<![CDATA[Mark R. Wick, MD - Blog]]>Thu, 10 Apr 2025 13:59:42 -0400Weebly<![CDATA[Probabilities & Immunohistochemistry in Anatomic Pathology]]>Fri, 09 Oct 2015 15:52:18 GMThttp://mrwickmd.com/blog/probabilities-immunohistochemistry-in-anatomic-pathology I have admitted, many times, to being a curmudgeonly surgical pathologist in several respects.  That should come as no surprise, given the fact that I have been in practice for 32 years.  However, one of the particular facets of my professional grumpiness seems strange to some people; that is, my opposition to the current use (?overuse) of immunohistochemistry (IHC) in anatomic pathology.  Why is this difficult to explain in my case?  The reason stems from my having been “in” on the fledgling application of IHC in the late 1970s and early 1980s, and then witnessing, and participating in, the growth and evolution of that discipline thereafter, for good and bad.

                Let me be clear about the fact that I consider IHC to be one of the greatest developments in Pathology—ever.  Indeed, Dr. Albert Coons, the originator of the technique (1), is one of my personal heroes.  Nevertheless, the technology is now being used in ways that were never intended by its early proponents.  IHC was, and is, a powerful method for determining cellular lineage, and for the diagnostic separation of many biologically-dissimilar lesions that resemble one another morphologically.  Having said that, it must also be understood that definite exceptions to such generalities exist.  For example, IHC is only marginally useful in distinguishing between sarcomatoid carcinoma and sarcomatoid mesothelioma (2).  Even more importantly, with a few selected concessions, IHC is NOT a reliable tool for separating benign from malignant tumors.  Moreover, it only crudely (at best) substitutes for formal biochemical or molecular evaluation of cellular products and constituents that affect prognosis (3).  Finally, to my way of thinking, it is appalling that many pathologists presently try to substitute the indiscriminate use of IHC for morphological proficiency in the clinical sphere.  Rather than mining the histological nuances of sections stained with hematoxylin & eosin, a large and often randomly-chosen panel of immunostains is ordered almost reflexively by such people.  This is intended to have an effect like that mentioned in the Bible in Ecclesiastes 11: 1—“Cast your bread on the surface of the waters, for you will find it after many days.”  In other words, the casting of many stains on a case should return good things to the person doing the casting.  In fact, the practice of randomly procuring immunostains usually produces the opposite result—the bread gets soggy and sinks, and no answer is forthcoming.

                As scary as the field of Statistics can be to physicians, it is extremely valuable at the same time.  And, principles of Bayesian statistics have a direct bearing on the topic introduced above.  The first is the concept of “prior probability.”  As defined in Wikipedia (4), the prior probability (“prior”) of an uncertain quantity is the probability distribution that would express one's beliefs about that quantity before other evidence is taken into account. For example, the prior could be the probability distribution attached to the relative likelihoods of selected differential diagnoses.  After additional information (e.g., IHC results) is integrated into the analysis, a “posterior probability” (5) emerges.

                However, that sequence of events will only be beneficial to refining the diagnosis IF the data used to produce the posterior probability are materially useful.  If they are instead random or internally-contradictory, no conclusion can be drawn from them.  Therefore, returning to our hypothetical case setting, one could conceivably obtain 40 various immunostains and still not derive useful input from the results.   The key element here is obviously the ability to refine the differential diagnosis properly by thorough microscopic examination and clinicopathologic correlation.  One can then choose a limited panel of immunostains that is targeted to the specific questions being asked.

                What about the converse situation, in which histological assessment is itself dispositive but immunostains are procured anyway, “just to make sure?”  Indeed, that practice has now become rife in dermatopathology in the analysis of pigmented skin lesions (6), with the routine but inexplicable application of stains for such markers as melan-A, Sox 10, and HMB45 to virtually all cases regardless of their microscopic appearances.  In that setting, let us consider the following scenario—a melanocytic lesion has the classical appearance of melanoma in-situ, with no hint whatsoever of dermal involvement morphologically, but reflexive immunostains appear to show rare melanocytes in the corium.   What to do?  The posterior probability attached to the case is now less in favor of the correct diagnosis than the prior probability was.   Rather than label the tumor as invasive, the wise observer would ignore the problematic IHC information.  Indeed, he or she would not have obtained any immunostains at all in the first place.  Other examples abound—for instance, cases of histologically-prototypical infiltrating lobular breast carcinoma that are stained reflexively for E-cadherin.  In 15-20% of those lesions, immunoreactivity for that marker will be observed unexpectedly (7).  Does such a result mean that the “correct” diagnosis is actually that of ductal carcinoma?  No, it does not.

                So, we come to the denouement of this discussion—the urgent need for experiential judgment and common sense in pathologic diagnosis.  A study done by my colleagues in 2012 is germane to that statement.  Shah et al. (8) evaluated 200 selected referral cases seen at our institution, which had been subjected to IHC.  Two of the three pathologist-authors were experienced people with keen morphological skills.  In comparing final diagnoses with those of the submitting pathologists—who comprised a heterogeneous assemblage regarding their practice settings and levels of experience—the level of agreement was 98% between the 2 groups.   However, IHC was felt to be necessary by the authors in only 11% of cases, whereas the originating pathologist(s) had obtained immunostains in up to 38%.  With potential motivations for the latter finding left aside, one can rightly conclude that the practice-environment and the level of histodiagnostic confidence were major contributors to this difference.

                In future, we will increasingly face the need to economize and streamline procedures in anatomic pathology.  The CMS has already begun a steady decrease in its reimbursement for IHC, and other technologies will undoubtedly follow suit.  The best thing that we can do in response is to train ourselves well in general Medicine and in classical morphology, to optimally use the wealth of information represented in those two disciplines.  The degree of “prior probability” that we can provide to the healthcare system is enormous in that context.

 

REFERENCES

 

  1.  https://en.wikipedia.org/wiki/Albert_Coons

  2. Doyle LA: Non-mesenchymal mimics of sarcoma.  Surg Pathol Clin 2015; 8: 493-513.

  3. Wick MR, Swanson PE, Marchevsky AM: Evidence-based practices in applied immunohistochemistry: dilemmas caused by cross-purposes.  In: Evidence-Based Pathology & Laboratory Medicine (Marchevsky AM, Wick MR, Eds), Springer, New York, NY, 2011; pp. 261-296.

  4. https://en.wikipedia.org/wiki/Prior_probability

  5. https://en.wikipedia.org/wiki/Posterior_probability

  6. Naert KA, Trotter MJ: Utilization and utility of immunohistochemistry in dermatopathology.  Am J Dermatopathol 2013; 35: 74-77.

  7. Chan JK, Ip YT, Cheuk W: The utility of immunohistochemistry for providing genetic information on tumors.  Int J Surg Pathol 2013; 21: 455-475.

  8. Shah AA, Frierson HF Jr, Cathro HP: Analysis of immunohistochemical stain usage in different pathology practice settings.  Am J Clin Pathol 2012; 138: 831-836.

]]><![CDATA[Where does the "silo" of Pathology fit into the current mise-en-scene of medical care?]]>Thu, 09 Jul 2015 17:41:07 GMThttp://mrwickmd.com/blog/where-does-the-silo-of-pathology-fit-into-the-current-mise-en-scene-of-medical-care
]]><![CDATA[Academic Medicine, Academic Pathology, & Professional Succession Planning]]>Wed, 28 May 2014 16:50:54 GMThttp://mrwickmd.com/blog/academic-medicine-academic-pathology-professional-succession-planning If one asks physicians of various ages the same question—“what defines ‘academic medicine’?”—a spectrum of answers would be expected.  Baby-boomers (born between 1946 & 1964) probably would frame their answers around the traditional “triple-threat” paradigm that was in place when most of them trained as house-officers.  That is, concomitant excellence in clinical practice, teaching, and research—with a substantial number of peer-reviewed publications—was the model in existence during their residencies and fellowships (1).  At the pinnacle of academic medicine in the 1960s and early 1970s, extramural grant funds were still plenteous, and medical school faculties could afford to support many “teaching” staff members at all academic ranks, even though some of them did not actually teach (2).  Faculties at that time comprised a mixture of “pre-boomers” with conservative values that were developed during the Depression-era and World War II or the Korean War, together with young boomers who had been influenced by the enthusiasm and vigor of the John F. Kennedy presidency.  President Kennedy’s famous inaugural address, in which he said “ask not what your country can do for you, but what you can do for your country (3),” was an important message for boomers.  They also had benefited from the increased public educational emphasis on Science in the post-Sputnik 1950s (4), and those factors conflated to create an enthusiasm—if not almost a religious fervor—for scientific and medical achievement.

That scenario began to change 20 years ago, with the proposals on health care reform that were advanced by President William J. Clinton and his wife, Hillary (5).  They essentially advocated a “leaner and meaner” healthcare system, including the academic portion of it, and serious concerns arose over the continuing governmental funding of medical research.  Hence, for MDs born between 1965 & 1979, representing “Generation-X” (GX), their training environment took on more uncertainty and an ever-greater emphasis on fiscal tightening.   When other social factors of that group are considered, such as the increased number of single divorced parents who raised them, the after-effects of the Vietnam War, and the scandal of Watergate, it can well be understood that GXers developed a more jaundiced view of the world and their place in it (6).  Those who entered Medicine did so with different goals and expectations that those of boomers, and they were much less likely to march pro forma to the same professional tunes.  Loyalty to superiors, employers, and institutions was a definite casualty of that change, and the meaning of academic tenure was seriously questioned as GXers repetitively moved to greener vocational pastures.  Because academic medicine in general was struggling to remain financially-solvent, a definite exodus into the private sector by university-based physicians in GX was observed in the late 1990s, which continues to this day.  For many of those people, the attitudes of boomers are regarded as outmoded and obstructionist, partly because the common reluctance of boomers to retire appears to stifle possibilities for advancement on the part of GXers.  Moreover, the concept of “professional duty” often differs considerably between members of those two groups.  Another consideration is that GXers went to college and medical school at a time when tuitions were rising explosively, producing large loan-balances that had to be paid after finally entering practice (7).

 Enter the latest generation that is now seen among medical students, house officers, and young staff physicians—the “millennials,” or “Generation-Y” (GY) (8).  They are a complex and interesting group, who, in some ways, seem to be an illustration of the Strauss-Howe generational theory (9).  That model holds that generational attributes are cyclic through time, and that after the “skip” of a generation or two, people will again adopt many of the values of their predecessors.  Accordingly, GYers appear to again value the concept of devotion to vocation, and they are better attuned than GXers to institutional loyalty and professional achievement for its own sake.  Nonetheless, there are some important differences as well.  Millenials tend to stress “life-balance,” and may well opt for more leisure time instead of more salary, as would GXers.  Perhaps because of their marked technocentricity—with expertise in all things digital and electronic—GYers have little patience or use for memorization and traditional modes of problem-solving.  They like to attack problems in groups rather than individually, using all the benefits and immediacy that the internet and personal data-assistants have to offer.   Perhaps because of the concreteness to this approach, millennials also prefer that their professional goals, tasks, and responsibilities be defined expressly.  It is not unusual to hear “what do I need to learn?” or “precisely what are my duties?”, or “what, exactly, are my work-hours?” in that context.  For boomers and even for many GXers, this attitude can be mistaken as that of intellectual and occupational slackers.  Instead, it is merely an expression of the dependence on social media-like interactions, and the hyper-focus in problem-solving, that are unique to GY (10).

How does all of this relate to academic medicine, and, more specifically, to academic pathology?  Along with all other medical specialties in university-based medical centers, academic pathologists are seeing that their roles in Medicine are less and less different than those of private-sector practitioners (11).  And yet, junior faculty members are still expected to be “triple threats.”  It is tremendously more difficult to perform translational research now, as compared with 30 years ago, because of the draconian elements of the HIPAA regulations and tight constraints on non-grant-funded work.  Service loads have also increased in academics, to the point where they exceed those of individual community pathologists at some centers (12).  That factor compromises educational activities, because people simply do not have the time to teach.  Salaries in academic pathology have indeed improved over time, but they are still less than those of private practice, when adjusted for “time in rank.”  For GYers, who regard their personal time as precious and have large loans to pay off, this constellation of descriptors has become virtually untenable.  Many junior faculty members in academic departments are willing to spend 3 to 5 years at universities, but then they commonly trade-up to better situations in the community after academic work experience.

At a national level, this situation has a definite impact on continuing medical education in pathology.  The damping-down of formal publications in our specialty has made it increasingly difficult to identify those with rising talent in academics, who can be called upon to speak at professional meetings, serve on society committees, and review papers that are submitted to professional journals.  Hence, the same aging persons—many of whom are now over 55 years old—are still asked again and again to do those tasks (13).

This essay should not imply that the only excellent practitioners reside in academic centers, because the community has very many of them in its ranks as well.  However, the same problems attach to them, with regard to the roles I have just mentioned.  How can they be found and vetted?  There is no easy answer to that question, aside from word-of-mouth recommendations.

Pathology as a whole needs to develop a systematic program of professional succession planning, and we need to do it now.  This task should be embraced by our specialty societies and actualized, not merely discussed.  Our responsibility as individuals is to make certain that happens.

References
  1. Benz EJ Jr: Doing our part to ensure the future of academic medicine.  Trans Am Clin Climat Assoc 2013; 124: 1-13.
  2. Wright NA: The waxing and waning of academic pathology: a personal view.  In: Understanding Disease: a Centenary Celebration of the Pathological Society (Hall PA, Wright NA, Eds), Wiley, London, UK, 2006; pp. 109-120.
    3.    http://www.jfklibrary.org/Asset-Viewer/BqXIEM9F4024ntFl7SVAjA.aspx (Accessed 5-25-14)

       4.  Powell A: How Sputnik changed U.S. education.  Harvard Gazette , Oct. 11, 2007.

       5.  Anonymous:  http://en.wikipedia.org/wiki/Presidency_of_Bill_Clinton (Accessed 5-27-14)

       6.  Anonymous:  http://en.wikipedia.org/wiki/Generation_x (Accessed 5-28-14)

       7.  http://online.wsj.com/news/articles/SB10001424052748703389004575033063806327030 (Accessed 5-25-14)

       8.  http://en.wikipedia.org/wiki/Millennials (Accessed 5-25-14)

       9.  Howe N, Strauss W: Generations: the History of America’s Future, 1584-2069, Quill Publishing, Kent, UK, 1991.

     10.  Hoover E: The millennial muddle.  Chron Higher Educ, Oct. 11, 2009.

     11.  Trotter MJ, Larsen ET, Tait N, Wright JR Jr: Time study of clinical and non-clinical workload in pathology & laboratory medicine.  Am J Clin Pathol 2009; 131: 757-767.

     12.  Hynes WM, MacMillan DH: Establishing a compensation model in an academic pathology department.  Am J Clin Pathol 2005; 125 (Suppl): S8-S15.

     13. Raphael S, Lingard L: Choosing pathology: a qualitative analysis of the changing factors affecting medical career choice  J Intl Assoc Med Sci Educ (E-publication, Accessed 5-27-14) (http://www.iamse.org/artman/publish/printer_288.shtml)

]]><![CDATA[Medicolegal Issues in Pathology]]>Tue, 01 Apr 2014 21:26:14 GMThttp://mrwickmd.com/blog/medicolegal-issues-in-pathology
]]><![CDATA[Attack by Centers for Medicare Services (CMS) on Diagnostic Immunohistology-- It Is Here Now]]>Mon, 09 Dec 2013 19:49:47 GMThttp://mrwickmd.com/blog/attack-by-centers-for-medicare-services-cms-on-diagnostic-immunohistology-it-is-here-now
Picture
           The CMS fee schedule for medical laboratories for 2014 has now been issued (1).  Despite opposition by the College of American Pathologists and even the American Medical Association, the government has continued to devalue the contributions of laboratory-based physicians to the clinical care of patients.  In particular, overall reimbursement for immunohistochemical procedures has been completely revamped, and two new CPT codes in that area—G0461 & G0462—have been added.  The latter designations make a distinction between payments for the first immunostain ordered on a particular tissue block (G0461) and any additional stains (billed as G0462) on the same block.  Predictably, G0462 payments will be substantially lessened as compared with past reimbursements (2).

                The reasons for this change are multifactorial.  First, administrators at CMS continue to have little or no knowledge of what anatomic pathologists really do, or how the information they generate is used in clinical care.  Second, laboratory tests are easy targets for funding cuts, because they are much more black-and-white than charges for most other clinical procedures.  Third, generational changes in anatomic pathology practice have caused a growth in diagnostic tentativeness, and a reflexive dependency on non-morphological analyses (3).  Fourth, Medicare & Medicaid are badly-flawed systems, and they do not work any longer (4).  In fact, I would be surprised if either of those programs survives for another decade.  Finally, a few unscrupulous practitioners in the ranks of pathologists have helped to bring the current reimbursement scourge upon us, by abusing the application of immunostains on a broad scale (5).  Indeed, in my consultation practice, it is a rare case indeed that does not arrive with several immunohistochemical preparations already having been done, no matter what the diagnostic question might be.

                An initial response to the CMS decisions might be to expand the use of other tests in anatomic pathology that are affected less by the monetary cuts.  For example, one could decide to increase the application of tissue stains in the 88312 and 88313 categories as an overarching reaction, in order to recoup lost income.  Nevertheless, that approach would be just as unethical as the indiscriminate overuse of immunostains, and it would not work.  CMS would certainly identify the emergence of such a practice pattern and penalize pathologists for it.

                For now, I suggest the implementation of several steps in response to the above-cited situation:

1.       Efforts should be expended to inform our clinical colleagues (surgeons, internists, pediatricians, gynecologists, etc.), health system administrators, and patients that we will no longer have the wherewithal to perform the breadth and depth of tests to which they have become accustomed in anatomic pathology.  This will doubtlessly cause a cataclysmic backlash from them, but we all must adapt to the “brave ‘new’ world” of medical practice together.

2.       Anatomic pathologists need to pursue a “back from the future” approach  to practice, with renewed emphasis on detailed morphological evaluations and the liberal use of collegial consultations between the members of practice groups.   We should not forget that, if they are documented, the latter steps do meet the medicolegal onus for “due diligence,” and there is no codified mandate to send difficult cases to extramural consultants instead (6).

3.       Laboratory physicians of today must be more attuned to historical methods of practice in anatomic pathology.  Just because a procedure is dated, that does not mean that it is useless.  Avenues of diagnostic evaluation such as traditional histochemistry and electron microscopy should be resurrected, reevaluated, and refined to meet current needs (7).

4.       A stronger emphasis must be placed in the future on evidence-based practice, formal evaluations of the efficacy of diagnostic criteria (8), and assessment of the cost-effectiveness of adjunctive testing in anatomic pathology.  We must not continue to do things that do not really work. 

REFERENCES

1.        Anonymous: Details for regulation #CMS1600-P. (http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysiciansFeeSched/PS-Federal-Regulation-Notices-Items/CMS-1600-P.html) (Accessed 12-9-2013).

2.       Ziman B: More bad news for laboratories in CMS proposed 2014 clinical laboratory fee schedule. (E-publication, 7-10-2013) (www.pathologyblawg.com/pathology-news/more-bad-news-laboratories-cms-proposed-2014-clinical-laboratory-fee-schedule/) (Accessed 12-9-2013).

3.       Michel RL: Generational differences now reshaping physician attitudes and will likely affect private pathology group practices. (E-publication, 7-24-2013) (www.darkdaily.com/generational-differences-now-reshaping-physician-attitudes-and-will-likely-affect-private-pathology-group-practices-723#ax222n0Omfeju) (Accessed 12-9-2013).

4.       Young T: Social Security, Medicare, Medicaid, & Welfare. (www.toddyoung.house.gov/issues/social-security-medicare-medicaid-and-welfare1/) (Accessed 12-9-2013).

5.       Wheeler TM: Immunohistochemistry: when do we have too much of a good thing?  (Medscape E-publication, 5-6-2010) (www.boards.medscape.com/forums/?128@@.29fdbd13!comment = 1)  (Accessed 12-9-2013).

6.       Wick MR: Medicolegal liability in surgical pathology: a consideration of underlying causes and selected pertinent concepts.  Semin Diagn Pathol 2007; 24: 89-97.

7.       Herrera GA, Turbat-Herrera EA: Current role of electron microscopy in the diagnosis of pigmented tumors.  Semin Diagn Pathol 2003; 20: 60-71.

8.       Foucar E: Classification of error in anatomic pathology: a proposal for an evidence-based standard.  Semin Diagn Pathol 2005; 22: 139-146.

]]><![CDATA[Very nice essay on the earnings of physicians in the U.S.]]>Thu, 05 Dec 2013 21:51:11 GMThttp://mrwickmd.com/blog/very-nice-essay-on-the-earnings-of-physicians-in-the-ushttp://benbrownmd.wordpress.com/]]><![CDATA[Quality Staining with Hematoxylin & Eosin]]>Thu, 10 Oct 2013 17:47:21 GMThttp://mrwickmd.com/blog/quality-staining-with-hematoxylin-eosin It is right and proper that each time a new technology enters clinical practice, the procedure must be validated adequately by comparison with existing methods, using appropriately- and stringently- characterized biological substrates.  Indeed, several international Pathology societies have devoted much time and effort over the years to outlining and testing processes for that purpose.  Guidelines and proficiency programs now exist—provided by the College of American Pathologists (CAP) and other regulatory bodies—for the quality-assurance of immunohistochemistry, in-situ nucleic acid hybridization, polymerase chain reaction-based assays, and other techniques used in the clinical laboratory (1).

In light of that reality, it has become increasingly apparent over time that the most basic of all tools in anatomic pathology—histochemical staining of tissue samples with hematoxylin & eosin (H&E)—is only passingly considered in the same context.   CAP inspectors are indeed required to make a subjective evaluation of each laboratory’s H&E preparations (1), but, sadly, no objective standards really exist for judging their adequacy.  All too often, a minimalistic approach is applied; in other words, if the sections can be interpreted at all microscopically, they are felt to be acceptable.

I believe that this is an important contributing factor to the playing-down of morphological skill, in the current practice of anatomical pathology.  If H&E sections are suboptimal, one feels uncomfortable in basing a definite diagnostic conclusion on them.  The result is either hyper-equivocation in reporting, or an immediate turning to non-or quasi- morphological methods as alternatives to microscopy (2).  Needless to say, the second of those actions delays case-disposition, and it increases the cost of anatomic pathology services in the healthcare system at-large.

How can this situation be changed?  There is certainly no easy remedy for the problems cited above, but, at the very least, anatomic pathologists must exercise the directorial roles that they have in the histology laboratory.  Even technologists without formal HT certification can be taught to perform good H&E stains, using the many help-sites on the internet and the variety of printed materials on that topic (3-7).  Laboratory physician-directors must then review the daily output of slides with careful attention to quality, stressing the particulars of good microtomy, tissue-mounting, and the proper differentiation of stains.  Even though health systems have become more and more insular with time, the trading of representative H&E-stained slides between different laboratories is another positive step down the road to improved quality.  Pathologists on the receiving end of such exchanges can then critique the senders’ work-products, making constructive criticisms whenever they can.  Formal documentation of that activity is recommended as well.

With improved H&E “substrates” to work with, it will no doubt be surprising to some practitioners that they will develop progressively-increasing levels of skill and confidence in morphological interpretation.  Changes in national healthcare are on our doorsteps, with increasing emphasis on cost-effectiveness.  Well-trained pathologists with good skills in microscopy can provide a huge diagnostic bargain to the system (8).  However, that will only occur if greater consistency is attained in the universal production of good H&E sections.

REFERENCES

  1.  http://www.cap.org/apps/cap.portal?_nfpb=true&_pageLabel=eLABLAP_page
  2. Shah AA, Frierson HF Jr, Cathro HP: Analysis of immunohistochemical stain
usage in different pathology practice settings. Am J Clin Pathol 2012; 138: 831-836.
   3.   http://www.feinberg.northwestern.edu/research/docs/cores/mhpl/HandE_troubleshooting.pdf
   4.   http://ukhealthcare.uky.edu/uploadedFiles/services-treatments/markey/Researchers/Shared_Research_Facilities/BCP/BSTP%20SRF%20H.2%20Hematoxylin%20and%20Eosin%20Staining.pdf
   5.   http://www.nsh.org/sites/default/files/Guidelines_For_Hematoxylin_and_Eosin_Staining.pdf
   6.   http://www.leicabiosystems.com/pathologyleaders/an-introduction-to-routine-and-special-staining
   7.   Carson F, Hladik C: Histotechnology: A Self-Instructional Text (3rd Ed), ASCP Press, Chicago, 2009'
   8.   http://en.wikipedia.org/wiki/Anatomical_pathology ]]><![CDATA[A down-loadable .pdf copy of the 1910 Flexner report is available at:]]>Thu, 26 Sep 2013 22:26:11 GMThttp://mrwickmd.com/blog/a-down-loadable-pdf-copy-of-the-1910-flexner-report-is-available-athttp://www.carnegiefoundation.org/sites/default/files/elibrary/Carnegie_Flexner_Report.pdf]]><![CDATA[Medical School Education in Pathology]]>Thu, 26 Sep 2013 19:15:49 GMThttp://mrwickmd.com/blog/medical-school-education-in-pathologyNow that the new academic year has begun again in U.S. medical schools, I can't help but write something about the way education is evolving.  In considering what I have to say, please keep in mind that I am now a 61 year-old "codger," and generational differences have certainly come into play.

Over the past 20 years, a progressive movement has reformulated the curricula at most medical schools, under the direction of the Liaison Committee on Medical Education (LCME).  Instead of having first and second-year students complete systematic courses on anatomy, histology, biochemistry, physiology, pharmacology, and physical diagnosis, all of those topics (...and more) are now jumbled together in "integrated learning exercises."  It is difficult to build a house if you don't know what nails and hammers are, and I would argue that the same analogy applies here.  We now have students trying to understand pathophysiology before they know normal physiology, and trying to identify morphological abnormalities before they learn any anatomy or histology.

Educators of today are fond of bashing the conclusions drawn in Abraham Flexner's famous report on the status of U.S. medical schools in 1910 (link-- Flexner Report), decrying as "antiquated" the need for the 2-year curriculum in basic science which he recommended (link- The Flexner Report 100 years later).  Indeed, a paper published in JAMA by Emanuel & Fuchs in 2012 concluded that medical school education could be truncated by 12 months, as could residency training across-the-board, "without compromising physician competence or quality of care."

I could not disagree more with these assertions.  Being a physician used to mean that one had a breadth and depth of knowledge that few other professionals possessed.  Today, pragmatics have thrown that personification into the trash heap.  Doctors of Medicine will soon be little different--if any-- than Doctors of Nursing Practice or Doctors of Pharmacy (PharmDs), with regard to their funds of knowledge or abilities to deal with complex medical problems.  And, after all, patients don't know the difference between those various doctorates, anyway.

In pathology, the task of training residents has now become one of rapid remediation, before any real learning can occur.  First-year trainees who know little or no anatomy, histology, physiology, or biochemistry certainly are not ready to learn anatomic & clinical pathology.  Hence, we currently provide a "cram" course for them on subjects that medical school used to provide for everyone.

It remains to be seen if the diploma-mills of Flexner's day will return to the scene, at least in substance.  If and when they do, patients will need to beware, and plaintiffs' attorneys will have more business than ever.


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