Editorial DOING BETTER AND FEELING WORSE: HEALTH IN THE UNITED STATES This is tim subtitle o f a remarkable issue of Daedalus, the winter 1977 issue from tim American Academy of Arts and Sciences. No less than 20 eminent educators, physicians, sociologists, philosophers, and economists examine the current health scene and offer projections for tim future. T h e r e are those skeptics who ask whether it makes any sense even to speak of a "heahh care system" in a country where services are so divided, largely controlled by private physicians who appear almost indifferent to demands for certain kinds of attention. All of us are aware of the continuing dramatic rise in healtll cost sometithes outpacing the price of other goods in this inflationary period. Yet the reports o f new evidence o f fi'aud and naalpractice in federal programs as well as the private sector provide additional tirol for the ah-eady held opinion that only substantial reforms will correct tim situation. Incensed critics point to such conditions as the inaccessibility o f services, unnecessary surgery, excessive prescription o f drugs, and u,mxplained hospital bills, which adversely affect tim confidence o f many Americans. However, these colnplaints cmmot diminish the many tangible medical accomplishments o f recent )'ears for which there is widely expressed satisfaction. The health care industry is extremely varied and complex. Abuses, wlmre they exist, will not necessarily be cured by some sweeping legislative act. Caution must be exercised not to create false optimism about die likely benefits o f any one measure of reform. T h e r e are ninny choices. These invoh'e so ninny bodies, public and private, and reqtfire so ninny different kinds o f evaluations that only a thorougll inquiry into tim politics, economics, and soci9 ology of healtll care will reveal all the problems that exist. We must develop a sensitivity about professional, public, and patient interests tlmt rise above tim rigid cost accounting arithmetic o f those who concentrate only on price. Hospital based pathologists in particular are vulnerable to the attack o f tim "slmrp pointed pencils." For patlmlogy appears to be a speciahy o f medicine in which everything can be counted, sorted, and subjected to the mathematics o f economics. In tim State o f New Jersey, for example, so-called "healtll analysts" have developed formulas, medians, ratios, density factors, utilization indices, and other
terms well known to econometricians. When they are applied to tim. real world of laboratory nledicine, an Alice' in Wonderland picture emerges. To be cost efficient is to spend less; to spend less is to do less and to do nothing is best o f all. Tllus, mediocrity is rewarded and inetficiency condoned. O u r fellow colleagues in the other specialties shake their heads as they watch pathology come u d d e r tim ax. When will they realize tllat they are next? It then becomes the responsibility o f pathology to lead medicine as it has done in tim past. In order to do so, pathologists need facts, figures, and the support o f clinicians. This excellent issue of Daedalus will be of significant importance to all who are concerned with tim future of pathology and its role in medicine. Future editorials will explore other pertiDent issues raised in tiffs searing, provocative monograph. BERNARD M. ~rAGNER, M.D.
Correspondence T o TIlE EDITOR: Tile Delphic prognostications o f tile pathology departnlent chairmen (Human l'athology, 7:607-6(19, 1976) concerning tim fimlre o f pathology as a medical speciahy would be a source of amusement to practicing patlmlogists were there not a danger tlmt influential groups such as medical schools, hospitals, and governmeut might give them serious consideration. T o illustrate, I reviewed standard reference sources to obtain an unselected list o f department clmirmen and their credentials as judges o f tim practice o f pathology. This is no easy task, in light o f tim short ,qcademic life expectancy of tiffs group. I documented t, nequivocally the chairmen o f 68 American departments and tabulated their credentials. T h e y are listed in the following table: CREDENTIALS OF 68 AMERICAN PATIIOLOGY DEI'ARTMENT CIIAIRMEN
Members ASCP* 37 (54%) Nonmeml3ers ASCP 31 (46%)
475
H U M A N P A T H O L O G Y - - V O L U M E 8, N U M B E R - 4 July 1977 Certified in clinical pathology only 1 (1.5%) Certified in anatomic pathology only 38 (56%) Certified in both clinical and anatomic pathology 21 (3 ! %) Not certified in pathology 7 (10%) Not a physician 1 (i.5%) *For the academic audience, the American Society of Clinical Pathologists. In the light o f the relationship of these individuals as a group to the practice of pathology, as manifested by their credentials, why would a n y b o d y p a y an)" attention to what they say? Indeed, fi-om my own personal acquaintance with many of these individuals, the tabulation undoubtedly grossly overestimates their involvement in the practice o f pathology by assuming that board certification is a meaningful index o f clinical expertise. T h e present disastrous state of academic pathology is widely perceived by practicing pathologists, and has been rendered inevitable by policies promulgated by the department chairmen and the organizations they control over the last 20 years. No doubt their gloomy prophecy will prove to be self-fulfilling if their statements and actions continue to be regarded as pertinent. HERBERT BRAUNSTEIN, M.D.
San Bernardino County Medical Center San Bernardino, California
T o Tile EDITOR:
476
Recently I have been distressed by the n u m b e r o f surgical pathologists who have left academic medicine to enter private practice. Many seem discouraged by the role they are asked to play in academic patllology departments and feel isolated from departmental peers, the majority of whom are engaged in activities unrelated to anatomical pathology. Most of us know that surgical pathology is a particularly demanding speciahy, which requires an enormous time comnaitment to acquire and maintain proficiency. In this respect it differs from some other medical specialties that can be practiced effectively on a part time basis. It also requires a lligh level o f professional competence, since the decisions made are both pivotal in patient care and not easily monitored by physicians wllo do not have similar skills. Since the consumers o f tire surgical pathologist's professional product are other physicians, lie also practices to a critical audience, quick to point out professional shortcomings. Because of these rigorous speciahy demands, few surgical pathologists are able to engage in productive laboratory investigation. Some may try to do a
little in odd moments, but their efforts are usually viewed as amateurish by departmental colleagues who are full time investigators. Alternately investigators who try to do a little surgical pathology usually are unsuccessful because o f the diagnostic precision required. As a result most colleagues wllo are either snccessful laboratory investigators or surgical pathologists view the two careers as mutually exchtsive. T o d a y most surgical pathologists who practice in a university environment find themselves working for a pathology department chairman who is a laboratory investigator, not infrequently in a pathology department composed principally of laboratory investigators. T h e reasons for tiffs are varied. Some have to do with a chairman's ability to bring research funding to the department; others concern the type o f work considered most suitable for a basic science department. Because o f the demands of laboratory investigation, some pathology department chairmen find themselves with only a rudimentary knowledge o f anatomic pathology, and a few, surprisingly enough, lmve not even attended medical school. As nfight be expected, die i~riorities of tills kind of chairman will be heavily weighted toward laboratory investigation, since it is something lie can understand, believes to be important, and presumably has been successful at in the past. It is also significant that there has been a slfift in the kind of laboratory investigation conducted in pathology departments. In the past usually it was considered appropriate only if it had some basis in morphology. However, today most o f it is biochenfical in its orientation, differing little from research done in other basic science departments o f the medical school or undergraduate science d e p a r t n a e n t s - d e partments that do not llave an added responsibility for patient care activities. In this circumstance the pathology department chairmaninvestigator is apt to regard his department's patient care responsibilities as a burden that interferes with his major interests. He ma t' even regard clinical practice as mundane, something not suitably scientific. It is not surprising tllat lie may wish to relieve himself of this responsibility as simply as possible. This is usually done by lfiring surgical pathologists who are assigned this responsibility with the hope that it may be accomplished with a minimal expenditur6 o f departmental space, money, and the chairman's time. In this setting the surgical pathologist may be regarded as sometlfing of a necessary evil, one who doesn't really fit but must be included to avoid complaints fi'om the clinical facuhy. In this setting, conflict may be expected with both the departmental chairman and die surgical pathologist's peers. Major areas o f conflict seem to invoh'e monet', teaching
terms well known to econometricians. When they are applied to tim. real world of laboratory nledicine, an Alice' in Wonderland picture emerges. To be cost efficient is to spend less; to spend less is to do less and to do nothing is best o f all. Tllus, mediocrity is rewarded and inetficiency condoned. O u r fellow colleagues in the other specialties shake their heads as they watch pathology come u d d e r tim ax. When will they realize tllat they are next? It then becomes the responsibility o f pathology to lead medicine as it has done in tim past. In order to do so, pathologists need facts, figures, and the support o f clinicians. This excellent issue of Daedalus will be of significant importance to all who are concerned with tim future of pathology and its role in medicine. Future editorials will explore other pertiDent issues raised in tiffs searing, provocative monograph. BERNARD M. ~rAGNER, M.D.
Correspondence T o TIlE EDITOR: Tile Delphic prognostications o f tile pathology departnlent chairmen (Human l'athology, 7:607-6(19, 1976) concerning tim fimlre o f pathology as a medical speciahy would be a source of amusement to practicing patlmlogists were there not a danger tlmt influential groups such as medical schools, hospitals, and governmeut might give them serious consideration. T o illustrate, I reviewed standard reference sources to obtain an unselected list o f department clmirmen and their credentials as judges o f tim practice o f pathology. This is no easy task, in light o f tim short ,qcademic life expectancy of tiffs group. I documented t, nequivocally the chairmen o f 68 American departments and tabulated their credentials. T h e y are listed in the following table: CREDENTIALS OF 68 AMERICAN PATIIOLOGY DEI'ARTMENT CIIAIRMEN
Members ASCP* 37 (54%) Nonmeml3ers ASCP 31 (46%)
475
H U M A N P A T H O L O G Y - - V O L U M E 8, N U M B E R - 4 July 1977 Certified in clinical pathology only 1 (1.5%) Certified in anatomic pathology only 38 (56%) Certified in both clinical and anatomic pathology 21 (3 ! %) Not certified in pathology 7 (10%) Not a physician 1 (i.5%) *For the academic audience, the American Society of Clinical Pathologists. In the light o f the relationship of these individuals as a group to the practice of pathology, as manifested by their credentials, why would a n y b o d y p a y an)" attention to what they say? Indeed, fi-om my own personal acquaintance with many of these individuals, the tabulation undoubtedly grossly overestimates their involvement in the practice o f pathology by assuming that board certification is a meaningful index o f clinical expertise. T h e present disastrous state of academic pathology is widely perceived by practicing pathologists, and has been rendered inevitable by policies promulgated by the department chairmen and the organizations they control over the last 20 years. No doubt their gloomy prophecy will prove to be self-fulfilling if their statements and actions continue to be regarded as pertinent. HERBERT BRAUNSTEIN, M.D.
San Bernardino County Medical Center San Bernardino, California
T o Tile EDITOR:
476
Recently I have been distressed by the n u m b e r o f surgical pathologists who have left academic medicine to enter private practice. Many seem discouraged by the role they are asked to play in academic patllology departments and feel isolated from departmental peers, the majority of whom are engaged in activities unrelated to anatomical pathology. Most of us know that surgical pathology is a particularly demanding speciahy, which requires an enormous time comnaitment to acquire and maintain proficiency. In this respect it differs from some other medical specialties that can be practiced effectively on a part time basis. It also requires a lligh level o f professional competence, since the decisions made are both pivotal in patient care and not easily monitored by physicians wllo do not have similar skills. Since the consumers o f tire surgical pathologist's professional product are other physicians, lie also practices to a critical audience, quick to point out professional shortcomings. Because of these rigorous speciahy demands, few surgical pathologists are able to engage in productive laboratory investigation. Some may try to do a
little in odd moments, but their efforts are usually viewed as amateurish by departmental colleagues who are full time investigators. Alternately investigators who try to do a little surgical pathology usually are unsuccessful because o f the diagnostic precision required. As a result most colleagues wllo are either snccessful laboratory investigators or surgical pathologists view the two careers as mutually exchtsive. T o d a y most surgical pathologists who practice in a university environment find themselves working for a pathology department chairman who is a laboratory investigator, not infrequently in a pathology department composed principally of laboratory investigators. T h e reasons for tiffs are varied. Some have to do with a chairman's ability to bring research funding to the department; others concern the type o f work considered most suitable for a basic science department. Because o f the demands of laboratory investigation, some pathology department chairmen find themselves with only a rudimentary knowledge o f anatomic pathology, and a few, surprisingly enough, lmve not even attended medical school. As nfight be expected, die i~riorities of tills kind of chairman will be heavily weighted toward laboratory investigation, since it is something lie can understand, believes to be important, and presumably has been successful at in the past. It is also significant that there has been a slfift in the kind of laboratory investigation conducted in pathology departments. In the past usually it was considered appropriate only if it had some basis in morphology. However, today most o f it is biochenfical in its orientation, differing little from research done in other basic science departments o f the medical school or undergraduate science d e p a r t n a e n t s - d e partments that do not llave an added responsibility for patient care activities. In this circumstance the pathology department chairmaninvestigator is apt to regard his department's patient care responsibilities as a burden that interferes with his major interests. He ma t' even regard clinical practice as mundane, something not suitably scientific. It is not surprising tllat lie may wish to relieve himself of this responsibility as simply as possible. This is usually done by lfiring surgical pathologists who are assigned this responsibility with the hope that it may be accomplished with a minimal expenditur6 o f departmental space, money, and the chairman's time. In this setting the surgical pathologist may be regarded as sometlfing of a necessary evil, one who doesn't really fit but must be included to avoid complaints fi'om the clinical facuhy. In this setting, conflict may be expected with both the departmental chairman and die surgical pathologist's peers. Major areas o f conflict seem to invoh'e monet', teaching
