WHAT ARE LOOKING FOR? -...

WHAT ARE EMPLOYERS

LOOKING FOR?

Fred Silva, MDExec. Director,

USCAP

WHAT ARE THE EMPLOYERS LOOKING FOR: TO HIRE YOU

1.) Private Practice:

2.) Academe:

3.) House Staff Thoughts:

4.) Jobs:

5.) The Future

NUMBER OF PATHOLOGISTS IN THE U.S.A.:

(virtually all American Board of Pathology Certified)

_________________________________________

2002: ?13,000-14,0001999: 15,2001997: 16,213Problem: How do you define a

pathologist? (?everybody; ?service only)

Primary Certifications Primary Certifications -- AP, CP and APCPAP, CP and APCP

WHAT ARE PATHOLOGISTS DOING NOW?

Primarily Private Practice:

• Results of Dr. Richard Horowitz’s Studies

• Results of CAP “Practice Characteristics Surveys” (1994-2004)

• Results of the “Future of Pathology Survey” by the CAP (Summer 2005)

• ABP Exit Survey (Dr. B.Bennett, APB)(2005)

Primarily Academic:

• APC Chairs Survey (2005; presented by Dr. R. Green, Chair, GME Committee of the APC)

• Others (ADASP, etc)

PRIVATE PRACTICE(Dr. Horowitz/CAP):

Multiple Studies Last 10 Years

DR. HOROWITZ’S STUDY:PRACTICE CHARACTERISTICS

Median Time Worked: 48 hoursSurgical Pathology: 25 hours (52%)Cytology: 6 hours (12.5%)Management: 7.5 hours (15.6%)CP Consultation: 2.5 hours

(5.2%)Others (autopsy, teaching, research, misc.)

Time Spent in Various Pathology Services, by Reporting Year (CAP)

Mean No. of HoursType of Pathology Service Per Week %Surgical Pathology 2004 25.4 51

2002 24.6 502000 25.0 511998 23.0 471996 23.0 47

Cytopathology 2004 6.2 132002 5.7 122000 5.9 121998 6.1 121996 6.1 12

CRITERIA FOR HIRING ACOMMUNITY PATHOLOGIST

RICHARD E. HOROWITZ, MDCLINICAL PROFESSOR OF PATHOLOGYUCLA and USC SCHOOLS OF MEDICINE

ADASP MEETING, WASHINGTON, DCMARCH 22, 2003

BASIC SKILLS NEEDED IN A NEW PATHOLOGIST

ESSENTIAL------------------USEFUL---------------------NOT IMPT100----------------------------50--------------------------------0

SURGICAL PATHOLOGY DX 100

FROZEN SECTION DX 93

GROSS DISSECT / DESCRIPT 85

NON-GYN CYTOLOGY 83

AUTOPSY PATHOLOGY 70

GYN CYTOLOGY 68

FNA 61

OTHER SKILLS NEEDED IN A NEW PATHOLOGIST

ESSENTIAL-- ----------------USEFUL---------------------NOT IMPT100----------------------------50-------------------------------0

IMMUNOCYTOCHEMISTRY 81

FLOW CYTOMETRY 26

MOLECULAR PATHOLOGY 23

PCR 19

GENETICS 14

ELECTRON MICROSCOPY 4

CLINICAL RESEARCH 23

SCIENTIFIC PUBLICATIONS 16

BASIC RESEARCH 8

NP SKILLS NEEDED IN A NEW PATHOLOGIST


PERSONAL & INTERPERSONAL 98

COMMUNICATION SKILLS 98

COMPUTER / INTERNET 76

EXP IN CLINICAL MEDICINE 63

CODING / BILLING 61

LABORATORY MANAGEMENT 50

TEACHING PROFICIENCY 46

COMMITTEE EXPERIENCE 43

ORG & COMMUNITY INVOLVEMENT 39

AP SKILLS NEEDED IN A NEW PATHOLOGIST


DERMATOPATHOLOGY 53

CYTOPATHOLOGY 49

NEUROPATHOLOGY 28

PEDIATRIC PATHOLOGY 23

FORENSIC PATHOLOGY 3

EXPECTATIONS OF THE

WORKPLACE

RICHARD E. HOROWITZ, MDCLINICAL PROFESSOR OF PATHOLOGYUCLA AND USC SCHOOLS OF MEDICINE

APC MEETINGMONT-TREMBLANT, QUEBEC

JULY 28, 2005

THE SURVEYS

APC THE SUCCESSFUL COMMUNITY HOSPITALPATHOLOGIST – WHAT IT TAKES1996 52/75 69%

ADASP CRITERIA FOR HIRING A COMMUNITY PATHOLOGIST2002 40/60 66%

APC EXPECTATIONS OF THE WORKPLACE2005 41/54 76%

AP SKILLS IN PRIOR SURVEYS

ESSENTIAL: SURGICAL PATHOLOGY DxFROZEN SECTION DxGROSS DISSECTIONNON-GYN CYTOLOGY

USEFUL: AUTOPSY PATHOLOGYGYN CYTOLOGYFNA, IMMUNOCYTOCHEM

NOT IMPT: ELECTRON MICROSCOPY, RESEARCH

IN 2005: AGREE 66%DISAGREE 10%NO ANSWER 24%

ANATOMIC PATHOLOGY EXPECTATIONS

ESSENTIAL: SURGICAL PATHOLOGY DIAGNOSISFROZEN SECTION DIAGNOSISGROSS DISSECTIONNON-GYN CYTOLOGYGYN CYTOLOGY (NEW)FNA (NEW)AP QUALITY ASSURANCE (NEW)

DEFICIENCIES: INTERFACE WITH SURGEONSGROSS PATHOLOGYAUTOPSY PATHOLOGYWORKLOAD AND TAT

AP COMMENTS (39)

NEW ESSENTIAL: GYN CYTOLOGYFNA, IMMUNOCHEMISTRY

DEFICIENCIES: GROSS SURGICAL PATHOLOGYDESCRIPTION, DISSECTIONAND SAMPLING

INTERFACE WITH SURGEONSAUTOPSY PATHOLOGY

NEW NEED: AP QUALITY ASSURANCEWORKLOAD AND TAT

CONTRARIANS: DON’T NEED GROSS, HAVE PA’sDON’T DO AUTOPSIES

Dr. Horowitz’s Studies (2005)

• Most Essential: Surgical Pathology, FS, Gross, and nonGyn Cytology

• New Essentials: Gyn Cytology, FNA, Immuno• Useful Subspec: SP; Derm; Cyto; Heme; BB; GI• Deficiencies: Gross SP (descriptions; dissection;

sampling); Interface with Surgeons• New Needs: QA/TAT/Workload

CP SKILLS IN PRIOR SURVEYS

ESSENTIAL: CLINICAL KNOWLEDGE & EXPERIENCE

USEFUL: TEST INTERPRETATIONCLINICAL CONSULTATIONBENCH SKILLS IN BLOOD BANK

NOT IMPT: REST OF CLINICAL PATHOLOGY

IN 2005: AGREE 34%PARTIALLY 20%DISAGREE 41%NO ANSWER 5%

CLINICAL PATHOLOGY EXPECTATIONS

ESSENTIAL: CLINICAL KNOWLEDGETRANSFUSION MEDICINECOAGULATION (NEW)ADMINISTRATIVE OVERSIGHT (NEW)INSPECTION STRATEGIES (NEW)

DEFICIENCIES: CLINICAL KNOWLEDGE

SUB-SPECIALIZATION EXPECTATIONS

PREFERRED: SURGICAL PATH FELLOWSHIP (NEW)DERMATOPATHOLOGYCYTOPATHOLOGYTRANSFUSION MEDICINEGI PATHOLOGY (NEW)

CP COMMENTS (28)

NEW ESSENTIAL: CLINICAL CONSULTATION SKILLSTEST INTERPRETATIONTESTING STRATEGIES

ADMINISTRATIVE OVERSIGHTTRANSFUSION MEDICINECOAGULATION

DEFICIENCIES: CLINICAL KNOWLEDGE IN HEMATOLOGY ANDINFECTIOUS DISEASE

NEW NEED: INSPECTION STRATEGIES

CONTRARIAN: LET’S GET RID OF CP AND JUST PRACTICE PATHOLOGY (1)

SUB-SPECIALTIES IN PRIOR SURVEYS

ESSENTIAL: NONE

USEFUL: DERMATOPATHOLOGYCYTOPATHOLOGYHEMATOLOGYTRANSFUSION MEDICINE

NOT IMPT: PEDIATRIC PATHOLOGYFORENSIC PATHOLOGYCHEMICAL PATHOLOGYMEDICAL MICROBIOLOGY

IN 2005: AGREE 46%PARTIALLY 32%DISAGREE 20%NO ANSWER 2%

SPECIALIZATION COMMENTS (27)

NEW ESSENTIAL: SURGICAL PATHOLOGY FELLOWSHIPDERMATOPATHOLOGYCYTOPATHOLOGY

DEFICIENCIES: INABILITY TO COVERINABILITY TO COMPETE

NEW NEED: GI PATHOLOGY

CONTRARIAN: DERM PATH IS NOT IMPORTANT (1)CYTOLOGY TRAINING IS OVERDONE (1)

MOLECULAR PATHOLOGY1996: IMMUNOCHEMISTRY WAS CONSIDERED USEFUL

OTHER TECHNIQUES WERE NOT IMPORTANT

2002: IMMUNOCHEMISTRY WAS ESSENTIALFLOW CYTOMETRY WAS USEFULOTHER TECHNIQUES WERE NOT IMPORTANT

2005: COMMUNITY HOSPITALS ARE NOW DOING:IMMUNOCYTOCHEMISTRY 88%TUMOR MARKERS 59FLOW CYTOMETRY 54PCR 37FISH 37IN SITU HYBRIDIZATION 27CYTOGENETICS 22TISSUE MICROARRAYS 15

MOLECULAR PATHOLOGY EXPECTATIONS

ESSENTIAL: IMMUNOCYTOCHEMISTRYINTERPRETIVE ABILITY OF ALL (NEW)

NON-PATHOLOGY EXPECTATION

ESSENTIAL: COMMUNICATION SKILLSINTERPERSONAL SKILLSABILITY TO INTERFACE WITH

PATHOLOGY PARTNERSLABORATORY STAFFMEDICAL STAFFHOSPITAL ADMINISTRATIONTHE COMMUNITY

DEFICIENCIES: ALL OF THE ABOVE

MOLECULAR PATHOLOGY COMMENTS (20)

KNOWLEDGE OF ALL THESE TECHNIQUES IS ESSENTIAL FOR INTERPRETATION TO CLINICIANS TO DEMONSTRATE THAT WE ARE NOT IGNORANT BECAUSE INTERPRETATIONS ARE BILLABLE

PERFORMANCE OF THESE TECHNIQUES IS ESSENTIAL FOR TUMOR DIAGNOSIS AND PEDIATRIC PATHOLOGY

WE DEPEND ON YOUNG PATHOLOGISTS TO BRING THESE TECHNIQUES WITH THEM FROM THE UNIVERSITY

IN FIVE YEARS IT WILL BE SIMPLE AND CHEAP ENOUGH

CONTRARIAN: STILL IN THE FUTURE (2)

NON-PATHOLOGY SKILLS IN PRIOR SURVEYS

ESSENTIAL: INTERPERSONAL SKILLS COMMUNICATION SKILLSCOMPUTER & INTERNET

USEFUL: MANAGEMENTCODING/BILLINGTEACHING

NOT IMPT: RESEARCH

IN 2005: ALL AGREED (100%)

NON-PATHOLOGY COMMENTS (76)

COMMUNICATIONWE EXPECT COMMUNICATION SKILLS

WRITTEN ENGLISH (SPELLING AND STYLE)SPOKEN ENGLISH

BEST DIAGNOSIS OF NO VALUE IF NOT COMMUNICATEDTHE NUMBER ONE MEASURE OF SUCCESS

INTER-PERSONALWE EXPECT INTERPERSONAL SKILLS

AFFABILITY AVAILABILITY

EMOTIONAL INTELLIGENCEINTEGRITYMOTIVATION, SELF STARTERS

COMMENTS RE THE PATHOLOGY GROUPEACH MEMBER REPRESENTS THE ENTIRE GROUPCOOPERATION, NO LONE RANGER

COMMENTS RE THE MEDICAL STAFFPROACTIVELY ENGAGE CLINICIANSNEED TO UNDERSTAND CLINICIANS’ PROBLEMSNEED TO KNOW HOW TO DO CONSULTATIONSBECOME INVOLVED

COMMENTS RE HOSPITAL ADMINISTRATIONESTABLISH PERSONAL RELATIONSHIPBE AN ADVOCATE FOR THE GROUPBECOME INVOLVEDBECOME INDISPENSABLE

CONTRARIANS: MY EXPECTATIONS ARE LOW –IT IS VERY DISCOURAGING!

I AM GRATEFUL TO THE MANY COMMUNITY HOSPITAL PATHOLOGISTS WHO RESPONDED TO THE SURVEY AND ADDED SO MANY PERTINENT

COMMENTS:

STEVE TOM KAREN KEN KEVIN RANDY RICHARD

PATRICK STEPHEN ERIC RICHARD GENE ANDY JIM

BECKY GORDON BRUCE DAVID MAC MARY FRED

TOM BOB SUSAN CARL JARED PAUL MARGARET

JAY MARGARET WAYNE TOM MARK TOM DAVID

DONALD PAUL JOHN TOM SUSAN DAVID PETE

RICHARD BOB PAULA PAT JOSE DENNIS TOM

– THEY ARE THE TRUE AUTHORS OF THIS REPORT!

2005: PRIVATE HOSPITALS

• IHC: 88%• Tumor Markers: 59%• Flow Cyto: 54%• PCR: 37%• FISH: 37%• ISH: 27%• Cyto: 22%• Tissue Microarrays: 15%

CAP FUTURE OF PATHOLGOY SURVEY (2005)

• SURVEY DATA (559 EMPLOYERS (14% RESPONSE RATE) ; 247 NEWLY TRAINED (27% RESPONSE RATE)

• HOW PREPARED NEWLY TRAINED PATHOLOGISTS WERE IN GEN.PATH, AP, CP, ADMINSTRATION

• 1-5 POINT SCALE

FUTURE OF PATHOLOGY SURVEY

(CAP: 2005)• PROBLEMS: CP and

Administration/Management; Interpersonal Relationships

• HIGHEST RATED: Anatomic Pathology overall

• HIRING DECISION: Medical knowledge; Interpersonal skills, Specialized Training;

Chair/PRODS Recommendation

PATHOLOGIST PREPARATION: EMPLOYER VIEW (CAP 05)

• Results suggest there is room for improvement in preparing pathologists

• Varied ratings of overall satisfaction with newly trained applicants for positions

• About 1/3 view new hires as somewhat prepared or only slightly prepared to enter practice (35% very prepared; 32% prepared).

FUTURE OF PATHOLOGY SURVEY (CAP 05)

PATHOLOGIST PREPARATION – EMPLOYER VIEW

• Among Employers:

– 1/3 found newly trained applicants had “major deficiencies in critical areas”

– Half agree that more guidance and support are needed now for new pathologists than was required 10 years ago

FUTURE OF PATHOLOGY CAP 05 SURVEY: PATHOLOGISTS PREPARATION – EMPLOYER

VIEW• Academic Hospital/Center employers’

ratings of applicants/new hires are more favorable than other employers’ (e.g., Private practice groups, private hospital) ratings

PATHOLOGIST PREPARATION –EMPLOYER VIEW (CAP 05)

• New hires are seen as better prepared for General and Anatomic aspects of practice than for Clinical and Administration aspects.

• Within the CP area, the items rated lowest were Lab Management and Clinical Chemistry & Microbiology

• All three Administrative items (manage billing, regulatory/compliance & lab personnel) received relatively low ratings

PATHOLOGIST PREPARATION –NEW HIRE VIEW (CAP 05)

• Most new hires are “confident” (54%) or “somewhat confident” (20%) in their skills as a pathologists as a result of residency training

• Patterns of ratings suggests new hires’perceptions of preparedness in specific aspects of pathology are aligned with employer perceptions

CAP 05 PATHOLOGISTS PREPARATION – HIGHEST

RATED ITEMSEmployer Newly TrainedAppropriately seeking AP Overall (4.20)Co-worker/Sr PatholConsulatation on cases (4.36)

App. Seeking co-worker/Sr Path. Consultation (4.12)

Judiciously ordering special AP Overall (4.16) stains (4.09)Seeks outside/expert

Hemepath (4.07)Consultation (4.06)

Autopsy Path (3.99)

Independent signout (4.02

FS (3.96)

1. CAP 05: PATHOLOGISTS PREPARATION – LOWEST RATED ITEMS

Employer.

Understand/manage Billing issues (2.31)Write grant application (2.44)Understand/manage Lab personnel (2.48)CP: Lab Management (2.58)Understand/manage Clin. Labs

Regulatory/Compliance (2.63)

HIRING DECISION –EMPLOYER VIEW:

How important is each in determining whether/not an

applicant is selected• Medical Knowledge (4.7)• Interpersonal Skills (4.6)• Specialized Training (3.9)• Chair/PRODS Rec. (3.9)• Research Pub/Experience (2.5)• Involvement in Nat. Prof. Organ. (2.4)

HELP FROM RESIDENCY PROGRAMS – NEW HIRE VIEW

(CAP 05)

• Passing Path Board Exams: 70%• Finding a Job: 50%• Negotiating Contract for Position: 10%

CAP 05 FUTURE OF PATHOLOGY SURVEY: WHAT

DID WE LEARN?• Initial data on how prepared newly trained

pathologists are for practice• Found considerable consistency between

employer and employee views of new hire strengths/weaknesses

• Data suggest academic employers tend to be more satisfied than other employers with new employees

FELLOWSHIPS

Subspecialties in Pathology (05)

#Prog. #Filled #Approved #CertificatesAccred. Positions Slots issued 01-04

Cytopathology 85 99 146 108, 92, 81, 104Hematology 77 79 126 55, 65, 71, 66Blood Bank/ 48 35 76 17, 25, 23, 33

Tx Med.Dermatopath. 43 43 68 34, 55, 48, 45 Forensics 38 36 91 31, 37, 26, 26Neuropath. 35 36 78 28, 0, 18, 0Pediatric 28 17 37 30, 0, 18, 0

PathologySelective Pathology 22 63

CytopathologyCytopathology -- ACGME Accredited ProgramsACGME Accredited Programs

Hematology Hematology -- ACGME Accredited ProgramsACGME Accredited Programs

DermatopathologyDermatopathology -- ACGME Accredited ACGME Accredited ProgramsPrograms

Forensic Pathology Forensic Pathology -- ACGME Accredited ACGME Accredited ProgramsPrograms

Neuropathology Neuropathology -- ACGME Accredited ProgramsACGME Accredited Programs

SPECIALIZATION SOUGHT BY PATHOLOGY GROUPS

(New Pathologists hired by 481 Groups between 2000-2002)

62% Wanted Sub-Specialty Training

CytopathologyDermatopathologyHematopathology

Horowitz 03

ACADEMIC PATHOLOGY(C.Fletcher/ADASP;

R.Green/APC)

OVERALL PERCENTAGE OF ACADEMIC FACULTY RANKS

All Basic Clinical Path. Depts. Sci. Depts. Depts. Depts.(114549) (20133) (94416) (5675)

Professor 23.7 36.6 21.2 30.7

Associate 21.6 22.8 21.4 25.2

Assistant 39.9 30.4 42.0 34.7

Instructor 14.9 11.3 15.7 10.1

ACADEMIC PATHOLOGY2003 - 2004

1737 Professors (30.7%)1432 Associate Professors (25.2%)1933 Assistant Professors (34.7%)573 Instructors (10.1%)

5675 TOTAL of 114549 (5.0%)

(JAMA 292:1026, 2004) (Sept. 1)

ACADEMIC FACULTY (2003 – 2004)(n=114,549)

Pathology 5675 5.0%Biochemistry 2355 2.1%Anat/Cell Biology 2230 2.0%

Int. Med. 26885 23.5%Pediatrics 12782 11.2%Psychiatry 8844 7.8%Surgery 8211 7.2%Radio (Dx) 5565 4.9%Anesth. 5253 4.6%

THE AVERAGE PATHOLOGY DEPARTMENT(PDAS: 2003 Survey: Sandi Jaros: 50 Depts Responding)

Hybrid of Basic Science and Clinical Departments48 Faculty:

34 MD or MD/PhD14 PhD

Faculty Efforts:34% Clinical Service26% Research19% Teaching12% Administration

ABP Certificates Issues (last two years)

2003 2004 Total

AP/CP: 372 327 699 (77%)AP 61 73 134 (15%)CP: 25 33 58 ( 6%)

ABMS FIGURES FOR PATHOLOGY (2005)

Total = 10,688

AP/CP 6,667 (62.4%)AP 2,978 (27.9%)CP 1,043 ( 9.8%)

Cyto 1,024Forensic 539Heme 487Derm 456NP 245BB 332

APB: TOTAL NUMBER OF CERTIFICATES ISSUES (1936-2004)

(Not counting combined primary/subspecialty certificates)

AP: 8055 (29%)

CP: 3254 (12%)

AP/CP: 16902 (60%)

TOTAL: 28211

ABP: TOTAL NUMBER OF CERTIFICATES ISSUED IN

SUBSPECIALTIES (Including combined primary/subspecialty

certificates)Cytopathology (1989-2004): 2573Hematology (1955-2004): 1316Forensic Path.(1959-2004) 1198Dermatopath (1974-2004) 1006Blood Bank (1973-2004) 1001Neuropath (1948-2004) 641Pediatric Path (1990-2004) 300Radioisotopic (1974-1083) 254 DiscontinuedMMB (1950-2004) 251Immunopath (1983-1997) 175 DiscontinuedChemistry (1951-2004) 173MGP (2001-2004) 56

ABP/Pathologists By Age

30-34 38 ( 1%)35-44 1099 (29%)45-54 1255 (33%)55-64 910 (24%)65+ 483 (13%)

Thus 37% (or more) equal/over 55My study of Oklahoma (1997) was that 50% of pathologists over the age of 55 .

CHAIRS SURVEY (2005): Dr. Ralph Green (n=33)

• MOST NEW HIRES IN AP– 16 Cytopathology– 14 Surgical Pathology (14 Blood Bank/TxMed)– 12 Neuropathology (12 Hematopathology)– 10-11 Dermatopathology– 9 Pediatric Pathology– 8 Gyn (8 Clin Chem)– 5 Breast (5 Micro)– 2 Molecular Pathology

SUBSPECIALTIES NOT FILLED

• First: Cytopathology and Dermatopathology

• Next: Cardiac Pathology• Next: Surgical Pathology• Next: Pediatric Pathology

• In CP: Blood Bank far and away the most common (Heme; Micro and Clin Chem all tied for a distant second)

WHAT ACADEMIC DEPARTMENTS ARE LOOKING FOR IN JUNIOR

FACULTY RECRUITS

Christopher D.M. FletcherBrigham and Women’s Hospital

and Harvard Medical SchoolBoston, MA

ISSUES TO CONSIDER

• Academic vs. private practice differences • Type of job in academic department • Expectations of hiring department • Expectations of candidate • Practical aspects – location / salary etc.

PRINCIPAL TYPES OF JOB INACADEMIC ANATOMIC PATHOLOGY

• Pure surg path } +/- clinical • Surg path & subspecialty } or translational • Pure subspecialty } research • AP (usually subspec) & lab research • Pure lab research

BASIC POINTS• There is no shortage of jobs • Almost all academic departments expect some

/ consistent academic productivity – otherwise no promotion

• Academic departments without this expectation either aren’t really academic or do not value anatomic pathologists

ACADEMIC ANATOMIC PATHOLOGYINSIGHTS REQUIRED ON DAY #1

• Commitment to an academic career • More intellectual stimulation • More freedom / protected time • Usually less money

ACADEMIC ANATOMIC PATHOLOGY (WITH AN ACTIVE DIAGNOSTIC

ROLE)KEY QUALITIES REQUIRED• Good training • Good diagnostic skills • Good interpersonal skills

ADASP SURVEY NOV. 2004What qualities are you looking for when

recruiting junior faculty in academic AP? (1)

#1. Good personality fit / team player #2. Good diagnostic skills

(+/- independent signout experience) #3. Academic orientation with interest /

capability in some type of research #4. Well trained / from ‘good’ programme

ADASP SURVEY NOV. 2004What qualities are you looking for when

recruiting junior faculty in academic AP? (2)SECOND TIER CHARACTERISTICS

#5. Good / strong references #6. Effective / energetic work habits #7. Publications / academic productivity #8. Good communication / presentation

skills

ADASP SURVEY NOV. 2004What qualities are you looking for when recruiting

junior faculty in academic AP? (3)OTHER CHARACTERISTICS MENTIONED

• Subspecialty diagnostic expertise • Clear career plan / goals • Skills match dept / institutional need • Smart / innovative / compulsive • Mature judgment • Responsible for own failures • Good medical school • Capable of multitasking • Institutional loyalty • ‘Willing to do anything’

ADASP SURVEY NOV. 2004Do you expect to see a track record of

publications ? If so, how many ?

YES 89% NO 11%

Average 3-5 (range 2-10) Quality more important than quantity

Presentations at national meetings desirable

ADASP SURVEY NOV. 2004How many years training

do you hope to see ?

Minimum 5 years 50% Residency + 1 fellowship 32%

(either 4+1 or 3+1) Minimum 4 years AP 10% Minimum 3 years AP 8%

ADASP SURVEY NOV. 2004Do you expect fellowship training in either surg

path or subspecialty ?

YES 93% NO 3.5%

Not essential 3.5% Is more than one fellowship desirable/preferred?

YES 50% (but not essential) NO 50%

ADASP SURVEY NOV. 2004Will you consider hiring an applicant

who is not yet board-certified ?

YES 82% NO 18%

• Must be board-eligible • Usually contingent upon passing within 1 yr • Need to be ‘special’(‘Often disappointing’; ‘Don’t get much done’)

ADASP SURVEY NOV. 2004Do you expect / prefer people who are also

trained / boarded in CP ?

YES 7% NO 93%

• Sometimes – e.g. haempath / molecular • Even if not, many successful candidates are

also CP boarded nowadays

ADASP SURVEY NOV. 2004For how long do you anticipate new junior

faculty will need ‘hand-holding’?

Up to 6 months 21% Up to 1 year 25% 1-3 years 36% > 3 years 7% ‘As long as it takes’ 11%

ADASP SURVEY NOV. 2004Will you sponsor successful candidates for O-1

visa?

With H-1 YES 72% NO 28%

With J-1 YES 48% NO 52%

• Only for except’l candidates 20% • Prefer not 25% • Institution will not 20%

ADASP SURVEY NOV. 2004OTHER GENERAL COMMENTS

• Increasing challenge to find academic surgical pathologists

• Many depts are looking for subspecialty expertise, but also need candidates to cover general surg path

• Increasing number of candidates have done 2 or more fellowships

JUNIOR FACULTY INTERVIEWS IN ACADEMIC ANATOMIC PATHOLOGY

BASIC GUIDELINES

• Genuine interest in the job • Professionalism / appearance • Clear idea of own goals • Ability to give a talk • Can’t be too demanding

HOW GOOD IS THE JOB MARKET?

1.) CAP Surveys2.) APC Sectional Meetings3.) APC/PRODS July Meetings3.) Websites/Word of Mouth4.) My Experience5.) Etc

JOBS IN ACADEMIC ANATOMIC PATHOLOGY

WHAT SHOULD RESIDENTS LOOK FOR ?

• Expectations of hiring department • Protected time • Infrastructure • Role models • Recognition re ‘hand-holding’• Rate of faculty turnover

JOB-HUNTING IN ACADEMIC ANATOMIC PATHOLOGY

OTHER IMPORTANT CONSIDERATIONS

• Need mentor for job search • Need good references

(Always communicate with mentor / referees)

• Usually limited financial flexibility • Make sure ‘significant other’ on board

CONCLUSIONS

• Exciting time in academic anatomic pathology

• Lots of jobs / opportunities • Salaries reasonably realistic • Important lifestyle decision • Most who do it love it !

ADASP STUDIES (2004-2005)1.) Under prepared in: Lab Management; QA/QC and

Molecular Diagnostics2.) Trainees comments: Problems in:

Amount of Time inadequateDecreased graduated responsibilitiesTAT: impacted the teaching of HS

3.) What is minimal training: 5 yrs: 50%Residency & Fellowship: 32%

4.) 93% Expect Fellowships50% more than one Fellowship (not essential but helpful)

Are there Jobs and How Well are Pathologists compensated?

• Starting salary offers $140,000 – above primary care specialties, slightly below surgical specialties

• 14,000 Pathologists U.S.; 2,500 in training (800,000 physicians in U.S.)

• Anticipated increased job opportunities in five years• Two offers for each graduating candidate; higher for

U.S. graduates• Every academic department in U.S. has a vacancy

(130 medical schools; 155 training programs)• Pathology Departments have $400 million in NIH

research grants – more than many NIH institutes (Special Opportunities for Physician Scientists)

• Diagnostic Medicine: $35 billion market, growth 5-7% yearly

» Dr. Bruce Alexander, UAB

What Do Residents Think?(ABP Exit Survey; CAP)

ABP EXIT SURVEY (2005)

Did your pathology training adequately prepare you for the ABP Exam?:AP: Yes 330/No 57CP: Yes 117/No 163

If Add The Repeaters:AP: Yes 421/No 113CP: Yes 225/No 226

WHAT IS NOT IN YOUR PROGRAM APPROPRIATE FOR

THE ABP TEST?1.) Because of attention to decrease Turn-Around-

Time for Surgicals: Decreased mentoring2.) Need Laboratory Administration and Molecular

Pathology training (most common)3.) CP: Poor training.

Exam Exit Surveys

• Did your pathology training adequately prepare you for this examination?– First time takers

• Anatomic Pathology– Yes – 330– No – 57

• Clinical Pathology– Yes – 171– No - 163

Exam Exit Surveys

• Did your pathology training adequately prepare you for this examination?– All Examinees

• Anatomic Pathology– Yes – 421– No – 113

• Clinical Pathology– Yes – 225– No - 226

Exam Exit Surveys

I was not prepared for the exam. Although the program was a poor program to make me ready for this test.

Preparation for practical was inadequate. Background training for practical was adequate but needs strengthening.

Exam Exit Surveys

“I believe my pathology program trained me very well for real life situations of clinical pathology but I have to say that the exam is far from what you need to know to practice pathology effectively.”

Exam Exit Surveys

“My program is a good AP/CP program. The CP test is unfair and irrelevant and is more stressing than positively evaluating for qualification of certificate.”

Exam Exit Surveys

“We are pathologists, not lab techs. The difficulty level and focus of the questions is absurd and has almost no relevance to pathology in the modern era.”

Exam Exit Surveys

“What was the practical exam about? Was that a pathology test? No correlation there with residency!”

Exit Exam Surveys – AP• I never saw cases by myself until I was out in

private practice. The first prostatectomy specimen I handled was in my first year of private practice.

• My program stressed work (i.e. grossing and autopsies) and put less emphasis on teaching basic path. The only time you could get additional info was to (1) go to Osler, (2) get one of the few pathologists that would go through stuff with you, or (3) try to get it from Robbins.

Exit Exam Surveys – AP

• My program makes PA’s not pathologists.• We are deficient in exfoliative cytology

(non-gyn) experience; also don’t get much primary lymph node or spleen and no electron microscopy outside of renal work-ups

• Our program has only one month of cytology.


• We don’t train for blind pattern recognition nor for demographic information (most common tumors of specific groups, etc) which makes the exam more difficult than I think it actually is.

• Most programs want you to gross; if you learn anything it is because you trained yourself.


• Not a lot of basic path taught in my training and not very good prep for cytology whatsoever.

• Very few staff are good/skilled in teaching, especially with the pressure to decrease turn-around-time, etc.

• Generally good but key areas left out such as lab administration and molecular path

Exit Exam Surveys – CP

• I came from a residency where AP was stressed and CP minimally emphasized.

• This is the worst part of our training. The department knows and has not done anything about it.

• Spending a few weeks in a lab ( micro, blood bank etc) and reading from standard texts does not prepare one for material covered in this exam.


• My training program was an AP/CP program but too heavy on AP without enough CP. Many of the CP instructors had no real interest in resident education. We were also short staffed (residents) which meant we had to cover more AP months.

• Only do AP. CP = Covering Pathologist


• Lacks management and statistics• Microbiology and chemistry were highly

deficient in the training program.• CP in my program is quite poor. Basically

“go read”. It didn’t prepare me well.• No training in lab management. Little

emphasis on lab testing in chemistry. Molecular diagnostics training weak


• How many of us are going to be practicing in an environment where we need to interpret daily multiple difficult Southern blot, electrophoresis, and obscure tests? Almost never is the answer and when we do we go read about it. Your ability to determine what is relevant and practical has somehow been obscured. Get back to reality folks! You are wasting money and our precious time.

Exit Exam Surveys – CP• Our program only focuses on product approval

(tests or blood products). We do not learn about the instrumentation, chemical reactions, etc. We never interpret molecular studies, in fact molecular is probably non-existent.

• Management and FDA/CAP/AABB etc is not covered in residency. A guideline book made available to all residents would be nice.

• Most of what we do on clinical rotations is scutpaperwork.

Exit Exam Surveys

• If I pass you can change my answer to “yes”.

JOBSJOBSJOBS

JOB MARKET

CAP SURVEYSWORD OF MOUTHAPC/PRODS SUMMER MEETINGAPC SECTIONAL MEETINGSWEBSITES FOR JOBMY EXPERIENCE

WEBSITES FOR JOBS

1.) CAP2.) ASCP3.) ASIP4.) USCAP (NatureJobs)5.) Gopher/U.Minnesota6.) Others

2006: TWO CLASSES COMING OUT: IS THERE ROOM?

Filled ApprovedABP 258 641 (10 SubSpecialty

Boards)

Non-ABP 180 210 (ICPI Book:06-07)

PrivatePract. 270-550 (CAP04)

Acad. 126-252 (Experience)

APPROXIMATE TOTAL: 934 - 1653(This is VERY approximate: There are lots of (necessary) assumptions: Try this at

Home!).Over 50 Academic Medical School Departments of Pathology participating in the

USCAP Fellowship Fair this year: Ran out of room.

THE FUTURE OF PATHOLOGY

RESIDENT TRAINING FOR NOW AND FOR

THEN

(Getting There in Four Steps)

WHERE ARE WE?

WHERE DO WE WANT TO GO?

HOW DO WE GET THERE?

AND HOW WILL WE KNOW?

STRATEGIC PLANNING

1.) Where are we?2.) Where do we want to go/be?3.) How to do get there?4.) How will we know?

GOALS OF PROGRESSIVE MEDICAL EDUCATION (U.S.

MEDICAL SCHOOLS-LAST 100 YEARS)

1) Active participation2) Problem-solving3) Self-learning4) Critical thinking

THE FUTURE: LIKELY ASSUMPTIONS

1.) Information will continue to increase

2.) Continuing Subspecialization

3.) Smaller biopsies/earlier lesions

4.) “New Therapies/New Diseases”

5.) Increasing number of Molecular Markers for Dx, Tx, Prog, Response to Tx, etc (& Mole. Tech.)

6.) Aging/More Chronic Diseases (including tumors)

7.) Increasing Fiscal pressure/constraints: Increasing efficiency necessary

FORMAT/OUTLINE1.) INTRODUCTION: THE FUTURE

2.) MATERIALS & METHODS: MANY VOICES SPEAKING A.) Literature Search (PubMed; Acad.Med)B.) Surveys (USCAP Leaders; PRODS)C.) Personal Experiences/Interactions with

APC/PRODS/et.al.

3.) RESULTS: THE PRESENT: BEING (Surveys: CAP 04; Horowitz)

4.) RESULTS/DISCUSSION: THE FUTURE: BECOMINGA.) Being a Complete Consultant: The Patient ReportB.) Information TechnologyC.) Research: Future DirectionsD.) Educational/Learning TheoryE.) Recruitment of the Best & the Brightest

5.) CONCLUSIONS

PREDICTION IS ALWAYS DIFFICULT,

ESPECIALLY ABOUT THE FUTURE

Yogi Berra

“You’ve got to be careful if you don’t know where you’re going ‘cause you might not

get there!”Yogi Berra

Nothing endures but changeHeraclitus (c540-480 BC)

“Plus ca change, plus la meme chose”

Anatole France

“For the times they are a-Changin’ ”

Bob Dylan (Robert Zimmerman) 1964

“Unfortunately, most architects…prefer to think of their creations as everlasting. The buildings they design resist change. They’re constructed not to adapt; also budgeted and financed not to, constructed not to, even remodeled not to.”

Stewart BrandHow Buildings

Learn

“Given that change is inevitable, Brand argues that architects should confront the issue head on instead of avoiding it. Buildings remain versatile when they’re constructed according to a strategy rather than a plan: ways in which circumstances might change in the future and what has to be done to accommodate those developments. A good strategy ensures that no matter what happens, you always have maneuvering room”

“Organisms must be prepared to adapt or risk extinction. Since it cannot imagine or foresee the future, however, evolution has instead encouraged mechanisms that confer flexibility and championed processes that allow for experimentation while minimizing the number of fatal mistakes”.

Debra NiehoffThe Language of Life (2005)

IDENTIFYING THE FUTURE

“…The most important work of the executive is to identify the changes that have already happened…to exploit the changes that have already occurred and to use them as opportunities. The important thing is to identify the “future that has already happened” –and to develop a methodology for perceiving and analyzing these changes”.

Peter F. DruckerThe Ecological Vision

A LOOK AHEAD

• THE THREE “P’s” OF FUTURE HEALTH CARE (Robert Rich, MD):

– Predictive– Personalized– Preventive

OTHER PLANNING ASSUMPTIONS: ESSENTIAL &

INCREASING

1.) EVIDENCED-BASED MEDICINE 2.) LONG-DISTANCE LEARNING/HI-TECH

APPLICATIONS 3.) LIFE-LONG LEARNING/CPD 4.) SELF-ASSESSMENT &

DEMONSTRATION OF COMPETENCE--PRACTICE-RELATED

THREE TRENDS THAT WILL RESHAPE OUR DISCIPLINE

1.) Rise of Consumerism: Patient as a Consumer2.) Power of the Information Age3.) The Genomics Era

“…to manage and interpret this data and to smoothly integrate this rich information stream into the diagnostic milieu…is perhaps the greatest challenge facing pathology today”.

J.H. Sinard & J.S Morrow

Human Pathology: 32: 143, 2001 (Feb)

PATHOLOGY DIVERSITY: Different Backgrounds, Interests,

Skills, Desires, Potentials, etc

1.) Clinical Service (Generalist; Specialist)2.) Research (Clinical and/or Basic)3.) Teaching4.) Leadership (Local/Regional; National)5.) Administration (Health Care/Hospital; Lab; etc)

Hard to Define a Pathologist: Pathologists Defined in Lots of WaysThus, Tailor Training Program to the Individual (after a Core

Education)

WHAT DO HS WANT?

1.) Pass the Boards2.) Get A Job

WHAT DO WE ALL WANT?

3.) Do well for all those we serve & Keep the Job

4.) To Survive, no…to Advance the Profession

WHAT IS THE OUTCOME INDICATOR FOR SUCCESS:

WHAT DO WE WANT THEM TO DO WHEN THEY COMPLETE THEIR RESIDENCY?*

1.) Able to take and Pass the Pathology Boards2.) Able to be Hired and Keep the Job3.) Able to Function in Practice (with minimal

oversight)/handle day-to-day service load4.) Able to function in practice (with moderate oversight)5.) Make a better salary than you do6.) Preserve the Profession/Help Those We Serve/Other

• *Depends on whom you ask

ACADEMIC MEDICINE: DEFINING HOUSE STAFF EDUCATIONAL

NEEDS FOR THE FUTURE

1.) Web-based learning: 2.) Extraction of Useful information from

the Biomedical Literature3.) Evidence-based Medicine4.) Decision Sciences/Logic5.) Critical Review of the Literature/Journal

Clubs

USCAP LEADERSHIP: SUMMARY

1.) Prepare to Adjust to Change: Future Uncertain & Increased Pace of New Knowledge & Respond to Changing Clinical Needs

2.) Lay Foundation for CPD– Critical Thinking/Journal Clubs– Approach to Problems/Research Projects– Information Technology/Where to find information & how

to transfer it to others– Increased Efficiency– New Molecular Technologies/Cross-fertilization– Diverse House Staff: desires/jobs/expertise– Still need the Light Microscope (LM Plus)

DEFINITIONS OF A PATHOLOGIST

1.) In the Literature: Different definitions2.) Functional: A Pathologist is what a Pathologist does3.) Inclusive: Someone being paid by the Department of

Pathology (Including PhD’s in Clinical Labs)4.) Exclusive: Service-oriented Physician -Pathologist (AP

and/or CP)5.) More Important Things to Worry About!!!

Keeping the Clinical and the Research/Academic Enterprises Together (Ramzi Cotran)Balancing the BooksDoing well all the things we do …

USCAP LEADERSHIP: II

1.) Will be Self-Evident (Market Driven)2.) Metrics: Survey Departing House Staff

& All players/Stakeholders3.) Recertification Pass Rates (ABP)4.) Attend/Participate at National

Meetings/Leadership Positions Involvement in Teaching

PRODS RESPONSES1.) Integration/Integrated Diagnoses: Interaction

with Clinicians2.) Graded/Integrated Responsibilities3.) LLL/PCD: Encourage belonging to Pathology

Organizations4.) Critical Thinking/Journal Clubs/New Lab

Tests/Business-Management5.) Adapt/Agents of Evolution in our Profession

(Recruit the Best & Brightest)6.) Retreats to Evaluate performance

PRODS RESPONSES: II1.) No Foolproof way to Track: No Crystal Balls2.) Successful Employment (Jobs): Time will tell3.) Leaders or Followers: Local/National Arena4.) Diagnostic Modalities Taken Away from us5.) ABP Pass Rates/RISE and RISE-like Exams6.) Surveys: (Of Everyone)

– Exit Interviews of graduating HS/Fellows– Recent graduates (what was of most value)– Employers of recent graduates (what most valued)– Directors of Fellowship Programs– Evaluation of Pathology as Specialty by those we serve

(Clinicians, etc)

EVOLUTION: OTHER SPECIALTIES

1.) UROLOGY: Driven by New Techology

2.) GENERAL SURGERY: Subspecialization

3.) RADIOLOGY: Taken Opportunities

“The unprecedented opportunities for American workers in the latter half of the 20th century came from creating new jobs, not from protecting old ones. A major component of job creation is investment in science research. Our rivals in Asia and Europe have clearly figured this out.”

Wall Street JournalMay 2005

WHAT ARE PATHOLOGISTS DOING NOW?

(BEING)….

AND WHAT DO WE NEED TO TRAIN THEM TO DO IN THEIR

NEXT 30 YEARS OF MEDICINE?(BECOMING)

CLASSIFICATION OF DISEASE:

1.) Clinically Useful

2.) Scientifically Accurate

3.) Reproducible: Communication: Common Terminologies

SURGICAL PATHOLOGIST: WHAT ARE THE CHARACTERISTICS OF AN

OUTSTANDING SURGICAL PATHOLOGIST

1.) Good training in Surgical Pathology2.) Knowing what you don’t know and not being afraid to seek

help/assistance3.) Visual Memory (remember cases)4.) Know Patient Outcome5.) See lots of cases/good experience6.) “Extraordinary things are not done with ordinary

efforts” : The EYE, The LEGS, The MOUTH7.) Keeping up/LLL with Classifications/Protocols/etc

“THE BEST WAY TO PREDICT THE FUTURE--IS TO MAKE (SHAPE) THE FUTURE”The Pathologist as a Diagnostic Specialist: A CONSULTANTA Data Integrator:

Clinical FindingsPast Med/Surg HxLab DataIHC/Flow/Genetic studiesProteomic studiesMultiple Knowledge BasesOutcomes Data

Sinard & Morrow: Human Pathology 01

BEING A CONSULTANT:Key Components: Availability,

Affability, and Ability1.) Communication with Clinician: knowledge of

past history/laboratory findings2.) Knowledge/Review of all previous materials3.) What are Clinician’s

Needs/Standards/Expectations4.) Know the Time Table and Results of your

Diagnosis: adequacy, margins, etc5.) What are the key/critical diagnostic issues and

role of special/ancillary studies6.) Heuristic studies (how to help s/he with the next

step in the patient’s care)

THE BIOPSY REPORT: A CONSULTATION

1.) Diagnosis/Description: Preliminary & Final (Comments; suggestions; heurism)

2.) Images/Photos: 3 copies: a.) chart, b.) consultant, c.) patient: Internet Access

3.) References/Link to NLM and EBM for the Chart and Physician

4.) Patient Education:One page summary (e.g. AMA)Other Medical Websites for more informationSocieties/Chat Rooms for further information

Pat Walker (Nephropath Inc.) Little Rock, Arkansas

Prognostic and Predictive Factors in

Breast Cancer

Stuart J. Schnitt, M.D.Beth Israel Deaconess Medical

Center and Harvard Medical School

Boston, MA

Prognostic and Predictive Factors: 2005

• Intensive efforts to identify new biological and molecular indicators of clinical outcome and response to therapy

• Studies have often yielded conflicting results and clinical confusion

• Traditional pathological factors remain the remain the routine indicators of prognosis and therapeutic response

Traditional Factors

• Lymph node status

• Tumor size• Histologic type• Histologic

grade• Hormone

receptor status

Computer Assisted Analysis of FISH Results

What Do We Ideally Want for Optimal Patient Management?

• Comprehensive profile of biological and molecular characteristics of a tumor that will enable us to:– distinguish prognostic groups among patients

with histologically similar/identical tumors– predict response to various therapeutic agents in

individual patients– identify new, tumor-specific therapeutic targets

based on an understanding of molecular oncogenesis

– develop drugs directed against such molecular targets

• A “HIGH RESOLUTION PHENOTYPING”

Recent Developments

• Sequencing of the human genome

• Development of high throughput techniques for molecular analysis

An “Array” of New Techniques

• Available to comprehensively study tumors at DNA, RNA, and protein levels

• Simultaneous analysis of hundreds or thousands of parameters

• Numerous potential clinical applications

• “High resolution phenotyping”

Gene Expression Profiling

adapted from Alizadeh et al. J Pathol 2001;195:41-52

RT-PCR

tumors

gene

s

Breast Cancer Subtypes as Determined by Gene Expression Profiling

Sorlie, 2001

Breast Cancer Subtypes Determined by Gene Expression

ProfilingSorlie, 2001

ER- ER+

Breast Cancer Clinical Outcome

as Determined by Gene Expression Profiling

• 295 pts, stage I-II breast cancer• Expression signature consisting of 70 genes

identified good and poor prognosis groups among both N- and N+ patients

• Better than standard prognostic systems based on clinical and histologic features (e.g., St. Gallen, NIH)

NEJM 2002;347:1999-2009

NEJM 2004;351:2817

•668 patients enrolled in NSABP B14•RT-PCR assay on paraffin sections (21 genes)•ER+, node negative

ONCOTYPE DX

(Genomic Health)

Expectations of A New Technology Over Time

Time

Expe

cta t

ion Unreasonably high

Unreasonably low

History of New Technologies in Evaluation of Solid Tumors

1950’s

Enzyme histochemistry

1960’s

Electron microscopy

1970’s

Immunohistochemistry

1980’s

Flow cytometry

1990’s

Individual biomarkers and molecular markers

2000’s

High throughput, multiparameter molecular

How Will The New Molecular

Techniques Be Used Clinically?

Tissue Sample

Molecular Analysis

PrognosticGroup

Therapeutic

Targets

PredictiveMarkers

Pathologist’s Role :

Collect Tissue Samples

Tissue Sample

MolecularAnalysis

Identification of Key Genes or

Targets

AntibodyProduction

DiagnosticIHC Tests

Pathologist’s Role:

Identify Suitable Candidates

for Targeted Therapy

The Future of Breast Pathology

OR ?

New diagnostic categories

New prognostic groups

New predictive factors

New therapeutic targets

“Novel technologies, such as tissue and expression microarrays and proteomics, present exciting potential, but their integration into clinical practice will depend on the proper design and analysis of clinical investigations.”

NIH Consensus Development Conference Statement: Adjuvant Therapy for Breast Cancer

JNCI 2001;93:979-989

MEDICAL INFORMATION: GROWTH/CHALLENGE

MEDLINE: MORE THAN 14 MILLION REFERENCES

2002 : ADDED MORE THAN 500,0002003: ADDES MORE THAN 525,000

Rosenbloom et alAcademic Medicine80:109, Jan. 2005

PATHOLOGY INTERNET SOURCES

• Over 20,000 English Health Care Internet Portals

• Over 200 Pathology Internet Resources: (cf. Mercury/Vaccines/Autism)

– Pathology Curricula (MS)– Pathology Curricula (HS)– Virtual Autopsies– Tours of Pathology Museums– Interactive Tutorial/Individual Proficiency Testing (JHH)– Second Opinions– Digital Microscopy/Microscopic Pathology Collections– Hi-Quality Meeting Proceedings (Video streaming)– Chat Rooms/Bulletin Boards

F. Gorstein & R. WeinsteinHuman Pathology, Jan. 01

“Where is the Life we have lost in living?Where is the wisdom we have lost in

knowledge?Where is the knowledge we have lost in

information?”Choruses from “The Rock”T.S. Elliot

“We are drowning in information but starved for knowledge”

John NaisbittMegatrends. 1982

Work to Embrace a Range of NewTechnologies:(Sinard & Morrow: Human Pathology 01)

1.) No longer AP system isolated (be a permanent data archive)

2.) Become quantitatively orientedi.e., digital/imaging archiving)

3.) Computational strategies for data capture, organization, interpretation, presentation, and decision-supported algorithms

4.) Pathology Informatics: A legitimate discipline for pathology

MOLECULAR DIAGNOSTIC TESTING

1.) Specific molecular reagents now exist for lab diagnosis of:Over 300 genetic diseasesInfectious pathogensTumor markers of Dx/Prognostic significanceDNA fragment patterns (fingerprints) for Paternity TestingForensic IdentificationTwin Zygosity determinationTransplant engraftment confirmation

“Dot blot”Southern BlotISH/FISH

Scientific Abstracts: New Techniques

0100200300400500600700800900

Gene E

xpres

sion

Gene

Mole

cular PCR

Hybrid

izatio

nChr

om.A

nalys

isM

icroa

rrays

FISH

Laser C

MD

20022003

Association for Pathology Informatics

http://www.pathologyinformatics.org•• Officers:Officers:

–– President President -- Mike Mike BecichBecich–– President Elect President Elect -- Bruce FriedmanBruce Friedman–– VP VP -- Ron WeinsteinRon Weinstein–– SecySecy/Treasurer /Treasurer -- Joel Joel SaltzSaltz–– Membership Membership -- Mark Mark TuthillTuthill

•• Mission:Mission:–– Support research, education, scientific Support research, education, scientific

meetings through electronic and meetings through electronic and printed communications. printed communications.

–– Develop standards for reporting, Develop standards for reporting, transferring, storing, and merging transferring, storing, and merging confidential and other pathologyconfidential and other pathology--related information.related information.

–– Play active role in legal, ethical, social, Play active role in legal, ethical, social, regulatory, and governmental issues regulatory, and governmental issues related to pathology informatics.related to pathology informatics.

–– Develop relationships with other Develop relationships with other professional societies and industry professional societies and industry partners.partners.

Fig. 2 - Matrixed Reporting-Pathology Information Therapy

Demograph ics Anatomic Pathology Report

AP images

Molecular Diagnostics Data

Image of a gel

AP/CP Summary Report by Pathology SubspecialistReferences/WWW Links

UPMC Patho logy

Prognostic Information

Tumor Marker Data

A multi-domain, multi-media,scalable, complex object fo rprimary care physicians, patients,researchers, etc.

Integrated Reporting

•• From Gilbertson and From Gilbertson and BecichBecich, Adv , Adv Lab Mgr 1998Lab Mgr 1998

Molecular Morphology ReportIncludes

Morphologic diagnosis

+ receptors+ proliferation markers+ phenotype markers+ oncogene /suppressor status

etc.

From Taylor et al.Immunomicroscopy and Molecular MorphologyElsevier/Saunders. 2005.

• Genomics• Proteomics• Patho-

bioinformatics: Understanding gene expression in the context of morphology

Imaging, Pathology and the Future

Imaging, Pathology and the Future

CBIRDigitization

Telepathology

TissueBanking

Bio-informatics

MorphologicAnalysis

ElectronicStaining

• Pathology can have a great future. The importance of tissue has never been higher.

• But we find our selves stuck with limited tools.

• Too many pathologists consider themselves “experts who look at glass slides” not “experts in analysis of tissue and disease”.

• What could we accomplish if we could apply computer power and network connectivity to morphology?

Conclusions

• Pathology is uniquely situated to take advantage of information technologies that are emerging and integrate them wholescale into our laboratories

• Aggressively recruit trainees and promote Pathology Informatics

• Grow Informatics Divisions in Pathology (residency training and fellowships) as an emerging subspecialty

TRIUMVIRATE

1.) In Vivo2.) In Vitro3.) In Silico

NEW TARGETED THERAPIES: DRUGS

1.) Herceptin/Her2/Neu (Genentech) 2.) Gleevec (Novartis)3.) Iressa/EGFR (AstraZeneca)

PATHOLOGY AS THE ENABLER OF HUMAN RESEARCH

1.) Biomedical Research Now operates in the realm of massive data management (storage & accessing)

2.) Data derived from comprehensive molecular analysis of tissue (G to T to P)

3.) Data from Tissue Analysis must then be aligned with Clinical Information (Data Repositories/Networking)

4.) Molecular Maps pegged to Tissue Architecture & Clinical Parameters & Outcomes

5.) Managing the Regulatory Environment for Human Research

HUMAN TISSUE: THE CURRENCY-OF-THE-REALM

James M. Crawford & Mark L. TykocinskiLaboratory Investigation: 85: 2005 In Press

PATHOLOGY RESEARCH: Understanding Structural and

Molecular Basis of Human Disease1.) Improve Diagnostic Abilities2.) Enable Best Possible Clinical Management:

• Clinical Decision-Making• Targeted Treatments• Monitoring Disease Course• Monitoring Therapeutic Effectiveness/Complications

James Crawford and Mark TykocinskiLaboratory Investigation: 85: In Press (2005)

NIH ROADMAP: NEW PATHWAYS TO DISCOVERY

1.) Technology from Molecular Analysis2.) National Biospecimen Network3.) Molecular Libraries/Molecular Imaging4.) Structural Biology5.) Bioinformatics & Computational Biology6.) Nanotechnology & Nanomedicine

MULTIDISCIPLINARY

EDUCATIONAL THEORY

ADULT LEARNING THEORY

COGNITIVE NEUROSCIENCES

HOW DOCTORS LEARN

SELF-DIRECTED LEARNING

DECISION SCIENCES

“the richest resource for learning resides in the adult learners

themselves.”

M.KnowlesThe Adult Learner:

A Neglected Species

CHALLENGES IN AMERICAN PATHOLOGY (ANATOMIC

PATHOLOGY)_______________________________________________1) Recruiting the best Medical Students into Pathology

(and enough students)2) Bringing the newest Molecular/Genetic Techniques

into Anatomic Pathology3) Becoming more efficient/effective (like Clinical

Pathology); Informatics/Being Central 4) Pathologists as Consultants (giving the Clinicians

value-added information) (& Patient advocates)

“ONE HUNDRED YEARS FROM NOW

--ALL NEW PEOPLE”

Soup for the Soul Series

New Great People Every Year: With New Ideas, New Enthusiasm,

New Backgrounds, Talents

LEADERSHIP

• “Part of Being a Leader is Creating Other Leaders”

• Mentoring

PROGRAMS AND PGY-1 POSITIONS_______________________________

Programs Programs Positions Positions Filled Total PGY-1Year RRC in Match Offered by Match Positions 1996 175 139 426 331 5721997 167 126 359 248 5431998 169 131 355 248 5411999 165 128 344 281 5562000 157 120 335 246 5102001 157 138 383 312 --2002 155 140 398 333 --2003 155 144 443 399 6232004 155 144 477 438 5832005 155 147 526 481 586 (total PGY1-4 =

2255)

From Bruce AlexanderHuman PathologyJuly 2001/ & Updated

PATHOLOGY POSITIONSOFFERED AND FILLED

0

100

200

300

400

500

600

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

# Offered

# TotalStudents

# U.S.Students

PERCENTAGES OF POSITIONS FILLED

0

10

20

30

40

50

60

70

80

90

100

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

% of totalpositionsfilledthroughmatch

% filled byU.S.students

THE FUTURE BY P.F. DRUCKERWhat does the Profession Need to be Successful (i.e, meet the needs of those we serve) for another 25 years?

To be Present & Future-Oriented1.) Constant Renewal: Constant Adjustment

(in touch with reality)2.) Balance the Long Term with the Short Term3.) Push & Further Young Pathologists

(Develop the people) (Mentoring)4.) Diversify: Every single task eventually

becomes obsolete(80% of what’s in the line in the next 10 years we haven’t even heard of)

The Health Care Triangle

WHAT AND HOW TO CHANGE?

1.) Increasing Diversity of Functions, People, and Subspecialties

2.) Information Technologies3.) New Methodologies/Technologies: Molecular

Dx/Tx/Prognoses4.) Change: Incremental/daily/person by person5.) Watch Customer(s): e.g.,Clinical Needs6.) Pathologists as Consultants (value added)

HOW TO GET THERE FROM HERE: SUMMARY

1.) Any Way You Can (Probably Multiple Routes: Regular “midcourse adjustments”)

2.) One Step at a Time (Incrementally: WhilePreserving the Good (Being), Adding the New (Becoming)

3.) One (Person) by One (Recruitment,Mentoring, Retaining of Outstanding People; “Reinforcements”)

4.) Ask the Customer

ACKNOWLEDGEMENTS• CAP/Constance Filling/Mary Kass et al. • Richard Horowitz (UCLA/USC)• Chris Fletcher/ADASP• Michael Becich (API)• James Crawford & Mark Tykocinski (Univ. of Florida/Penn)• Bruce Alexander (RRC/ACGME/Etc)• Betsy Bennett (ABP)• Bill Hartmann (ABP)• USCAP Leaders (Survey)• PRODS (Survey)• Stu Schnitt (BID)• APCs, GRIPE, All Path. Organizations,et al.• Life, the Universe, and Everybody Else (Doug Adams)

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