CAP at 75 - Leading Through Change--Then and Now

• CAP Historical Timeline

Julie McDowell:

Welcome to the CAP's CAPcast series, celebrating our 75th anniversary. We're here with Doctors Paul Bachner and Paul Raslavicus. Serving back-to-back terms, Dr. Bachner was President from 1999 to 2001, and Dr. Raslavicus was President from 2001 to 2003. In this CAPcast episode, Doctors Bachner and Raslavicus discuss seminal aspects of their presidencies, including navigating their leadership transition during 9/11 and the focus on bioterrorism following the terrorism attacks. Dr. Bachner will also discuss how the CAP's educational focus shifted under his leadership, and Dr. Raslavicus will discuss why he's so passionate about advocacy and both will offer advice to not only incoming and future CAP leaders, but also pathologists who are early in their careers.

Julie McDowell:

So to begin with, there was a lot going on during both of your presidencies, Dr. Bachner, SNOMED, the most comprehensive clinical terminology was created by the CAP and is now used throughout the world, but it has undergone many transformations since your presidency. Can you tell us a little bit about these changes?

Dr. Paul Bachner:

Yes, I certainly can. SNOMED is really one of the crowning achievements of the CAP, and it was created many, many years before my presidency, and actually the first version of it was actually called SNLP, SNLP, the System that Ties Nomenclature of Pathology, and it was only later that other arms, if you will, of the vocabulary were added and it became SNOMED, the Systematized Nomenclature of Medicine.

For many years, SNOMED was maintained exclusively by the CAP and developed and grew, and very early on in the course of my presidency, as a matter of fact, I think it was within a week, I traveled to London to meet with representatives of the National Health Service who had a somewhat similar program called the Reid Codes named for Dr. Reid, R-E-I-D. And they were basically for private practice primary care physicians. As a result of that meeting, the two codes were merged and the SNOMED then became SNOMED CT or SNOMED Clinical Terms, and that was sort of a very major achievement. And then subsequently there were negotiations with the National Library of Medicine, which I was a member of the committee, but I think by that time Dr. Raslavicus was president and he oversaw that merger process. So I'll let him talk about that.

Dr. Paul Raslavicus:

Well, yes. I sort of came in at the end of the creation of SNOMED CT and actually signed for the college to provide the National Library of Medicine the right to distribute the nomenclature at no cost to any user in the United States. It was really a finale in the growth from SNLP nomenclature pathology to a full terminology for clinical medicine. The addition of the Brits into the formula, in which Dr. Bachner was very important, really since then has moved it into a totally international or a worldwide accepted nomenclature run by an organization that has a slightly complex name, I think say International Health Terminologies Standards Organization or something similar. But they've gone back to using SNOMED for marketing purposes, SNOMED CT. It's developed throughout the English-speaking world as well as many other countries.

Julie McDowell:

So Dr. Bachner, another change that started during your presidency was the transformation of education from an ancillary program to a freestanding one. Can you talk a little bit about how that happened?

Dr. Paul Bachner:

Yes. It was a slow evolutionary process, but with some pride, I can say that it started during my presidency and then was continued by Dr. Raslavicus and even subsequent presidency. The college has always had a mission of education in addition to laboratory excellence and advocacy for the members. But for many years, education was really sort of the handmaiden to the surveys and accreditation programs. The national meetings which were joint with the ASCP, the educational content was driven more by the ASCP than by the CAP.

During my presidency and during Dr. Raslavicus' presidency, the two organizations decided to go their separate ways in terms of the national meeting and the ASCP has a very successful national meeting now, as does the CAP. But parallel to that process, the CAP devoted major, the board agreed to put major resources into education and made education into a freestanding program that was designed to meet the needs of the members in an environment where the science of laboratory medicine was rapidly expanding and becoming more complex with the advent of molecular and genetic pathology.

So it was a see change for the CAP. Ultimately, a council, a freestanding council on education was created a staff with very specific and high level training in program development and education was developed. And now the CAP has, I think it's fair to say, in addition to laboratory excellence and advocacy, education of our members has become a major program. During the COVID epidemic, a whole group of online programs were developed to help pathologists and other laboratory professionals deal with the very complex issues of testing for COVID. So when I look back on my presidency, if there's anything I sort of take pride in, it's the start of the process of education as a primary of which then was followed up by Paul and by other presidents.

Julie McDowell:

Dr. Raslavicus, can you talk a little bit about what changes occurred during your presidency related to education offerings from the CAP?

Dr. Paul Raslavicus:

Well, certainly the national meeting, the joint national meeting had seen a decrease in attendance that lasted a number of years where, in a short period of time, there was almost loss, 50% of the attendance of that meeting. And there was a joint group between the CAP and ASCP, I think during Paul Bachner's time that met to discuss the issue of the national meeting. As it evolved, the two organizations met "truly joint meetings" for a couple of years, and they were not satisfactory, I believe, to either group. And so they went their different ways. One of the consultants at that time spoke about the two organizations, one being more introverted and the other one being more extroverted, and that was presenting some conflicts in how the programming was being made.

So the college went off to develop a very broad individual involvement in their programming. They evolved into larger and specific topic oriented presentations for a period of time, at least, I don't know if it's continues, it actually would present some of these programs and with other pathology organizations such as USCAP, and they were well attended. The other thing that happened, as a consequence of the change in education, was really the redevelopment and reactivation of the college's residents forum into an active organization, which had its own fairly long meetings. It had its own powers and in fact developed voting powers within the board because the board was very interested in allowing the people that were receiving the education to have a word to say in what kind of education was made and how it was presented.

So I think you see at this point in time, a couple decades of evolution of education within the CAP, and it is dramatically different than it was at that period in time. It also opened up much better attendance in the exhibit halls, and I believe really invigorated the membership because they're really part of what's going on to a very great extent.

Julie McDowell:

I want to shift from education right now to talk a little bit about a historic event that occurred during your presidency, Dr. Raslavicus. You began your presidency during the 9/11 bioterrorism attacks. Can you talk a little bit about what that was like and how you navigated and led the CAP during this time?

Dr. Paul Raslavicus:

Well, actually, the person that was there in the driver's seat during the attack in September 11 was my predecessor, the other Paul, and maybe he could tell first what happened, if anything special in the first 30 days or so.

Dr. Paul Bachner:

Yeah, 9/11 took place during the last month of my presidency and obviously it's many, many years back now, but if you start to remember, there was a great deal of confusion when it happened. No one knew whether there would be other attacks. There was a great deal of concern about air travel and safety of air travel. So one of the things that happened during my presidency with the support of the board was we put a halt to all air travel by members and put and held no meetings. And this was of course, pre-Zoom so there was really no way to hold meetings other than by telephone conference call. But the college essentially stopped meeting for a month because we just felt that it was necessary for the safety and the sort of confidence level for our members. There were a number of other things that the college did to support our members, but that really was just about the last month of my presidency and what happened after that, Dr. Raslavicus can talk about.

Dr. Paul Raslavicus:

Well, as it happened, my inauguration was not that far from New York City, in fact, it was in Philadelphia. And my inauguration speech was extremely focused on what happened in New York and really had a lot of patriotic thoughts were brought into it, such as from many separate states, we're now a United States and we will not tolerate this kind of aggression, et cetera. And it starts with these thoughts and it actually finishes with God Bless America kind of thought, reciting one of the famous American patriotic poems. And the meeting was well attended, I think it was the first meeting after a month long break.

But after that, and very shortly thereafter, bioterrorism became the name of the game because of the anthrax attacks, which occurred I think in October and perhaps early November. Those led to a number of meetings of the college with the Secretary of Health and Human Services, Tommy Thompson, previous Governor of Wisconsin to discuss this. This further led into a number of publications and messages from the CDC to the National Clinical Laboratories about how to be prepared for a bioterrorist attack and how to identify organisms such as anthrax in the clinical lab. So there was a focus for a significant time, perhaps a year or two before the pressure went off of that and we went on to talk about other things.

Julie McDowell:

Dr. Bachner, you've got two specific pieces of a device for incoming CAP Presidents. What is that?

Dr. Paul Bachner:

Actually, I have three. The first is to listen far more than you talk. That's not a novel concept in the management theory, but I can tell you that during my presidency, I tried and I learned to listen carefully because the knowledge base that exists in the college from its members and the committees and the councils is mind-boggling and is unmatched anywhere I think in the world of medicine or science. So my first piece of advice is keep your ears open and your mouth shut as much as possible.

My second piece of advice is the college is a very, very complex organization and is blessed with having a very capable staff. And so my second piece of advice is work closely with staff.

And my final piece of advice is to skip dessert because it makes the process of all the meetings that you attend easier. One, it means you get to go to bed an hour earlier and you don't gain any more weight than you need.

Julie McDowell:

How about you, Dr. Raslavicus? What advice do you have for incoming CAP Presidents?

Dr. Paul Raslavicus:

Well, I sort of second what Dr. Bachner has said, and I think that I certainly knew that I was not an executive person, but I was the leader of the board and it was the board that was making the decisions, and I represented their opinion as well as mine. So that it is by far not just a particular presidency, but it is not an executive position such as a US president has. The board is filled with very competent and confident people with strong opinions, and sometimes it is not possible to determine which way things are going to go at the end of the day for one individual. So you moderate the system, but you do not really control it. For example, my experience was that every incoming president presents a strategic plan for the future, and when it comes in one way, it might come out quite different when it is vetted by the individuals that comment on it and promote it.

One of the issues at that time was how much international involvement should the college have? Or should it just focus its work on the US pathologists, which we represent? It is true that we had a number of things that we were doing internationally. We were actually inspecting over a hundred laboratories around the world under our inspection program at that time, we had major role in an organization that in fact, the college helped establish at the end of World War II called the World Association of Societies of Pathology and Laboratory Medicine, and we were their laboratory equality bureau. And there were some people who wanted to have more involvement internationally and in fact, at one point we voted to add presenting pathologists in the US and the world however, our motto goes. Thereafter, it got removed for a few years, and I think it is well back again that we are involved in world pathology. So that's a little brief summary of what was going on during mine.

Julie McDowell:

Dr. Bachner talked a little bit about how his advice would be to listen more than talk, but I know both of you maintain a mindset that change is inevitable. Can you talk a little bit about how this approach has served you in your life in leadership? Dr. Bachner, can we start with you?

Dr. Paul Bachner:

Well, yes. The change that has taken place in pathology and medicine in my period of practice, which is now essentially retired although I still do some teaching, but it's almost 50 years, the change is incredible. When I teach my residents laboratory medicine, I sort of share with them how thyroid disease was diagnosed 50 years ago, and they don't even know what I'm talking about. It's a language that's totally unknown to them. And then when I tell my residents that when I finished my training, there were three lymphomas, they stare at me as if I'm from the dark ages, because now the last time I looked, there was something like 22 lymphomas. So change has been enormous and continues, and the change not only is in the science, but in the practice of pathology and see changes in the last 10 years and how pathologists practice the size of the groups, the nature of the groups, the relationship of the groups, the shift of pathology practice in part from a private basis to a hospital owned practice.

So a great deal has happened. And one of the things I learned during my presidency was that it was all well and good to make plans and have a strategic plan, but things happen. It's like the famous saying of some Prussian General that it's all very well to have a plan of battle, but it goes away as soon as the first bullet is fired. And I found during my presidency that things just changed and things would come up and one would just have to sort of deal with it as best one could and gather as much advice as you could and deal with it. But change was with us then, is with us now and will be with us in the future.

Julie McDowell:

Dr. Raslavicus, what's your thoughts on this in terms of change being inevitable?

Dr. Paul Raslavicus:

It is really true when you look at Dr. Bachner talks about how things were 30, 40 years ago, a hundred years ago, we were barely looking through the microscope and there was absolutely nothing more to look at than red and blue colored artifacts. And it was during our active involvement that molecular pathology came into being, nuclear medicine now known as computer tomography came in, and some of us in pathology, because the radiologists did only x-rays, so some of us in pathology actually were certified in nuclear medicine and did things such as lung scans and brain scans. Some of us were able to maintain our interests, otherwise some people just faded out of that particular zone. Now we're trying to come back into fine needle aspiration.

I remember on my first job in pathology, I was walking around and doing bone marrow biopsies on some patients in beds until the surgeon said, "Wait a minute, you don't have any surgical privileges." So you have to ride with the change and the college and its membership are the ones that are going to determine the future of our specialty and which areas we are proficient and interested and learn and in which areas we give up. So change is inevitable, but the purpose of, I think, our organization is and has been to reconfigure the future to the best interests of the people that we represent and who are the legacy for the future.

Julie McDowell:

So finally, I'd like to hear from both of you about how the CAP helped you to grow and develop as both a pathologist and a leader. And if you can tell us a little bit about some of the experiences that made you a better pathologist. Dr. Raslavicus, can we start with you?

Dr. Paul Raslavicus:

When I arrived on the scene, I was an officer, junior medical officer in the Navy. We met downtown on State Street in Chicago at what at that time was a famous hotel. And people were concerned even then about well-known pathologists at that time. He had something called a Sayonara Hypothesis, and that is if we don't change and we don't broaden our aspects, we're runners. So that struck an interesting thought in my mind because other people, like a pathologist physician by the name of Shenkin were very interested in promoting advocacy. And I wound up heading in that direction more than I did, rather in the direction of teaching pathologists. And therefore, I became very active in the affairs of the Washington office and as well as with the AMA representing the College of the AMA.

And from there was the time where Medicare was changing the way they're paying all physicians, not just pathologists. And the first attempt by the government was to declare all of pathology as a non-professional field. So first we had to defend anatomic pathology. And then second, we had to defend as much as we could of clinical pathology as being physician services. That led me into become the representative for organized pathology in the creation of the scale of reimbursement for services. And we had a specific fight about what's a pathologist service? Is that everything that the surgeon does at that time or is that a service for the entire hospitalization of a patient? And through my efforts and the leadership of one or two Presidents that existed at that time, we wound up being able to define service and pathologies being the specimen. So if there was four or five specimens in one procedure, in fact, there were four items of service.

The levels of service were integrated throughout all of medicine into one bucket. So that, I don't want to call it was a privilege. It was a bit of a problem to represent the entire specialty as a solo person and defend the proposed relative value given to our procedure A to somebody's postoperative examination of a patient that got surgery two months ago. And I got quite involved in that. I think Paul can verify that.

And through that, I became more and more involved in administrative affairs. In fact, in practice, I advocated for pathologists being more involved with their laboratories. Here in the Boston area we created one or two pathologists that owned the freestanding labs, lasted almost up to this time as a division of Mayo Clinic. And from that, I wound up getting a Master in Health Administration Degree in mid-career. I'm glad to see that the incoming president, Emily also has an MBA degree because that way I could defend our position better with all those people who are administrators, who many of us think are the issue that we have to very closely monitor.

Julie McDowell:

Well, thank you. And Dr. Bachner, can you talk a little bit about how the CAP impacted your development as a pathologist?

Dr. Paul Bachner:

Yes, I certainly can. Before I do so, I just really want to emphasize the seminal role that Dr. Raslavicus has played in the development of the RBS system. Every pathologist today in practice owes him a huge vote of thanks. So in terms of your question, I think most people know that I've been at University of Kentucky for the last 20 years, but prior to that, I was a New Yorker going to medical school and my residency in New York and practiced for many years in the New York area. And like most New Yorkers, I had a very New York-centric view of the world. And what the college did was tremendously broadened my outlook on life and on pathology. I quickly learned that people who didn't have a New York accent could be very smart and very clever and very knowledgeable.

And as you know, I've just had the honor of editing the 75th anniversary history of the CAP, which gave me an opportunity to look back on some of the giants that I had the privilege of contacting. And without trying to be exhaustive, couple of names come to mind, Howard Ronsley, Sen Hauser, who just had a seminal role in getting me to think in different ways and recognizing different approaches to problems. I've had the privilege of serving as lab director in many places, of being chairman of an academic department. And all of the things that I learned in the college from committee members and colleagues and people that I had contact with and staff as well, really broadened my horizons from a very parochial New Yorker to one who I think had a more broad view of the CAP.

Julie McDowell:

Well, thank you both very much for speaking today. Is there any final thoughts that you want to share before we close out. Dr. Bachner, anything you want to share?

Dr. Paul Bachner:

Well, I would share something with the younger pathologists and the residents perhaps, who are listening to this podcast, and that is for 50 years, I have been hearing comments about the demise of pathology. And guess what? It has never come true. Pathology continues to be a vibrant and exciting practice, and they should not be deterred by the naysayers that they hear.

Julie McDowell:

How about you, Dr. Raslavicus? Any advice for younger pathologists?

Dr. Paul Raslavicus:

Yes, I think I would definitely say to all of you who might be listening that it is critical that you join into the organization, become an active member if you're not already are. Give your talents to those who come after you because just like you are our legacy to the present, those who are coming behind you will be your legacy. And when you finally close your practice like I think we have both by now, you don't want to just wind up saying, "Well, I was there but I didn't do anything." You are the future of our specialty to a great extent, the health of the people that need medical attention. It's very important that you participate. And don't just say, "Well, I was there, but I was too busy."

Julie McDowell:

Thank you, Dr. Bachner and Dr. Raslavicus for this great discussion. CAP members can download the 75th anniversary history book authored by past president Dr. Paul Bachner on the CAP's website. Please visit cap.org and type in 75th anniversary into the search function at the top of the site to find the link to the book download page, which is featured on the CAP's E-store.

Thank you for listening to this CAPcast. To listen to our other episodes, find us on the MyCAP app, available for CAP members, as well as SoundCloud, Apple Podcasts, Stitcher, Google Podcasts, Spotify, and Amazon Music. Just search for CAPcast from the College of American Pathologists on these apps. Once you find our podcast, be sure to click the subscribe button so you don't miss new CAPcast episodes.

Download Transcript