Why I Entered the Field of PathologyMichael Laposata, MD, PhD

There were just too many heart attacks in my family. When I learned that both heart attack and stroke were caused by fat deposition inside blood vessels, I decided to do something with my carer that led to fewer people suffering from acute coronary syndrome and disabling stroke. I did a summer research project before starting medical school involving platelets, and the last time I had that much fun must have been in a playpen. The MD PhD program was a new thing right at that time, and since the research lab was so fascinating, I spoke with Dr. Lockard Conley, the chief of hematology at Johns Hopkins to obtain some advice. He suggested that I enroll in the MD PhD program and learn the basic biology of the blood vessel wall, platelets, lipids, and coagulation factors. However, most importantly he told me to not become a hematologist like him. I was stunned. He said that hematology was going to be merged with oncology and that insurance companies were going to pay handsomely for oncology, but not for hematology. When I asked him what he thought I should do for my graduate medical education so I could pursue my interest in atherosclerotic vascular disease, he told me to be a pathologist! That was the last thing I expected to hear. He said that pathology has so many different service lines that it manages, as more complex and more expensive diagnostic studies are developed, pathologists will one day be absolutely essential to provide diagnostic expertise for all but the simplest cases. He said coagulation was likely to become a specialty in pathology, just like transfusion medicine had made the transition from internal medicine to pathology.

As we were sitting in his office, he asked me if I wanted to pursue training in clinical pathology with a focus on coagulation. Talk about making a major life decision in 30 seconds or less! I told him yes, and then he asked his assistant to call Dr. Philip Majerus in Washington University where clinical pathology was springing up and had the right cohort of forward-looking pathologists across both anatomic and clinical pathology. I bought the plane ticket to St.Louis, gave the talk to become a postdoc in Dr. Majerus’s lab, applied to and was accepted into the clinical pathology program at Washington University, and then I realized I had a lifetime of work to do. I saw that Dr. Conley was right when he said there were many service lines, but I also saw that pathologists were not actually involved in helping the doctors taking care of the patients whose blood was passing through their laboratories. The blood came in, and the numbers went out, and if the physician receiving the results did not understand the meaning of the test results, the patient often experienced a misdiagnosis. Misdiagnoses cost a fortune, they hurt people, and I watched as nobody was involving me in pathology when they needed help to figure out the causes of hemorrhage and thrombosis because there was an assumption that pathologists only manage the labs, but do not provide diagnostic information, without being asked, outside of anatomic pathology.

So, what I saw as a pathology resident made it clear that to me that I and my 20,000 plus colleagues had a mission to tell doctors which tests to order and make it easy to do that. We also had to tell them what the test results meant in the context of the clinical problems of the patient. This had to be true not just for anatomic pathology but for all the other service lines pathologists manage. We had to be the doctor for all the doctors who saw something they did not fully understand, or even worse that they thought they understood, but actually didn’t.

For all of this time since 1985, during my time on the faculty at the University of Pennsylvania, the Massachusetts General Hospital/ Harvard, Vanderbilt, and the University of Texas in Galveston, we have been stepping only gently forward into this powerful diagnostic role that defines what a pathologist does --- that has longevity and that cannot be replaced by even the smartest machine. We are the doctors who are the experts in formulating diagnoses accurately, quickly and at the lowest cost. As healthcare gets more complex and more expensive, as long as we step up and fully direct complex diagnostic evaluations well, hospital leaders will come to know that they need us more than anyone else. The clinical service of pathology must define itself as the diagnostic discipline across all the areas for which we are responsible for the testing.

A pathologist anywhere today can gain a specialty expertise for a disorder that makes them valuable to all fellow pathologists across the country, especially now that we are learning the intricacies of Skype and Zoom. The APC can bring networks of pathologists together to help a local pathologist for a case in their own hospital, making all pathologists valuable in a way that they have never been before. We can organize our expertise in pathology across all disease groups. The earning potential needs to grow for synthesizing diagnostic data. It certainly will not be getting larger if our practices confine themselves to the service lines involving only a microscope. We have the talent and the broad expertise among us, and we must create a system in which we all help each other as diagnostic experts.