The Essential Role of Pathologists in Health Care
and Health Policy
Ryan C. Romano, DO; Timothy Craig Allen, MD, JD; Melissa M. Blessing, DO
I n the June 2011 edition of CAP Today, then-College of
American Pathologists (CAP) President Stephen N.
Bauer, MD, authored an article titled ‘‘50 Ways to Leave
the Basement.’’1 In addition to challenging pathologists and
laboratory professionals to redefine pathology for our
clinical colleagues, patients, and the public, the article
provided specific examples of how to do so. One particular
line stands out: ‘‘To secure our place in the evolving
landscape, we must become aggressive intellectual and
economic capitalists.’’ Aggressive, one might say, is too
strong or that it connotes adversarial undertones, but
aggressive we must become, as we calmly and confidently
guide a detailed, well-informed dialogue highlighting our
critical role in patient care. We are physicians after all,
having been educated alongside colleagues who went on to
become internists, neurosurgeons, and radiologists to name
a few. However, legislators, clinicians, and patients are often
unclear on the role of pathology as a specialty and our ability
to direct cost-effective, quality care by merging diagnostic
skills with guidance on ancillary testing and patient
management. Similarly, as pathologists, we are often
unaware of the potential effect we can and should have
on the changing face of medicine. We can accomplish our
collective goals and take an active stand in the evolution of
health care by focusing on 3 primary objectives—that is, to
educate, to motivate, and to cultivate. This article will
focus on applying those objectives within the arena of health
care policy.
EDUCATE
In their primer on political advocacy, Gohlke and
colleagues2 aptly and simply state that ‘‘advocacy revolves
around education.’’ We must start by providing education,
both formal and informal. Our objective should be to
educate ourselves, legislators, and patients on 2 important
topics: the role of the pathologist in guiding cost-effective,
quality, health care delivery and the effect of current health
care policy on our specialty.
Educating ourselves and our colleagues on the essential
role of pathologists in health policy is critical. It is easy for
trainees and those in practice to overlook current health care
policy trends because our time revolves around learning our
Accepted for publication June 20, 2014.
From the Department of Laboratory Medicine and Pathology,
Mayo Clinic, Rochester, Minnesota (Drs Romano and Blessing); and
the Department of Pathology, University of Texas Medical Branch,
Galveston, Texas (Dr Allen).
The authors have no relevant financial interest in the products or
companies described in this article.
doi: 10.5858/arpa.2014-0335-ED
Reprints: Ryan C. Romano, DO, Department of Laboratory
Medicine and Pathology, Mayo Clinic, 200 First St SW, Hilton 11,
Rochester, MN 559005 (e-mail: romano.ryan@mayo.edu).
Arch Pathol Lab Med—Vol 139, April 2015
profession, signing out cases, or providing consultation.
Although education related to the science of pathology and
its application to clinical practice is essential, it cannot be
our sole priority. Even a small, individual shift in focus
toward learning about advocacy has enormous collective
potential. We cannot afford to delay our involvement. The
past few years have seen dramatic changes that affect our
field. The Affordable Care Act stands out as a significant
change affecting every medical specialty. Changes in our
health system structure, reimbursement, practice structure,
and competency requirements potentially affect our salaries,
our autonomy, and our ability to incorporate new technol-
ogy.3 A quick search of the College of American Patholo-
gists’ CAP advocacy page and online publication Statline
informs us of other pressing issues we must educate
ourselves about, including the importance of closing the
Stark self-referral loophole, repeal of the Medicare sustain-
able growth rate formula, and clinical laboratory pay cuts.4,5
Many of these topics have been chronicled and discussed
extensively in recent months, and thus, we will not focus on
them here, but it benefits us to prioritize self-education on
these issues. Advocating for our patients and for ourselves
as practicing physicians, who best understand how our
specialty and our skills can be used for optimal patient
outcomes, is the ultimate goal. We must begin by educating
ourselves.
Educating patients is another key—to inform them about
what we do and how our ‘‘behind the scenes’’ work is at
play in some way in most medical encounters in this
country. Advertising is one way to do that, as numerous
other physician and allied health professional organizations
do. However, advertising has its limitations, such as cost
and clearly defining our target audience, especially given
that our target audience includes essentially every health
care consumer nationally. Further, patients rarely, if ever,
have direct access to pathologists—some of this is our own
doing and to some degree is perpetuated by legislation. A
striking example of the latter is legislation in New York state
restricting patient-pathologist communication.19,20 Rana
Samuel, MD, with support from the New York State Society
of Pathologists and in conjunction with the CAP, is leading
the fight against that legislation. Without access, how will
patients ever be able to know what we do and see the value
in our work? We should all be encouraged to inform
ourselves regarding our state statutes and how they may be
affecting our practice, patient access, and outcomes.
Finally, lawmakers know little about what we do. It is up
to us to tell them. A few pathologists have led the way,
inviting lawmakers into their practice or laboratory to
highlight what we do, emphasizing the ways in which we
have a positive effect on patient care, and addressing some
of the consequences if pathologist reimbursement is cut.
Others attend local and national policy events, which not
Editorial—Romano et al 441
only promote our interests but also provide welcome
education to our legislators. The long-term value of
networking and educating at all political levels should not
be underestimated.
MOTIVATE
Concurrent with our efforts to educate, we must motivate.
Thankfully, external market pressures should be sufficient to
rouse all pathologists and laboratory professionals to action.
Whatever assistance those pressures may provide in giving
us reasons to get involved, however, they also pose
significant risks if we do not act, and act quickly. The CAP
leadership has been instrumental in guiding us through a
changing landscape and will continue to do so, but we must
also engage at all levels of our organization, from the
president and board of governors to first-year residents and
newly trained allied health laboratory staff. We must remain
committed to our mission and to working together as we
navigate an evolving health care economy.
Enthusiasm and optimism go a long way in promoting
long-term success, for each of us as individuals, for our
group practices and laboratories, and for our specialty.
When speaking with clinical colleagues, friends, families,
neighbors, and lawmakers, we can highlight the unique
aspects of pathology that set our specialty apart. ‘‘Talk up’’
pathology; be positive; emphasize the sophisticated nature
of your work. Speaking positively about our specialty’s
historic contributions, current applications, and future roles
in controlling health care costs and optimizing quality can
help clarify misinformation about pathology, while redefin-
ing the pathologist as a critical member of the health care
team with essential input into the future of medicine. We
must especially seek to motivate those in key positions to
affect change: lawmakers. Reaching out to our local,
regional, state, and/or federal government representatives
and senators is important not only to educate, as discussed,
but also to encourage these individuals to align with our
interests. It will take effort, but these efforts are rooted in
common ground. Every township, city, county, and state is
looking for better health care outcomes with lower costs,
and as has been stated countless times in numerous articles
and editorials, we, as pathologists, are best positioned to
lead this movement. As noted in a February 2014 Archives of
Pathology & Laboratory Medicine editorial titled ‘‘Medicine Is
Politics,’’6 we must be prepared to provide evidence-based
data in support of nearly every argument we make in
guiding an informed health care policy debate. Data to show
trends in improved outcomes and cost savings related to
changes in pathology practice or more-effective clinical
consultation are needed from all areas of anatomic and
clinical pathology, and we should look outside of traditional
‘‘pathology’’ journals when we submit our findings in
manuscript form for publication to engage a potentially
larger audience.
Although we, as pathologists, will likely generate much of
those objective data, many would argue that data high-
lighting the contributions of pathologists will hold less
weight if it is generated by pathologists. Thus, the input of
patients, who are also constituents, should comprise some
of those data. For example, our colleagues within the
American College of Radiology, another specialty with
limited direct patient access, enlisted the help of patients to
support opposition to reimbursement cuts for imaging tests.
In 2011, the American College of Radiology surveyed 1000
442 Arch Pathol Lab Med—Vol 139, April 2015
US registered voters on how they felt their care was
influenced by the use of imaging modalities and whether or
not they would support reimbursement or funding decreas-
es for those who provide those services. Overwhelmingly,
the survey results showed that patients felt diagnostic
imaging was vital to their care and that patients were
opposed to Medicare cuts for medical imaging.7 Is this self-
serving? Not when you consider these are objective,
unbiased opinions of patients who are consumers and
voters with valuable insight into health service delivery. We
should look for ways to gather these patient-derived
metrics, and the model used by the American College of
Radiology is one we may consider emulating.
We are also seeing increasing importance being placed on
patient quality and satisfaction surveys. These patient-
derived metrics provide data that may soon guide payment
schemes to supplement objective outcome measures. They
also provide insight into perceptions of value, motivate
practice changes, and are a component of the CAP
laboratory general checklist for accreditation.8 Because most
of those surveys rely on clinical measures as the framework
of scoring quality indices, there are few data on patient
satisfaction when it comes to laboratory and pathology
services, and those that do exist include both clinicians and
patients as our customers.8,9 The important role of
pathologists in every arena of health care, including
managing and avoiding adverse events, must not be
underestimated.10 Payment schemes are expected to in-
creasingly factor in patient-derived metrics (such as
satisfaction surveys) to supplement objective outcome
measures. This produces some trepidation in health care
organizations, particularly when it comes to managing
adverse events. Weissman and colleagues10 saw that in
cases in which an adverse event occurred during a
hospitalization, patient satisfaction was expectedly lower.
Interestingly, however, they showed that patient satisfaction
was comparable among those who experienced an adverse
event and those who did not when the health care team
exercised all 3 phases of something called service recovery, a
concept that reflects the efforts by a provider to return the
patient to a state of satisfaction following a lapse in service.10
These 3 phases include high participation in patient care
following the event, timely discharge, and disclosure of the
circumstances surrounding the event.10 The latter is where
we can have a substantial effect. Adverse events in
pathology practice may involve such elements as incorrectly
matched blood products or delayed histopathologic diag-
nosis. As our work will directly affect patient satisfaction
measures, and considering that our specialty is not immune
to adverse events, seeking opportunities and defining
mechanisms for us to be involved in service recovery
following an adverse event is clearly in our best interest.
Who better to direct service recovery than pathologists
following a pathology-related adverse event? Discuss this
concept with your colleagues, state society members, and
professional organization leadership to determine what, if
any, legislative barriers may hamper our involvement in
service recovery. Then, look to emphasize to policy makers
not only the value of, but also the need for, our
participation.
How do we transition from simply providing data to
articulating an outcome-oriented vision of our effect on
quality care, motivating both lawmakers and voters to
advocate for our essential role? We must frame the
discussion so that our ideas are obvious, appeal to common
Editorial—Romano et al
sense, and ensure they are fiscally sound. We underestimate
the power of ‘‘framing’’ only at our own peril. It is common
practice in politics and relies on imagery and metaphors.
George Lakoff, PhD,11 professor of cognitive science and
linguistics at the University of California, Berkley, outlines
strategies in his book Don’t Think of an Elephant! An excerpt
reads, ‘‘People do not necessarily vote their self-interest.
They vote their identity. They vote their values. They vote for
who they identify with.’’(p19) Examples he cites relate more
specifically to the populace voting for a candidate, rather
than to a lawmaker supporting a cause of his or her
constituents, but the model still applies to our situation as
pathologists. Our challenge is to frame our discourse with
lawmakers around common values, ones that are accepted
as good or optimal. By focusing on words such as quality
and patient safety, which are not only meaningful words but
are the central tenets of our mission as pathologists, we
maintain the frame around which all other discussions flow.
We then bring in examples of how reimbursement cuts
threaten our ability to maintain quality by forcing labora-
tories to cut personnel, decrease the time allowed for
training and continuing education, and possibly require the
use of cheaper and (potentially) less-reliable reagents, and
tie that into effects on patient safety. In anatomic pathology,
similar examples can be used regarding limitations on the
number of sections initially cut and how that may delay
diagnosis should additional sections be needed.
Attorneys and other groups with strong influence over
educating legislators rely heavily on anecdotal and theoretic
arguments in their discussions, centered around the
potential future implications of a particular vote on a piece
of legislation. Yes, that’s correct—theoretic arguments and
potential future implications—and this is effective, very
effective. Anecdotes are powerful, particularly when tied to
emotion. Attorneys and others are well-versed in playing on
that emotion, but, as pathologists and physician-scientists,
we tend to collectively be more analytical. This is a good
thing, and it is important for patient safety and quality care,
but logic, analysis, and statistics only go so far. Try to answer
this question—why do many sweeping changes in legisla-
tion follow emotionally charged events? Statistics are just
that, statistics, numbers which generally hold less weight
than the one, single, gripping, emotional story presented on
Capitol Hill or that plays out in the media. Anecdotes are
powerful persuaders if framed correctly and aligned with the
values and identity of your legislator. Stephen Sarewitz,
MD,12 touches on the power of an emotional connection in
his May 13, 2014, online commentary ‘‘Learning How to Be
Effective Influencers,’’ published on CAP Connect. Share
anecdotes with your colleagues, neighbors, legislators, and
so forth, about examples where you’ve seen a pathologist’s
involvement make a difference in patient care. It may be an
unexpected ‘‘catch’’ on a small biopsy, or a recommendation
to repeat a test using a different assay to confirm an initially
equivocal result. We must not just say what we do but be
prepared with examples to highlight our abilities to bridge
clinical and laboratory medicine—something no other
specialty is able to do—and to emphasize how those
abilities change patient management.
Motivating practicing pathologists, as well as the future
leaders in our field—pathology trainees—to be politically
aware and involved is also essential. ‘‘Physician advocacy is
increasingly recognized as a professional responsibili-
ty.’’ (13p827) Program directors and trainees will be well-
served to integrate this tenet into their education. As
Arch Pathol Lab Med—Vol 139, April 2015
mentioned above, changes in our health care system are
happening rapidly and have the potential to significantly
alter the future practice of pathology. Our profession is
already at risk for a significant decline in the workforce in
the near future (although recent assertions have challenged
that prediction), and ensuring that our field is protected
from unfair pay cuts and other undesirable restrictions
looming on the horizon rests on those who stand to be most
heavily affected.14,21 Current residents must own the future
of pathology. Involvement in CAP committees—including
the political action committee (PAC; known as PathPAC
within the CAP), the federal and state affairs committee, and
the grassroots PathNET committee—are motivating and
educational options for trainees and practicing pathologists
alike. Participating in CAP’s annual policy meeting in
Washington, DC, is another phenomenal opportunity to
simultaneously educate and motivate ourselves and elected
officials. Again, might we consider borrowing on the ideas
of another specialty? The American Academy of Orthopedic
Surgeons recognized that orthopedic resident involvement
in their organization’s sponsored political action committee
was a dismal 0.3%.13 Shah and colleagues13 evaluated a
number of parameters influencing resident involvement in
the PAC, including implementation of a faculty matched-
contribution program. That is, a faculty member matched
the donation given by a particular resident. They saw an
increase from 10% resident involvement to 95% resident
involvement following the initiation of that simple concept,
largely because residents could see that this practice was
greatly valued by faculty.13 Our otolaryngology colleagues
also see the value in monetary support for PACs, with one
author asserting that ‘‘making donations is step 1 in almost
any ‘how-to’ manual on advocacy.’’15(p802) Other barriers to
physicians donating to PACs include the perception that the
PAC represents a ‘‘special interest’’ group or that money
donated to a PAC may be directed to a candidate whose
position on a particular issue is contrary to that of the
individual donor. Simon15 addresses both of these concerns,
aptly noting that ‘‘almost everyone supports a cause that
others would consider ‘special interest’’’(p802) and that an
individual donor ‘‘supports the agenda of the PAC, not
every conviction of those to whom the PAC contribu-
tes.’’15(p802)
For our specialty to remain a respected, exciting, and
desirable field, and for current trainees to have the privilege
of being part of a solid workforce, residents must take
responsibility for the continued success of our specialty.
Educating themselves, motivating others, and taking action
are critical. Additionally, current trainees must remind
themselves that even though pathology is often considered
a behind-the-scenes profession, our viewpoints are valuable
and are, in fact, critical to the evolving health care climate.
Motivated trainees who are involved in health policy, and
particularly those who are mentored by experienced
pathology leaders, will critically shape the future of our
profession.
CULTIVATE
Cultivating relationships is mandatory for the successful
implementation of the above strategies. Lawmakers, health
system leaders, clinicians, and, of course, patients are all
people with whom we share common goals and to whom
we must reach out.
Editorial—Romano et al 443
 Cultivating relationships with legislators may be as simple
as writing a letter asking for support for a particular bill,
attending a town hall meeting, or sponsoring a fundraising
event. Many state medical and subspecialty associations have
a ‘‘Day on the Hill’’ event for physicians to meet their district
legislators and to lobby for current or upcoming bills. Larger
events, like CAP’s annual PathPAC-hosted policy meeting in
Washington, DC, provide an opportunity to learn about
current policy issues, to be coached on effective communi-
cation with lawmakers, and to lobby en mass for issues near
and dear to the profession while networking with like-
minded colleagues. Opportunities abound for resident
involvement, and legislators particularly enjoy speaking with
young, motivated, and passionate physicians who are aware
of, and able to articulate, the impacts of current health policy
bills and issues. Lawmakers are bombarded by numerous
special-interest groups lobbying for their goals. Practicing
pathologists and trainees—and even interested medical
students—would be well advised to also cultivate relation-
ships with their local legislators. These mutually memorable
interactions may have a far reaching effect on what becomes
the law that we will live and practice under and may form the
basis for a longer-term networking opportunity.
Political activism from our professional societies is
important, but nothing speaks to key decision makers more
than the voices of patients. As we educate patients on the
value of pathologists, we should also encourage patients to
seek out interactions or consultations with their patholo-
gists. Notwithstanding a projected workforce shortage of
pathologists and the fact that we are already trying to do
more with fewer resources, perhaps the best way to promote
pathology is through patients. We should welcome this
increased demand and strategize on how best to deal with
it. Patients can request consultations with us or ask their
treating physicians about the pathology and laboratory
services used by that health care group. Further, testimo-
nials from those whose care was positively influenced by a
pathologist are another way to highlight the positive effect
that pathologists have on patient-centered care. Transfusion
medicine and fine-needle aspiration clinics are perfect
examples of settings/services in which we can really begin
to engage patients and encourage them to seek out
information about pathologists. This absolutely requires
that we be ready for increased demand, but the alternative is
watching other specialties take an increasing share of the
market that controls dissemination of information to
patients. After all, if pharmaceutical companies and profes-
sional societies, including the nation’s pharmacists, target
self-promoting advertising directly to patients, why should
we have reservations about doing the same?
There are many challenges we will be facing both within
our specialty and along with physicians from other
disciplines as the effects of policy changes begin to take
shape. However, with every challenge comes opportunity,
and we are poised to make the most of these challenges. It
will be difficult and will require us to tread in perhaps
uncomfortable and uncharted waters. We have outstanding
leadership within our specialty, dedicated personnel, and
energetic and innovative trainees and junior pathologists. In
addition, we have outstanding resources available to help
provide guidance and a means of communication as we
work together toward our goals. CAPconnect is one forum
that facilitates optimal use of these resources. For example,
in one week, CAPconnect provided the following content: a
podcast featuring Rana Samuel, MD, highlighting her work
444 Arch Pathol Lab Med—Vol 139, April 2015
through the New York State Society of Pathology in
collaborating with CAP to fight legislation in New York
restricting pathologist-patient communications; an article
from Michael Misialek, MD, on his political fundraising
activities in Massachusetts; and a Webinar moderated by
Richard Friedberg, MD, PhD, featuring distinguished CAP
members on how to articulate our value to health care
executives.16–18 We must all look for ways to get involved
and be our own advocates, no matter how small or
insignificant we may think our contribution will be. If each
of us can simply pick one thing to focus on and put that little
bit of extra effort toward enhancing and promoting
pathology, we may be surprised at how much we can
accomplish collectively. Just one thing, that’s all it takes.
From private practice to the laboratory, academia, and
forensics, the rapidly evolving health policy environment
affects each of us greatly. We must have a voice.
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