CLINICAL PATHOLOGY TODAY* CARL W. MAYNARD "Apart from the guarantee of our own convictions, the observable direction of living nature is our guarantee of right." (Julian Huxley) Custom decrees that each president of this society shall render an up-to-date report on the state of the clinical pathologist, as he understands it. My predecessors have done their duty in this respect with noteworthy success. They have defined the clinical pathologist as "a consulting physician whose chief interest lies in the diagnosis of disease by laboratory methods." They have shown that the clinical pathologist is an inevitable and essential product in the evolution of scientific medicine. They have recognized the fact that since his contacts are chiefly with fellow physicians rather than with patients, he must be of exceptional personality and training. They have demonstrated that both the patient and the patient's medical attendant benefit from his'counsel. Indeed, in the diagnosis of malignant disease, and in the development of hospital organizations, he has been classed as indispensable. The economic phase of the specialty is influenced by numerous factors, among which may be noted the facts that much medical laboratory work is institutional; that technical diagnostic procedures can be carried out by highly trained workers who are not physicians; and that current practice in medical education presumes that all graduates will possess a certain degree of skill in the use and interpretation of laboratory findings. Based on these accepted facts it has been suggested that clinical pathology is a specialty only of convenience, not of necessity. A survey of the practice of medicine today establishes beyond question Presidential Address before the 17th Annual Convention of the American Society of Clinical Pathologists, San Francisco, June 9-11, 1938. 383
384 CABt W. MAYNAED the essential importance of the specialty. Unless the future brings lesser ideals and lower standards of scientific excellence in the care of the sick, the necessity for physicians specially skilled in diagnosis by laboratory methods will continue. When the first clinical pathologist began his practice he was pioneering a missionary with a new medical gospel. Today every medical student has the opportunity to learn the elements of laboratory diagnosis. The graduating interne enters practice more or less familiar with the common laboratory procedures, and for a time may perform them himself. He can employ a technician, and frequently does so. If his technician has a current certificate from the Board of Registry, she should do reliable work. This is a proper procedure, and the only way many unhospitalized patients can be furnished prompt and economical routine laboratory assistance. But the basic sciences are extensive and changing. The general physician cannot keep up with them as his clientele increases. Within a few years his medical school technique is forgotten or superseded, and he does need, and call for, assistance from the laboratory specialist. The clinical pathologist is a physician, not an overpaid technician. He developes technical procedures for the benefit of the sick, then plans for their widest possible use. Measures which are universally known, easily applicable, and self-interpreting are properly carried out by each physician for his own patients. The rhinologist does not treat all cases of rhinitis, nor the ophthalmologist every conjunctivitis. In the assembling and development of useful laboratory aids, in the training of technicians and the supervision of their work, and in the field of tissue pathology, the clinical pathologist is established. His leadership in a most progressive phase of medical diagnosis will continue to be indispensable. As to the present condition of the clinical pathologist, in June, 1938, there are, however, several phases worthy of notice. 1. The prevalent opinion that laboratory costs are high, if not excessive. Every reader is familiar with the current expression "expensive laboratory service." This idea was prominent in the report of the Committee on the Costs of Medical
PRESIDENTIAL ADDRESS 385 Care, and in that report was linked with the suggestion that laboratory services should be rendered by the State or by its subdivisions. A recent commentor suggests that the pathologist has been less vocal in keeping his work before the profession because so much of his work is mechanical. The failure of the Committee on the Costs of Medical Care so much as to mention the Clinical Pathologist as a part of the medical picture, was undoubtedly due to ignorance on the part of the Committee, and ignorance could well have been due to the lack of a pathologist spokesman. We have been too much devoted to mechanical work with not enough real practice of clinical pathology. Certainly laboratory tests do cost something; even more certainly their direction and interpretation must be considered as part of the costs of medical care; and just as certainly does this expense contribute as much to the patients' welfare, dollar for dollar, as does any other part of the healing art. Consultation fees need not be charged for the simplest of routine tests, and charges are adapted to low incomes by every physician. The expression "expensive laboratory service" should be replaced by "indispensable laboratory service." 2. The variety of situations in which the clinical pathologist is carrying on his activity, and the opportunities in these situations. The American Society of Clinical Pathologists has 533 members, which includes approximately half of the physicians who are eligible for membership. A rather loose classification indicates that of this number there are about 27 teachers and research workers, 265 hospital pathologists, 44 group clinic pathologists, 168 pathologists practicing privately, and 29 public health workers; federal, state, county and municipal. The intimate correlation of teaching and research prevents more than a formal division under the two terms. In fact many research problems are receiving competent attention from workers in each of the subgroups of clinical pathology. The teacher must fit the medical student with a fundamental understanding of the laboratory sciences in their relation to the diagnosis and treatment of disease. He may well be ex-
386 CARL W. MAYNARD pected to present the need for the specialist in clinical pathology, his professional advantages, and what he may expect financially. Contemporary attempts by members of the medical profession, and others, to promote governmental aid in financing medical schools may prove to be an early step in changes which will involve the clinical pathologist as a teacher, along with the rest of the educational organization. Pure research endeavors likewise are subject to economic influences. Endowments rise and fall, commercial possibilities stimulate current financing, and the federal government contributes. Opportunity is here for the pathologist who is qualified by ability and training. The field of the hospital laboratory is by nature a large one, and has its own problems, often discussed before this Society. The concentration of patients necessitates a concentration of diagnostic facilities. Since a certain part of hospital laboratory work is routine, a repetition of well-established procedures, it is proper that we have secured technical assistants to carry out this routine. Large institutions, well endowed, furnish abundant opportunity for the clinical pathologist as organizer, director, and consultant. The smallest hospitals, dependent entirely upon earnings, must have such technical help as they can afford, and too, such professional laboratory supervision as they can afford. The hospital neither large nor small presents a special problem. Here earned income can furnish equipment and technicians, but the struggling institution often accepts the clinical pathologist as a too expensive technician rather than as a valuable member of the staff. As a compromise, the combination pathologist-roentgenologist has been an economic success in some institutions. Hospitals furnish concentrated opportunity and concentrated difficulty. From the standpoint of service to the sick, it is certainly in the hospital that the pathologist-consultant finds his greatest opportunity. The furnishing of laboratory service to the ambulatory patient and to those confined in homes, is as large a field as that of the hospital, but scattered over much more territory. It is here that the private clinical pathologist is particularly needed. In
PRESIDENTIAL ADDRESS 387 his absence, and for routine work under the supervision of a physican employer, the technician is of definite value, but there is a natural, though unfortunate, tendency for the employer to ask more than routine services from his technician. Here the clinical pathologist can be of assistance by teaching, in medical society and hospital staff meetings, the use and interpretation of measures which the clinician and his technical assistant can safely employ. Such educational activity is a valuable part of the practice of clinical pathology, and may also remind the medical profession that consultation from the laboratory is available in diagnostic problems. In the group clinic laboratory is found another plan for giving to the nonhospitalized sick diagnostic consultation as well as routine laboratory service. Each community has its own particular conditions which determine whether the group clinic or the private laboratory will best meet the needs of the profession. The cooperative laboratory, with pathologist and technicians furnishing unlimited but properly chosen diagnostic aids to the patients of the physicians associated, has been found satisfactory in some locations. Three branches of the federal government provide opportunities for a limited number of experienced laboratory workers. The Navy employs pathologists in all naval hospitals and on board the hospital ships. These pathologists are commissioned officers in the Navy. In the Army there are 49 officers who are listed as laboratory officers and pathologists. One has the rank of Colonel, 29 are Lieutenant Colonels, five Majors, and fourteen Captains. Work done under their direction is similar to that in the laboratory of the general hospital. Some of the laboratories also do water and food analysis. The Public Health Service has in its professional ranks eight men who are classified as pathologists. In addition to this the Service includes 38 clinical medical technicians and 41 research medical technicians. Except for three technicians at the National Institute of Health, the technical assistants of the Public Health Service are understood to be under immediate professional supervision.
388 CARL W. MAYNARD State, county and municipal health departments should present abundant openings to physicians trained in clinical pathology. Valuable work in preventive medicine is done by the tax-supported laboratories of the United States. Where appointments are permanent, subject to Civil Service, attractive work is available for competent clinical pathologists. There are tendencies, however, in public health laboratory work which keep it from harmonizing fully with medical ideals. Political influence has been known to supply incompetent technicians to directors who wish only expert assistance. Again, the ambitious laboratory chief may do all the work his public health field calls for, then seeking valid argument for increased support, be led to expand beyond the poorly-defined limit between preventive laboratory service and the practice of general clinical pathology. This tendency, though difficult to defend, is natural, and is part of the background of changing ideas in medical practice. 3. Much of the agitation for increased governmental activity in the care of the sick is being based upon the idea that there is a social class, the low-income group, neither indigent nor affluent, which cannot easily pay for medical care, and which accordingly is chronically suffering from lack of proper attention. Regardless of the merits of the agitation, the subject has received much publicity. The apparent need for a new type of medical practice has thus been urged, first by the Committee on the Costs of Medical Care, and more recently by the American Foundation, which has assembled and published portions of letters from selected physicians, under the title "American Medicine." The evidence selected for emphasis from the testimony given, and the occasional forced conclusion, suggest that these investigations have been planned as propaganda for the socialization of medical practice. Whatever the purpose, a portion of the press has acclaimed the material presented as newsworthy. A considerable number of county medical societies have established plans for helping the low-income group in the financing of adequate medical care. This has been done by physicians who have seen a definite way to be of service in today's social economy. By physician-controlled prepayment or postpayment
PRESIDENTIAL ADDRESS 389 contracts, individuals and families having incomes between $900. and $1800. a year, or thereabouts, are being given the privilege of choosing a doctor from the medical society's members, and receiving personal care, payment being adjusted in some way to fit within the available budget. Just as group clinics have succeeded partly in somewhat similar work, these experiments by medical societies are partly successful, and with experience should become of great value, if the need for them continues to exist. The clinical pathologist should fit easily into this picture. If the method involves the adjustment of charges by every cooperating physician, the pathologist is of course included. If payment is prorated from a prepaid fund, laboratory advice will be called for with less hesitation than has often been the case under purely individual practice. If hospitalization is included in a prepayment plan, the pathologist's services should be paid for, with those of roentgenologist and anesthetist, as professional care, not as part of the hospital per diem. Each community has to work out appropriate details in its own medical society plan, and the pathologists in each group must join in deciding how medical care is best to be furnished. 4. The possible eventuality of a nationwide insurance project, federally controlled and tax supported, furnishing medical care and hospitalization to the entire populace, cannot be ignored. If it comes, the clinical pathologist should fit into the plan as. well as others with special fields of work. The organization of considerable numbers of physicians, under whatever auspices, creates an increased opportunity and demand for physicians of special ability and training. We will do well, however, to learn from the experience of clinical pathologists in England. According to Dr. S. C. Duke, President of the Association of Clinical Pathologists, the British State Medical Service provides no facilities whatever for laboratory aids to diagnosis. After the Association was organized about eleven years ago, an attempt was made to have laboratory investigations included under the panel benefit. For a time success seemed possible, but it has never been attained. Efficiency demands, but other government expense prevents. The voluntary hospitals in some cases allow
390 CAKL W. MAYNAKD the use of their laboratory facilities by panel physicians, and so in part help make up for the deficiency of the State Medical Service. State Medicine may not become a reality in the United States soon, but the clinical pathologists should have a share in whatever planning is being done. To summarize the situation as reviewed: 1. Clinical pathology has evolved as a necessary part of medical practice. 2. Technical assistants can legitimately perform routine laboratory tests for clinician employers who are prepared to make their own interpretations and assume responsibility therefor. 3. The clinical pathologist is entitled to adequate professional compensation for diagnostic consultation, for laboratory supervision, and for other professional services. 4. The American Society of Clinical Pathologists includes in its membership several types of workers, the majority of whom supervise hospital laboratory services, or combine private laboratory practice with hospital work. 5. A small number of clinical pathologists are found in the various government services. 6. Clinical pathologists will be essential in health insurance plans equally with other specialists, whether the plans are controlled by the medical profession or by the federal government. 7. The American Society of Clinical Pathologists should share in the planning of improved medical care for the low income group.