CAP at 75 - Working Arm-in-Arm to Transform Pathology

• CAP Historical Timeline

Julie McDowell:

Welcome to the latest episode of the special CAPcast series celebrating the CAP's 75th anniversary. This discussion features past presidents Dr. Steven Bauer and Stanley Robboy serving back-to-back terms. Dr. Bauer was president from 2009 to 2011, and Dr. Robboy was president from 2011 to 2013. Both led the CAP during a transformational time in pathology. Doctors, Bauer and Robboy you all have talked about the four-year block of a presidency as back-to-back presidents. Can you say a little bit more about that and the time commitment it takes? Dr. Robboy, can we start with you?

Dr. Stanley Robboy:

Actually, it's more than a four-year block. Up until our times, very often the presidencies would be two years and often things would shift from two years to two years. We thought there was too much at risk and we thought along with the board it was much more important to have a unified theme that would carry on for multiple terms. And so it was not just for four years, but it was really for longer and it was to be a theme that was not particularly of the president's, but it was a theme that was pertinent for the organization and for the board to determine.

Julie McDowell:

Dr. Bauer. What are your thoughts on this?

Dr. Stephen Bauer:

A lot of this was tied into the way that the board managed long range planning, and historically, each incoming president had their own long range planning committee that they organized and ran, and they set the agenda for it. And depending on the outcome of the deliberations of that group, the direction of the college could shift every two years with each new president. And I think that we recognized fairly early on that with the degree of threat and opportunity that we faced, that we couldn't have the college shifting gears constantly, that we had to maintain a steadier course. And so beginning with my presidency, we eliminated that president directed or president-elect directed long range planning process, and that enabled us to shift into this mode of trying to keep the college working on some consistent themes.

Julie McDowell:

So speaking of threats and opportunities, one thing that you both grappled with or confronted during your tenures was next-generation sequencing. And you had to think long and hard about what it would take for this technology to be widely available as well as the cost and any payment issues. Can you explain some of the multidimensional issues that were addressed and how you address them? Dr. Robboy, can we start with you?

Dr. Stanley Robboy:

Let's go back to the period of about 2006, 2008. And it was clear at that time that American medicine, not just pathology, but American medicine as a whole was in great, great difficulty and it was broken and it had to change. And if anyone has read Winston Churchill's book, The Gathering Storm, the title really explained where American medicine was. And the issue we often talk about is you can be at the table. If you're not at the table, you'll become the menu for the table. And from our board, we wanted to really be there in front.

We wanted to help set the table. So we wanted to be at the forefront of whatever change was going to come, helping to set the menu and to really plan for the future of medicine. In this meant we had 28,000 members and if pathology would collapse, if medicine would change so drastically, it could be a great detriment to our specialty. And so in our planning, and this is where Steve and I think he'll talk about it probably more during this time, headed up the transformation committee. It was to look globally at where we were, where was pathology, what were really the threats, what were the potential opportunities? And after an entire year, we spent talking about what were the major issues, the workforce, payment for pathology, the value that we bring, and the new technologies, and the future of medicine. And I think that became the transformation. Maybe Steve, you might want to amplify in this.

Dr. Stephen Bauer:

Well, I think that we really started with looking at the practice of pathology and then trying to make a list essentially of all of the technologies that we saw evolving at a very rapid pace, and to try and estimate the effect that these potentially had on the practice of pathology. And then to look at all of the complexities that flowed out of that but fundamentally, what we really were talking about were major shifts in the way that we practiced. And we had gotten ourselves into a position where we were heavily dependent economically for many pathologists on just routine surgical pathology and only things described by a few CPT codes. And we knew that that was a major risk for us to be so dependent on that one source of income. So we were concerned about both the economic future of the society and its members, and also really pathologists as they practice medicine and how we fit into the broader practice of medicine. And so that's a terribly complex undertaking to look at your practice and how it's going to be affected by all of these technologies.

Julie McDowell:

Is there anything else about the transformation in your work during this time, particularly focused on the transformation that you would like to highlight Dr. Bauer?

Dr. Stephen Bauer:

Well, I think probably the biggest thing for me was how slow it seemed to progress. We were facing these really major challenges, and the college has a very deliberate way going about decision and planning. And in some ways it's very, very good, but it makes it difficult for us to be nimble. And so for me, I think one of the things that was most difficult to deal with was just this sense of frustration that we weren't going quickly enough. I think our sense of pressure to do something rapidly probably was good in the sense that it drove us a little bit harder. It was probably a little bit off though in terms of how quickly changes really were occurring.

Julie McDowell:

Dr. Robboy, anything you wish to share about your experience working on these transformation issues?

Dr. Stanley Robboy:

Well, as Steve said, it was something that was new to both of us. It was far larger than anything we ever imagined. And we were very fortunate because we brought in as a new CEO one of the former managing partner of Accenture, and he had taken a number of the Fortune 500 companies through transformation. And so he really helped galvanize all of the intellectual power we have at the college. We started off with a smaller committee, and eventually we ended up with four committees, each of 20 people working nonstop for a period of time. And the first was to lay out what were the major areas that we needed to deal on. And then the second was actually within each area we talked of the new technologies, what we're going to focus on and how are we going to take all of our members and bring them up to speed.

And for example, with the DNA, we realized we can't take 20,000 members and make them all experts, research experts, but we could make all of them comfortable so that when any clinician who would sometimes be like a deer in the headlights had to deal with this, they would come to the pathologist and want to know what is the right test to do. And we worked with all the pathologists. This was part of our feeling our way along. We started setting up courses, we started setting up webinars, and each little success led to something bigger. And by the end of the year, we were giving multiple seminars and having our whole division on the technology so that our pathologists really felt comfortable. At the same time, we're working with the government because the government was mildly concerned if people were ordering the wrong tests.

And at the beginning they were, each test could be very expensive, and so that's a cost that government didn't want. Plus, if the test was used badly, then patients would be treated for disease they might not have. So that would complicate it. So we set up this very long range goal to help all of our pathologists become the go-to person and more from our scientific side to set up so that the tests were done correctly and from the accreditation side, so that when the tests were done, people could rely on them.

Whether you went locally to my hospital UNC or to Duke University, or if you were in Beijing or you were in London or in Chicago, if you had the test done, it would be the same result. So we tried to look at all of these and make sure that the college came out of it better. The individual pathologist came out of it better. The patient certainly had to come out of it much better, and that was always the major focus, and the government had to have good tests done at a reasonable cost. So we made sure through this transformation that all of these bases were covered.

Dr. Stephen Bauer:

We did recognize very early on that we weren't going to be able to change the technology and how it was going to develop. Those were forces that were going to move independently of us and that what we could do was to help pathologists be ready so that as they did develop, that they were able to integrate into their practice. And I think that a lot of the things that were put in place by the college, for example, improvements in our ability to teleconference or to do things with the internet, paid off in the pandemic because if we hadn't made those initiatives to improve our systems to be able to handle that kind of activity, we would've been in real trouble with the way that the country shut down and with the loss of our face-to-face meetings.

Julie McDowell:

Another major issue was whether the CAP was going to have more of a global presence. Did both of you think that it was critical that the CAP go global? Dr. Bauer, can we continue with you?

Dr. Stephen Bauer:

Yes, we did. I certainly did. The college has always had a global presence or has had an international presence. We weren't global, but we were very international. At the time that I became president, we were already had programs running in 80 different countries through accreditation and through proficiency testing. So we had a fair amount of success internationally without ever having had any formal plan for developing it. It really occurred just opportunistically as people in other countries would actually approach us and ask us to, could we provide services for them? And we recognized that we were vulnerable to changes in the United States, and that by broadening our programs internationally, we could reduce our overall risk to the organization.

Julie McDowell:

Dr. Robboy, what's your thoughts on this?

Dr. Stanley Robboy:

Well, I agree with that, but let me take it a step further because certainly during both of our presidencies, there was a great deal of discussion from various sides whether we should continue with our global presence or curtail it, where should we go? And something that Steve mentioned, we live by regulatory rules, and one potential rule would allow foreign competitors to come in as long as they had a US presence and start the same programs that we had. And if you had someone coming in at half the cost, not worrying about the quality that could end up being very detrimental to the college. We also had so many residents coming to the United States who then went back to their countries and they wanted to take the American medicine with them. They wanted to raise the quality. So it became natural both as an opportunity and to eliminate a threat to bring the college really strongly overseas for the accreditation program.

And that's been marvelous because we now have the residents who are now there and the leaders in their country. We certainly have the economics from it that provides the money for the college to do so many of the outreach programs that do that financially would be a loss. So it's really been a major win for everybody, and it's brought the quality that we've known here in this country to other countries. It was fascinating as we went and we traveled in several of these countries in Dubai, for example, the sheikh, I think it was in 2013, actually made a proclamation that by 2015, any laboratory that was not certified by the CAP could no longer exist in the country.

In China and in India, when we went there, the pathologists sometimes would plead with us, "Please, whatever we do, do not take a bribe." We're not allowed to take bribe. But they would say, "Please don't take a bribe." Because they wanted the quality that we had and they wanted that quality in their countries. And the only way that they could achieve it was by having our accreditation program as rigorous there as it is in the US. Those were the threats and the opportunities and was an incredible time doing this arm in arm with Steve as we went through this period.

Julie McDowell:

Now, Dr. Bauer, I know that you got involved in organized pathology and federal legislation early in your career, and that really laid the foundation for your role in leadership at the CAP. Can you tell us a little bit about your experience and what advice you might have for other pathologists who might be newer in their careers?

Dr. Stephen Bauer:

Well, I really got involved by complaining to one of my senior partners about some federal legislative activity and he never really replied. I asked him, "How can they do this to us?" And he didn't ever really reply to my question, but he just looked at me and he said, "They can do it, and you can either decide to complain about it or you can decide to do something about it, which would you prefer?" And so I said, "Well, I'd prefer to try and do something about it." And it turns out that he had been very active in the California Society of Pathologists.

So fairly soon I got an invitation to represent pathologists on a panel that was going to be advising the state of California on contracting for clinical laboratory services for the Medicaid program in the state. And in the process of doing that, I was representing the California Medical Association, and during the process, I met other pathologists from the California Society of Pathology and just through the interactions we had there and having lunch together before or after meetings, I didn't realize it, but I guess some of those lunches were essentially interviews.

And I got an invitation to be on the board for the State Path Society, and from there I met individuals who've been active in the college and was able to join the college committee. So that really was how I got involved. And I think the message I like to give to younger pathologists is that there's a tremendous need out there for them to become active, and there are tremendous opportunities for them, and there are a number of ways that they can go about becoming involved. They can become involved at the state or local level in their societies there, or they can become involved directly in the college.

And the grassroots way of becoming involved in the college before you go on a committee even is oftentimes through the House of Delegates and you'll meet people through the House of Delegates. You'll familiarize yourself with a lot of the issues through being on the House of Delegates. If you can look for somebody like I had who was a mentor to me and open the doors for me, attend meetings, talk to people, get to know them, and look for people who can help you open doors. If you really want to become involved, you'll find that you're warmly welcomed.

Julie McDowell:

Dr. Robboy, you joined the CAP early in your career. What prompted you to join and even become a lifetime member so early in your career?

Dr. Stanley Robboy:

When I was graduating from my residency, first thing I did was look out at what are all the pathology organizations and what did I want to do later in my life? Which area of pathology was I going to be in? And part was also who was going to represent me, who was going to be able to talk for me in a way that I couldn't. I was an individual. What organization could stand up to the government to other forces and say, "This is what we want from medicine." Certainly I was going to join the AMA, but what were the pathology specific organizations? And the single organization that seemed to have the skill and presence in Washington that I wanted to see was the CAP. So I decided I was going to join the CAP. Well, I looked at the dues and the dues were expensive, especially when you're finishing your residency, you have no money.

And I also saw that the life membership then was only 12 years worth of dues, and I thought, "Well, I have probably 40 or 50 years that I'm going to be in pathology." So it certainly sounds like a much better deal to become a life member early on than to pay dues every single year. Another piece, a quiet piece is once you join an organization, then you tend to get very much involved, and I knew this would happen in my life because I could stay in and not have to pay dues every year. So that was a decision to become a life member. Then as it happened in 1974, just two years after I came back from the Army, I embarked on a project way beyond anything I ever thought I was going to do. I ended up trying to computerize the whole Department of Pathology at Mass General Hospital.

You have to remember, this was at a time that the technology was pretty primitive. PCs hadn't been invented yet. Smartphones a long way away. The computer terminals we had were dumb terminals. And when I envisioned this project and was asked to do it, having help from our hospital, storage was very limited. We had 27,000 patients a year, and the thought of taking all those reports, 27,000 reports, keeping the information for the next 10 years, having to introduce new patients was way beyond anything that natural language could do. And so I looked at the college, I said, "I need a coding system where I can reduce the whole report into several codes." And there was SNOMED. And so I asked to join the SNOMED committee. So this is two years out of residency, what struck me when I went onto the committee that I was young and I thought people would say, "Okay, you're kid, you keep quiet. You're in the back of the room."

But instead, what I found was a leadership that so... Embraced all of us who are young and said, "We'll put you to work. Give us your energy. Help us devise something, work with us so you'll have the oversight and develop something that will really be useful." So in the SNOMED, I know personally, I added several thousand terms with my medical resident whose now very senior in the college, Ray Aller. We built a whole system of syntax, and through this, we had a really functioning system at our hospital thanks to the college. Well, 47 years later, I'm still for every year, have been on a CAP committee and have loved every moment of it. And you're as young as you feel and you're as old as you feel. I tell you, I feel like a young kid every day waking up looking at what are we going to do next? It's been a great treat to be with the CAP. It has always been phenomenal.

Julie McDowell:

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

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