlissioll a n d Scilnllillg electromnicroscopy in order to attempt to establish precise diagnoses as guides to therapy or prognosis. To this cost we must add mandatory record keeping of reports, filing and storage o f slides, maintenance of a t n m o r registry, and participation in tumor, x-ray, and other conferences related to decision making for the direct benefit o f the patient. T h e frozen section requires a surgical pathology consuhation. T h e review of outside slides is also a consultation procedure. All such services that participate ill tile therapeutic decision process for a defined patient are professional services. I believe that surgical pathologists slmuld have tile training and clinical opportunity to practice oncology. Who knows nlore about the neoplasnls, structurally and biologically? Who is more knowledgeable about the natural history of disease? Who is better prepared to stud)" the plmrnmcod)'nanlics? The surgical pathologist can only command a reasonable salary when the vohnne o f services is significant. Otherwise he must consider supplementing his incolne by clinical practice as an oncologist, geneticist, or other clinical application Ol- as a paid teacher, researcher, or administrator. In sumnmry, unless we are prepared to identify the new role o f the practicing pathologist, I call see nothing but the progressive and rapid abandonnlent o f the discipline. We must immediately resolve the issues of his professional status and Ilis e c o n o m i c opportunities, redefine his training, and identify acceptable related clinical practice outlets.
:527
closer to tile patient a n d to clinical medicine. The interpretation of bone marrow preparations constitutes in conjtnlctiot] with liver, kidney, small intestine, a n d muscle biopsies what might be called "medical lmthology, '' which makes u p a n increasing p r o p o r t i o n o f the daily "surgicals" o f the practicing pathologist. References 1. Burkhardt, R.: Farbatlas der Klinischen llismpathnlogie yon Knochenmark und Knochen. Berlin, SptingerVerlag. 1970. 2. Jamshidi, K., and Swaim,W. R.: Bone marrow biopsy with unahered architecture: a new biopsydevlce.J. Lab. Clin. Med., 77:335, 1971. 3. Rysdin, A. M., et al.: A simple technic for the preparation of bone marrow smears and sections.Am.J. Clin. Path., 53:389, 1970. 4. Ry~din,A. M., et al.: Lymphoid nodules of bone marrow: normal and abnormal. Blood, 43:389, 1974. 5. I.una, L. G.: Manual of lllstologic Staining Methods of the Armed Forces Institute of l'athology. Ed. 3. New York, McGraw-tlill Book Company, 1968, p. 119. 6. Leder, L. D.: Uber die selektixe fermentcytochemische Darstellung yon neutrophilen m)eloischen Zellen und Gewebsmastzellen im I'araffinsclmitt- Kiln. Wodlenschr., 43:533, 1964. 7. R],idln, A. M., and Ortega, R. S.: t.ipld granulomas of the bone marrow. Am. ,l. Clin. Path., 57:-157, 1972. 8. Rywlln,A. M., et al.: Eosinophilic fibrohistiocyticlesion of bone marro~': a distinctive new morphologic finding, probably related to drug hypersensitivity. Blood, 40: 464, 1972. 9. Ryxdin, A. M., et al.: Cerold histiocytosisof spleen and marrow in idiopathic thrombocytopenic Imrpura (ITP): a contribution, to the understanding 'of the sea-blue histioc.vte. Blt~)d, 35:587, 11171
IS PATHOLOGY A VIABLE DISCIPLINE? ARTHUR A. STEIN, M.D.*
Rapidly c h a n g i n g economics, new m e t h o d s o f education, a n d tile i n t r o d u c t i o n of accountal)ility have radically c h a n g e d tim role o f tim pathologist in itospital practice d u r i n g the past few )'ears. With c h a n g e s itt the cconomics o f practice we have observed a sldft in n u m p o w e r , training, a n d roles. I n New York State tile shift from p e r c e n t a g e o f gross r e i n t b u r s e m e n t or lease a r r a n g e l n e n t s to full timc salaricd employees is well established. F u r t h e r m o r e , redefinition by law has s t r i p p e d clinical pathology front tim accepted category o f practice of medicine. Tiros, the largest i n c o m e s e g m e n t o f the practice o f pathology is not a professional serwce. Nonpttysician director j o b descriptions for individual clinical laboratories have b e e n *Professor of l'athology, Albany Medic;tl College. Attending Pathologist, Albany.Medical Center ttospital, Albany, New York.
-525
H U M A N I ' A T H O L O G Y - V O L U M E 6, NUMBER 5 September 1975 written, established, and accepted. Only morphologic services, the performance o f the autopsy, cytology, bone marrow evaluation, and surgical pathology remain as professional services. Ah'eady there are groups challenging the medical professional classification of cytologic services. T h e growing numbers and roles of physician assistants and associates and the training of the parapathologist to screen tissue sections guarantee further erosion of the pathologist's professional morphologic duties. Over the past decade there has been decreased interest and acceptance of clinical teaching of morphologic pathology. T h e clinician and house staff rarely attend the necropsy or other pathology teaching sessions unless they are made mandatory by tile chief of service. Even p:micipatory teaching with othcr disciplines is poorly attended. In general, the standard method of presentation has been dubl)ed by students as "aduh show and tell." This response is pmt of a general reaction to classic methods of teaching. Approxilnatel)' two-thirds o f the trainees who take the board examinations in pathology are foreign graduates. Ill the morphologic area, where prose is mandatory, there are difticulties ill generating reports. In the areas of patient or physician contact there are problems o f individual acceptance. In other situations too there may be language or custom barriers. Many times basic research generates laborator)" oriented technology that can be applied to the clinical situation, hnmunoIhtorescence and electronmicroscopy are two such situations. Are there lnore? Certainly emission spectroscopy of cells, tissue culture techniques, analytical q.uantimtive cell sl)eCtl'OSCOp)', pattern recognition programs, and computer data utilization are all around tls. For this immediate future the rectlrring question will again be, "Will the acccptable efforts of clinical medical practice be recognized by our associates and third party payers?" I'robably not! As we move down the structural scale in morphologic obserwttions, we find that wc share tools with many other disciplines. Elcctrolmlicroscopy, microspectroscopy, and microdensitonletry, tot example, are not the exclusive donmin o f the pathologist. In addition, there ;ire many internal divisive moves. Tile pathology service itself is divided I)y subspeciahies, such as neuropathology, ophthahnic pathology, renal pathology, and derlnatopathology. Introduction of new technical apl)lications tends to further support subspccialization, such as tile role o f fluorescent antibody techniques for the nephrologist or the dernmtopathologist. Fractionation ill pathology is also occurring on the basis of discipline procedure rather than organ (e.g., immunopath-
526
ologist, nuclear medicine, molecular pathologist, electronmicroscopist). Still other external divisive forces are in motion. T h e r e is tile revival b)" key strong departments to develop integrated nmltidis, ciplinary nficrosystems. Thus, tile specialist, for example, a surgeon, becomes expert in other basic disciplines, e.g., pathologT, anti thus departments of surger)', gynecology, and ophth;dmology have clinicians competent in a limited area o f pathology service. In retreat, the pathologist has assumed lnanagement duties, inch,ding supervision of l)ersonncl, logistics, finance, marketi,lg, and long range planning, t Iowever, lie is really unprepared to provide professional management to such a large dollar business. T h e n he also becomes an administrator involved with various committees, such as infection control, and medical education coordination. Wc can fight to preserve the status quo or We c;ln particil)ate with an opportunity to create a viable role for the pathologist. I doubt that we can turn the clock back. Therefore, expenditures of dollars and effort to recaptt, re "the way it was" are fruitless. After clearly establishing rcalistic goals that are economically SOtlnd, let tis review otlr resotllCes and establish priorities and a strategic plan of action with both short and long term goals. It shoul(l also I)e un(lerstood that in the philosopl W o f assessment of cost a laboratory fnnction has a two-fold ptirpose. First one nltlSt generate data and second one must evaluate tile data in relation to the specific patient. Tim generation of lllOSt data is not accepted as the practice of medicine. Therefore nonphysician microbiologists, clinical chemists, cytotechnol()gists, and inmnulohematologists can and will direct major laboratories legally and professionally. I believe that we nmst understand that with the growth of third party I)ayntcnts and imminent national health insurance, we will bc paid for tile delivery of a direct patient medical service or the exl)ression of a valued medical jtltlgment based on our training and experience.
I'ROFESSIONAL C L I N I C A L P A T H O L O G Y SERVICES Since data generation is not a professional service by law, why should we be training physicians for this fnnction? T h e fnture must be considered in relation to the professional output of clinical pathology. How? Consider, for example, the practicing physician ill infectious disease, in nuclear medicine, ill metabolic diseases, and in clinical pharmacology.
CURRENT TOPICS I'I;',OFESSIONA L M O R I ' H O L O G I C SERVICES
Cytology Eighty-five to 90 per cent of cytologic specimens are read and reported b)" cytoteclmologists without review by tile pathologist. T h e experience in quality control in New York Ims indicated that many pathologists need retraining in the evaluation of these residual smears. T h e National Cancer Institute and industry are actively supporting studies ill tile mechanization o f processing and diagnosing these cytologic sllecimens by a battery of teclmiques.
Chromosomal Analysis Some morphologically oriented patllologists have grown interested ill the area of chromosmnal analysis and cell genetics. Again this type of clinical service does not require a physician's background 6nless he is prepared to become a practicing geneticist. There are ah'ead)' immediately available COlnputerized systems to generate the necessary data from chronmsonml preparations.
Necropsy Pathology As tile percentage o f deaths that should undergo necropsy is changed by hospital approving groups, there will be redt,ction in the lmmber o f necropsies llerformed. As the ntllnber o f physician associates ill patllolog)" increases, much of the physic|airs physical effort in the performance of the necrops)' will be reduced. Ill the past tile pathologist performed tile necropsy without a direct charge. Now the fee should be seriousl)" cost analyzed. Work|nell'S COmllensation recognizes the value of tile necropsy and has established a reasonable fee. T h e third party carrier must recognize this service as a real quality control cost in the deliver)' of Ilealth care. Ill a similar way private insurance COmllanies have a vested interest ill the results of a necropsy. In forensic services too tile necropsy is |Ill integral p:nt, but their performance requires quality control. Again there is a real need for econolnic review and regional planning for the unifornl availability o1 these services to low density polmlations.
Currently, at tile light microscopic level, there is a need for comllarative pathology ill environmental inedicine, l lowever, 1 feel that tiffs area o f safety evalnation will be a team effort including the veterinary pathologist, the fish pathologist, the plant pathologist, and the clinical pathologist.
Surgical Pathology In surgical pathology we have the only area of agreement on professional pathology services that third party payers, administrators, and even our colleagues recognize, t lowever, these services lnUSt be re-evaluated from a cost basis, including the n u m b e r of special stains and related services like immunofhxorcscence a n d trallsnlissioll a n d Scilnllillg electromnicroscopy in order to attempt to establish precise diagnoses as guides to therapy or prognosis. To this cost we must add mandatory record keeping of reports, filing and storage o f slides, maintenance of a t n m o r registry, and participation in tumor, x-ray, and other conferences related to decision making for the direct benefit o f the patient. T h e frozen section requires a surgical pathology consuhation. T h e review of outside slides is also a consultation procedure. All such services that participate ill tile therapeutic decision process for a defined patient are professional services. I believe that surgical pathologists slmuld have tile training and clinical opportunity to practice oncology. Who knows nlore about the neoplasnls, structurally and biologically? Who is more knowledgeable about the natural history of disease? Who is better prepared to stud)" the plmrnmcod)'nanlics? The surgical pathologist can only command a reasonable salary when the vohnne o f services is significant. Otherwise he must consider supplementing his incolne by clinical practice as an oncologist, geneticist, or other clinical application Ol- as a paid teacher, researcher, or administrator. In sumnmry, unless we are prepared to identify the new role o f the practicing pathologist, I call see nothing but the progressive and rapid abandonnlent o f the discipline. We must immediately resolve the issues of his professional status and Ilis e c o n o m i c opportunities, redefine his training, and identify acceptable related clinical practice outlets.
:527
