Opportunities for Academic Pathology: The Thoughts and Perspectives of a Legal Observer.

As American health care undergoes great change, academic pathology is uniquely positioned to establish pathologists as key to the new health-care environment. Pathologists are at the forefront of major innovations in health care and are specialists who interact with all other medical specialists and essentially the entire range of health-care services. Academic pathologists benefit from being subspecialist experts who provide care to patients referred from large geographic areas, who can attain high academic stature over the course of their careers, and who serve as mentors for learners across virtually all medical specialties. Academic medical centers, in turn, have excellent credibility in the community, strong information technology infrastructure with the ability for data accrual and analysis not available in community health-care settings, and strong liaisons with civic authorities and policy makers. However, pathologists have to overcome their own tendencies toward modesty and lack of assertiveness, in order to help counter the significant trends in the health-care marketplace that disempower health-care providers and place health industry decision-making in the hands of nonmedical stakeholders. Specifically, academic pathologists need to proactively play a major role in institutional efforts to improve performance in quality, patient safety, efficiency, and coordinated care delivery and become leaders in the delivery of effective and efficient patient care. They need to play an essential role in utilization management, including molecular testing. They need to develop their value propositions for payers and seek to gain access to payers in order to represent these value statements. They should gain visibility directly to patients seeking expertise for second opinions and pursue opportunities for outreach programs in the community well beyond the academic medical center. Absent such efforts by academic pathologists, pathology is at risk of continued commoditization by nonpathologists, with weakening of the value proposition that pathology might bring forward.

I have spent almost 30 years as a regulatory health-care attorney representing pathologists and laboratories. Over 90% of my legal practice today is focused upon the legal issues of pathologists and laboratories, including both those in academia and those in the private sector. The following essay is an expansion upon observations that I made during a panel session entitled “Current Challenges in the Business Landscape for Pathology” at the July 2015 Annual Meeting of the Association of Pathology Chairs. As I discussed during my presentation at this meeting, and as discussed in more detail subsequently, I believe that academic pathology is uniquely positioned to seize opportunities in the evolving health-care landscape and firmly establish pathologists not only as the “doctor’s doctors” but also as the principal gatekeepers in the new health-care environment.

Current State of Affairs

It is no secret that health care is rapidly evolving, and there is significant uncertainty among not only health-care providers but also patients with respect to what the changes will mean. There are some very clear trends, however (Table 1).

Table 1.

Negative Trends in the Health-Care Industry That Impact Pathology.

Loss of control by health-care providers (including pathologists): influx of nonmedical stakeholders Short-term profit motive by some stakeholders, driven by increasing the volume of laboratory testing Restrictive local coverage decisions (LCDs) by payers Government and private payer audits on pathologist-ordered testing Laboratory utilization initiatives by non–health-care providers

In recent years, we have seen an acceleration in the loss of control by health-care providers, including pathologists. Significantly more non–health-care providers (individuals who do not hold professional health-care licenses, individuals who have not spent most of their careers in health-care administration, and business people who are turning to health care for both short- and long-term profit potential) are taking a leadership role in the provision of health care. In the pathology and laboratory world, this is especially prevalent in molecular and genetic testing. I field large numbers of telephone inquiries from venture capital analysts who are interested in taking a financial position in pathology and laboratory operations, growing the “business” for a few years, and then “flipping the business”—in other words, selling the pathology and/or laboratory operations for a significant profit. As a general matter, such investors are looking at pathology and laboratory services from a strictly financial standpoint, often with the goal of driving up volume in the short term to increase valuation of the operations. Such activities often drive volume without the requisite medical necessity for the services, thereby devaluing the services as well as increasing the cost not only to patients but to the economy as a whole.

At the same time, and unfortunately, there are a minority of health-care providers, including pathologists, who also are attempting to secure short-term profits by driving up the volume of pathology and laboratory services, without regard for the medical necessity of such services. Although pathologists are often reluctant to openly discuss such abuses, most pathologists and other close observers in the pathology and laboratory community will acknowledge the significant increase in the ordering of certain types of services, such as special stains, that coincided with reductions in reimbursement for slide processing, particularly CPT® (Current Procedural Terminology) code 88305-TC. In addition, almost everyone in the pathology community is familiar with the increase in utilization that has resulted from in-office technical and professional pathology services established by nonpathology specialists, such as urologists, gastroenterologists, and dermatologists.

These developments have led to some very negative consequences for pathologists. The restrictive local coverage determinations issued by Medicare Administrative Contractors, such as the recent local coverage decisions (LCDs) that severely limit payment for special stains, are a reaction to the real and perceived abuses in utilization for pathology and laboratory services. Government and private payer audits on pathologist-ordered testing, such as FISH (fluorescence in situ hybridization) and flow cytometry services, are also increasing, with significantly more skepticism on the part of the payer as to whether such services are truly medically necessary. Beacon LBS, the LabCorp-owned company that offers services to third-party payers to “manage” pathology and laboratory testing, is also a reaction to the dramatic increase in costs associated with pathology and laboratory services, particularly in the molecular and genetic testing realm.

A common theme among the LCDs, payer audits, and Beacon LBS of the world is that these are primarily laboratory utilization initiatives by non–health-care providers. All of this adds up to a loss of control of health care by health-care providers and an intrusion upon the practice of medicine by pathologists.

The Strengths (and Weaknesses) of Pathologists

The following generalizations obviously do not describe all pathologists but have at least some kernels of truth (Table 2). Pathologists truly deserve the moniker of the doctor’s doctor. When compared to many other specialists, pathologists are meticulous, observant, and careful, rigorously basing their medical interpretations and decisions upon measured and deliberate analyses. However, they are not merely “backroom” health-care providers. Pathologists are also at the forefront of some of the most exciting innovation in health care today, leading the way in the development of promising new diagnostic testing, particularly in the oncology area.

Table 2.

Strengths and Weaknesses of Pathologists.

Strengths: Rigorous approach to medical decision-making Innovators in the science of medicine Interact with all other medical specialties Have access to essentially the entire range of health-care services Oversee the major diagnostic service in medicine Provide “the diagnosis” for many patients and critical information for their treatment and prognosis Weaknesses: Modesty Ceding of control Lack of assertiveness

Pathologists are also one of the few medical specialists who have the potential to interact with all other medical specialists and, if the opportunity is taken, have access to almost the entire range of health-care services solicited by and provided to patients. Likely, all readers of this essay know that clinical laboratory testing is the most pervasive diagnostic service provided in this country, and as the directors of the laboratories that perform clinical laboratory testing, pathologists have a role in the delivery of these diagnostic services. In the anatomic pathology arena, pathologists are the physicians who provide diagnoses following surgeries and biopsies, placing the pathologists squarely in the center of patient care. For example, most patients consider a cancer diagnosis to be one of the most significant health-care crises that can arise in their lives. The pathologist plays the central role in the diagnosis of the patient’s cancer and increasingly in guiding treatment protocols based upon the outcome of the pathology and laboratory services provided.

Unfortunately, most patients and most health-care administrators (and too many fellow physicians) are unaware of this pivotal role of pathologists. The stereotype pathologist is quiet, unassuming, and unlikely to toot his or her own horn. Even pathologists themselves joke that they are too often the physicians who live in the basement of the hospital. The modesty of most pathologists often contributes to the loss of control over their medical practices, as they often cede leadership roles to others, and too often their unique skills and accomplishments are overlooked and underrated by those who are in leadership positions. It is important to recognize these weaknesses in order to prepare a strategy for retaking control of the delivery of pathology services and assert a leadership role for pathologists. Although it is important to take advantage of strengths, it is equally important to understand weaknesses and address these weaknesses.

The Strength of Academic Medical Centers

Academic medical centers have unique and significant strengths that pathologists can leverage in today’s health-care environment (Table 3). The “credentials” of most academic medical centers that can be leveraged as value propositions are described in more detail subsequently.

Table 3.

Strengths of Academic Health Centers of Advantage to Pathologists.

Credibility: Focus on all patients, regardless of ability to pay Educational role in training future physicians and health-care workers Serve as foundation for medical research Range and depth of subspecialty expertise

Broad talent base

Strong information technology (IT) infrastructure

Patient data on large and diverse patient populations: Collaborations with other academic medical centers

Liaisons with stakeholders: patients, medical providers, payers, community, policy makers

Academic medical centers have credibility. The importance of this single word cannot be overstated. As explained earlier, health care is less of a profession every day and more of a bottom-line business, with all stakeholders (health-care providers, patients, third-party payers, and federal and state governments) increasingly skeptical of the health-care system. In the midst of this skepticism, however, academic medical centers still retain a fairly spotless reputation in most quarters, underscored by their focus upon the care and treatment of all patients (regardless of the ability to pay), the delivery of top-notch medical care, their role in providing the education and training of future physicians and other health-care providers, and their unparalleled status as the foundation of medical research in this country. When most members of the public or health-care providers are asked what motivates the large for-profit hospital chains or the national for-profit laboratories, most will respond “money.” When asked the same question of academic medical centers, the responses generally will include “providing world-class care,” “training new doctors,” and “medical research.” Money is not seen by most as the primary driver of academic medical centers, although we all know that adequate funding is critical for academic medical centers to pursue their missions.

Another well-recognized strength of academic medical centers is the range and depth of subspecialty expertise. More specifically with respect to pathology, most academic medical centers have a broad bench of talent, with highly trained and specialized pathologists upon whom treating physicians and patients rely for accurate and timely diagnoses, particularly with respect to challenging medical conditions.

A third strength of academic medical centers is their strong information technology (IT) infrastructure. This infrastructure is critical in the compilation, retention, analysis, understanding, and utilization of a fourth compelling strength of academic medical centers, patient data. In today’s health-care world, data are of paramount importance. All stakeholders are scrambling for clinical outcome data, financial data, patient population data, and so on. As discussed in more detail subsequently, patients, payers, other health-care providers, and government officials will increasingly rely upon data repositories in order to identify true centers of excellence (not just those who describe themselves as centers of excellence), cost-effective providers, population and disease trends, the development of best clinical practices, coverage determinations, payment policies, graduate medical education funding, research funding, and so on. Without strong IT systems, however, not only is it difficult to gather such data, the data cannot be effectively utilized. With respect to all these various categories of data, each academic medical center is an ideal data source in light of the large volume of patients treated and the wide range of conditions and disease states diagnosed and treated. However, their individual data potentials are exponentially increased when they collaborate with other academic medical centers to create large data repositories.

Another often overlooked strength of academic medical centers is the large number of experienced and skilled liaisons that such centers typically have as part of their personnel staff. Most academic medical centers have large numbers of patient liaisons, outreach programs for referring clinicians, patient-friendly medical information and marketing initiatives, experienced payer contracting teams, and lobbyists or other liaisons to government agencies as well as lawmakers.

As explained in more detail below, these liaisons can be leveraged by pathologists at those centers to establish their value propositions.

Value Proposition of Academic Pathologists

Pathologists in academic institutions have the ability to leverage the strengths described above among other physicians and referral sources, with patients, within the academic medical center itself, with both government and private payers, and with federal and state legislators (Table 4).

Table 4.

Value Propositions for Academic Pathologists.

Being a resource to other physicians, through pathologist expertise and subspecialization Being a resource directly to patients seeking expertise for second opinions Using the institutional marketing department, including web presence and public relations Essential role in institutional performance in quality, patient safety, efficiency, and care delivery Essential role in utilization management, including of molecular testing Ability to develop value propositions for payers Includes access to payers for negotiations Credibility in discussions with legislators and other policy makers Leaders in delivery of effective and efficient patient care Potential for outreach programs for the community well beyond the local academic medical center Opportunity to build data repositories to drive future value proposition development and documentation Mentors of learners: pathology residents, pathology fellows, medical students, graduate students

Subspecialty Support of Other Physicians

Many pathologists gravitate to and/or are recruited by academic medical centers because of their expertise and subspecialization. The unique patient mix of academic medical centers enables these pathologists to continue to strengthen their expertise in their chosen areas of specialization throughout the course of their careers. In contrast, most pathologists in small community hospitals or even larger city hospitals may not have the opportunity to focus and develop their skills in a particular subspecialty area. As a result, pathologists outside the academic medical centers rely upon their academic colleagues for consultation services with respect to difficult-to-diagnosis cases. Similarly, many physicians in other specialty areas are frequent referral sources for pathology consultations, particularly with respect to consultations for pathology services that align with their own areas of subspecialization.

Typically, the referrals that academic pathologists receive from other pathologists in nonacademic settings as well as physicians in other specialties are via “word of mouth” or historic consultation patterns within their own practices or hospital settings. This consultation referral base can be expanded by academic pathologists who pursue targeted marketing initiatives. For example, a pathologist with particular expertise in diagnosing alopecia may wish to secure speaking engagements at dermatology as well as dermatopathology meetings on a local, regional, or even national basis. Similarly, being a frequent contributor not only to academic journals but also to more broadly based medical publications read by physicians across multiple specialties can assist the academic pathologist in expanding his or her referral base well beyond the former word of mouth sources of referrals. Over the course of their careers, academic pathologists can become well-recognized national and international experts in their subspecialty fields and hence the ability to serve as resources to a broad community of physicians.

Patients

Besides courting pathologists and physicians in other specialty areas for referrals, pathologists in academic medical centers should not forget that patients are increasingly proactive in selecting their medical providers, often turning to the websites of academic medical centers for medical information. We all know that patients across the country routinely turn to the Mayo Clinic’s website for information on specific medical conditions. Besides being a source of information for the public, a website such as the Mayo Clinic’s website also provides significant exposure of the Mayo Clinic’s physicians to the public. Patients who are seeking information on specific medical conditions may be more inclined to schedule appointments with physicians at the Mayo Clinic as a result of the information that they obtained from the Mayo Clinic website.

The Mayo Clinic website example also underscores the credibility that status as an academic medical center brings from a patient perspective. Education materials, promotional materials, blog postings, and so on, on academic medical center website simply drive more web traffic than those from smaller community-based hospitals, and pathologists at the academic medical centers can leverage the credibility advantage of the institution.

Within regional markets, academic medical centers can have very high stature. Patients with cancer and other diseases are referred for definitive clinical care from the home state, contiguous states, and potentially beyond. Broad patient referral bases support the academic department of pathology’s ability to be leaders in clinical care and research and the ability of their faculty pathologists to gain stature in their own subspecialty areas.

In turn, on a local and regional level, speaking to patient advocacy groups and community groups can showcase the expertise of the pathologist and bring additional public relations benefits to the academic medical center itself. The “center of excellence” approach of different specialists who focus on similar disease states can be very effective in patient-focused seminars and presentations, and pathologists should ensure that they are included in such panel presentations.

Although patients would not typically be scheduling appointments with pathologists, patients who are facing serious medical conditions, particularly those with difficult-to-treat cancers, do spend significant amounts of time on the Internet looking for specialists who can assist in the diagnosis and treatment of their cancers. Too many patients do not fully appreciate the role that pathologists play in oncology diagnosis and treatment. A strong website presence of an academic pathologist with particular expertise in diagnosing and assisting in the treatment of specific diseases can and has led to specific patient-driven requests for consultations from the pathologists. Well-informed patients will encourage or even demand that their attending physicians refer specimens to the academic pathologists for review. Increasingly, patients will take matter in their own hands and directly arrange for the consultations. However, without well-designed, patient-friendly websites that encourage patients to seek services from academic pathologists, patients will not realize that these opportunities exist, and the pathologists will miss important referral opportunities.

Marketing Departments

With respect to these marketing initiatives among other physicians as well as patients, pathologists at academic medical centers may wish to utilize the expertise within the medical center. As mentioned previously, most academic medical centers have marketing departments, and these departments generally are available to departments within the institution as well as individual medical staff members to assist in designing promotional materials, developing a web presence, or even assistance with speaking engagements before medical societies or community venues. Unlike pathologists in smaller community settings, the academic pathologists have the benefit of marketing and even patient representative expertise, typically without any additional expense to the pathologist. Academic medical centers also have extensive IT infrastructure that can be of assistance with respect to a web presence for the pathologist.

Within the Academic Medical Center

Pathologists have an underexploited value proposition within their own academic medical centers. Pathologists actively supervise and participate in the medical center’s laboratory operations, which run on a 24/7/365 basis. There are numerous studies indicating that a medical center’s laboratory services touch more patients than any other single service within the hospital and are the single most important ancillary diagnostic tool utilized by physicians. In major academic medical centers, pathologists are physically in the institutions’ laboratories every day of the week all year long to monitor quality, respond to patient care issues, attend to blood banking issues, interact with attending clinicians, and so on. This results in high-quality rapid turnaround of diagnostic cases, allowing more timely medical decisions by attending physicians and shortened length of stay for inpatients.

The focus of academic pathologists upon quality laboratory operations reduces the risk of malpractice liability for the medical center, its laboratory operations, members of the medical center’s medical staff, and referring providers in the community. There is a real cost savings associated with the skill and experience that the pathologists bring to the management and supervision of the laboratory in terms of decreased liability risk. However, many hospital administrators underappreciate time, experience, and skill that are required to effectuate such risk reduction. In addition to decreasing malpractice risk, the focus of academic pathologists upon the pathology and laboratory operations of the academic medical center also is important for the bottom line of the institution. The skill and expertise of academic pathologists enable them to advise the medical staff of the institution with respect to effective and cost-efficient ordering of laboratory services. The clinical and molecular pathologists within academic medical centers spend substantial time reviewing laboratory testing and assisting medical staff members in the interpretation of results, the diagnosis of patients, and the evaluation of treatment options. The time and effort spent by pathologists in these activities is directly related to fewer unnecessary laboratory tests and transfusions, better patient diagnosis and treatment, and earlier discharges, thus saving academic medical centers’ significant money. It is important to remember that virtually every academic medical center is compensated by the Medicare program for inpatient care on a bundled DRG (diagnosis-related group) basis and for outpatient care on a bundled facility fee basis. This means that the cost of almost all Medicare pathology and laboratory testing is bundled into a single payment rate. Where a fixed amount is paid to the academic medical center for an episode of care, a faster diagnosis and more effective treatment of the patient will result in an earlier discharge and a better bottom line for the medical center. Therefore, the more focused the laboratory testing, the better not only for patient care but also for the bottom line of the medical center.

Pathologists at academic medical centers often have extensive involvement in the oversight and utilization of cytogenetic and molecular testing. This type of testing is a very expensive proposition for all institutions, with much of the testing outsourced to specialty laboratories and purchased by the academic medical center. The cytogenetic and molecular testing options available to attending physicians today are vast, and it takes specific subspecialty expertise to assist medical staff members in sorting through the array of testing available to them and assist them in selecting the most efficient and effective testing for the needs of the patient. Effectively demonstrating the benefits of these services to the academic medical center depends in large part upon data to demonstrate more effective patient care and more cost-efficient patient care. As noted above, academic medical centers typically have strong IT infrastructure, with a greater ability to compile statistics that would assist the pathologists in establishing their value proposition to the academic medical center with respect to cost-effective and quality patient care. I am increasingly hearing stories of pathology residents who are particularly interested in data informatics and who will gladly assist in studies designed to support the value proposition of the services of the pathologists in the clinical laboratory operations. The value of residents not only to assist with this type of data compilation but also to bring their own IT knowledge to the table is a significant benefit that academic pathologists have compared to their colleagues in community settings.

Third-Party Payers

The same data that academic pathologists can utilize to support their contribution to the medical center’s financial bottom line also can be utilized by the medical center in its negotiations with third-party payers and accountable care organizations. With the increasing importance of shared savings under accountable care organizations, bundled third-party payer payment methodologies, and other payer incentives to provide cost-effective care, the academic pathologist’s part A services are critical to the financial success of the academic medical center. Without education (and frequent reminders) from the pathologists, the academic medical center may not appreciate the key role that pathologists play in the financial success of the center in the new health-care payment environment. Again, tapping into the data informatics available through the medical center’s IT infrastructure and the capabilities of willing residents to assist in data analysis, pathologists can promote their value proposition to the academic medical center.

As explained above, this value proposition is critical for third-party payers and accountable care organizations as well. Although most academic pathologists are not actively engaged in the negotiation of payment rates under the academic medical center’s third-party payer contracts, they can play a vital role in this process and could benefit from greater visibility in the payer contracting process. Increased costs of laboratory testing, especially of molecular testing, has become a major concern of payers, and many accountable care organizations already are intensely scrutinizing laboratory expenses. By emphasizing the critical role of the pathologist with respect to cost-effective quality patient care, the academic pathologist may have the opportunity to maintain current payment rates for the pathology and laboratory services and avoid the payment reductions that are frequently imposed by payers, if the payers can be convinced that incentivizing the pathologists to provide their critical part A and medical director services promotes a much more effective financial bottom line for the payer. In other words, without adequate compensation, the pathologists would not have the same incentive to provide these otherwise uncompensated services. Third-party payers and accountable care organizations who are looking for a real-value proposition and who have a good understanding of the role of pathologists may be receptive to these conversations. Again, data regarding actual cost savings and outcomes can be critical with respect to these conversations, and academic pathologists do have greater access to the IT infrastructure knowledge, expertise, and even warm bodies (in the form of residents) to assist in the numbering crunching and analysis.

The credibility of academic pathologists is also critical when it comes to coverage decisions by third-party payers, particularly the Medicare program. We are all too familiar with the inconsistency in coverage for molecular testing among the various Medicare administrative contractors, the increasing and often unfounded focus upon stringent and often arbitrary medical necessity guidelines, and the imposition of significant burdens upon the practice of medicine by pathologists through Medicare local coverage determinations affecting the ordering and performance of special stains and other additional pathology services. Too often private and government payers have a knee-jerk reaction to increases in utilization among pathology and laboratory services, responding by restricting or eliminating payment for testing or imposing significant hurdles for coverage. When organized pathology and individual pathologists petition the payers for relief, their pleas often fall upon deaf ears because the payers believe that they are primarily motivated by dollars. Academic pathologists, on the other hand, have a greater ability to bend the ear of these payers. Not only do pathologists affiliated with academic medical centers have the credentials that may be more impressive and persuasive to the payers, they also tend to be viewed as less money driven, given that most academic pathologists work on a salaried basis, rather than a private practice compensation model. Therefore, their comments are often viewed as less tainted by the dollars.

Importantly, academic pathologists also have the ability to secure an audience with government and private payers more readily than pathologists in community practice. The name of the academic medical center carries weight when attempting to schedule a meeting. Most medical centers have liaisons within the medical center who work regularly with the government and private payers and who can facilitate the scheduling of meetings with the payers. Once the academic pathologists have a forum with payers, they also have greater access to the data, analyses, and other research materials that can be persuasive with the payers in establishing the importance of coverage of the particular pathology or laboratory service or the inadvisability of certain local coverage determination policies from both a patient care as well as cost-effectiveness standpoint. Whether fair or not, the voice an academic pathologist who has subspecialty expertise, who is involved in research and teaching, and who may be a “headliner” in the medical community carries more weight than the voice of a typical community pathologist when dealing with government and private third-party payers.

Legislators

The same value proposition that academic pathologists can bring to conversations with government and third party also extends to federal and state legislators. Although many laws and regulations governing health-care services are well intended, they often have unintended consequences of burdening patient care and interfering with medical decision-making. At times, these new laws and regulations can result in poorer patient care and more expensive patient care. As an example, relatively few physicians would argue that mandated International Classification of Diseases, Tenth Revision (ICD-10) coding will make them better or more efficient physicians. In fact, most medical practices have scaled back patient appointments in anticipation of significant delays in physician coding and documentation based upon ICD-10 implementation. Given their credibility, perceived lack of pure financial motivation, critical role in patient care, and as a primary resource for the training and education of future physicians and health-care providers, academic pathologists have the ability to be more persuasive with federal and state legislators with respect to both desirable and undesirable proposed and existing laws and regulations. They can utilize the academic medical center’s political liaisons to schedule an audience with the elected officials to present their concerns. Moreover, many elected officials are more than happy to be invited to tour an academic medical center’s department of pathology and laboratory facilities, and such tours present a wonderful opportunity to gain political allies.

Additional Suggestions for Capitalizing on the Value Proposition

As explained above, pathologists who practice in academic medical centers have significant strengths and advantages which, if leveraged, can strengthen their own practices as well as support and expand the role of pathologists within health care. Unfortunately, if pathologists do not take charge of their specialty, nobody else will, and pathology will continue to be further commoditized by nonpathologists. Although no individual pathologist has the time to explore every angle to promote the value proposition of academic pathologists, there are a few key suggestions that academic pathologists may wish to consider as achievable targets to establish their value proposition.

One of these suggestions is to emphasize and promote the gatekeeper role of pathologists with respect to almost all medical care delivered to patients today. Few patients grasp the role of pathologists in their diagnosis and treatment, and unfortunately not enough physicians in other specialties or academic medical center administrators fully appreciate the role of the pathologists. Academic pathologists must “toot their own horns” regarding their gatekeeper role. However, they cannot stop there. Pathologists must also seek out, volunteer, or even grab opportunities to provide leadership in driving effective and efficient patient care. The gatekeeper role does mean more work, more challenges, and increased malpractice risk for the pathologist. However, without accepting the additional work, challenges, and risk, academic pathologists risk further erosion of the importance and value of their specialty and their role within health care.

Pathologists can publicize their gatekeeper role as well as promote themselves to the public through expanded outreach operations. Although many academic pathologists contribute to highly successful outreach pathology and laboratory programs, too many academic medical centers are focused solely upon their own inpatient and outpatient care, without recognizing the potential of active involvement in community health care. Over time, more and more of the provision of health care has shifted from the hospital setting to the community outreach setting. Unless pathologists are actively involved in the provision of pathology and laboratory services in the community setting, too much of this care will be left to the large national commercial laboratories.

Pathologists in academic centers also should take the opportunity at this time to begin laying the foundation, if they have not done so already, for a strong data repository that can be utilized to support the value propositions discussed above. Without good baseline data, it is difficult, if not impossible, to demonstrate increased quality of patient care as well as more effective and efficient patient care. Moreover, neither can be measured without ongoing collection and analysis of data. These efforts assist not only the pathologists but also the academic medical center as a whole, and most centers are very supportive of the development and expansion of data repositories for these purposes. Academic pathologists are uniquely positioned to play a leadership role in the development of these repositories and in analyzing them: their department generates the majority of quantitative information in the patient clinical record, and the pathologists are the “first to see” these data. Unlike community-based pathologists, the career paths of academic pathologists are aligned with the academic effort of exploring data repositories for knowledge generation. Increasingly in today’s health-care environment, there is an assumption that the one who controls the data controls the purse strings. Although this may be a bit of an exaggeration, it is advisable for academic pathologists to try to position themselves as the primary promoters and managers of these academic medical centers’ data repositories, so that they are the “go to” resources for the use of the data.

Finally, academic pathology departments are the home of physicians-in-training and other learners: pathology residents, fellows, medical students, graduate students, and beyond. The mentoring relationship between the faculty pathologists and the trainees in their department and institution supports both the career development of the learners and the creation of new knowledge.

In summary, from my perspective as a nonpathologist observer over the past almost three decades, I believe that pathologists and academic medical centers are uniquely positioned to reverse the disturbing trend toward commoditization of their specialty and promote a strong value proposition for the medical specialty of pathology. However, unless more academic pathologists assist in these efforts, I fear that the current efforts may not be adequate to fully safeguard the specialty.