By Jan A. Nowak, MD, PhD e-mail: jan@nowaks.org

AMP’s Training and Education Committee has assembled a program, a panel discussion, for the Trainee Luncheon at our 2009 Annual Meeting.  The proposed theme for the day is “Can you be ONLY a molecular pathologist  ... especially in these times?”  The panel includes representatives of various practice situations: academic, community hospital, and industry.  All the panel members are distinguished molecular pathologists.

The organizers, I think, really want to address whether one can obtain employment solely in a molecular diagnostics laboratory, or whether one needs to couple this pursuit with another pathology skill, e.g., cytology, surgical pathology or transfusion medicine.  The practical import of this for a trainee, and those who oversee training programs, is that these considerations influence how one trains in preparation for that career.  There are really two dimensions to the question.  The first deals with the practical skills one needs to obtain employment in one’s field in an agreeable setting.  Like it or not, the realities of procedural and professional reimbursement, as well as demands for specific professional services will largely determine the marketplace for pathologists with specific skills.   The second question is, to a degree, more philosophical, but still has very practical ramifications:  how does one become a molecular pathologist or perhaps more to the point, what does it mean to be a molecular pathologist?  I won’t try to guess what sage advice the luncheon panel will offer for someone looking to land their first job, but I would like to explore what it means to be a molecular pathologist in today’s world.

Of late, I have been thinking more and more about the model of medicine, the biopsychosocial model, I was imbued with during medical training at the University of Rochester.  Most of us practice a biomedical model of medicine:  every disease has an underlying biological/biochemical etiology.  Physio-chemical-genetic abnormalities define the disease.  Our job as pathologists is to detect that abnormality.  The biopsychosocial model, in contrast, is a systems approach that recognizes that a person’s well being is reflected in multiple levels of organization: genetic, biochemical, tissue, organs, organ systems, person, etc.  A perturbation at any one level can be manifest at one or more other levels, including the psychological and societal.  Exploring this biopsychosocial perspective is valuable for us as pathologists today in two respects. First is an expanded concept of “disease” that comes with this model.   The notion of “disease”, certainly in the patient’s mind, is very much intertwined with the patient’s first interaction with a clinician.  A contract is entered into by both the patient and the clinician to address the patient’s concern, and simply the suggestion of an abnormality to explain the patient’s symptoms can cause considerable angst. Even if corroborated by a laboratory test result, we need to acknowledge that acceptance of, and coping with, that result are part of the disease process.  I wonder, then, about those tests that we propose for asymptomatic patients under the guise of preventive medicine.  Increasingly these are being offered directly to consumers, with the explanation that the results are of “no known clinical significance”, or are intended solely to induce “lifestyle changes”.  Is it possible to perform any test on a healthy asymptomatic patient without instilling some modicum of anxiety?  Is it conceivable that one can receive news of harboring genetic changes “of no known clinical significance” and not feel like damaged goods, or be concerned about the potential consequences for one’s self or one’s family?  Are we creating “disease” where there is none and conveniently discounting it because it does not fit our biomedical model?  From this vantage it seems pretty clear that our responsibilities as the producers of test results go far beyond the paper the results are written on, indeed well beyond what we think of as the traditional practice of pathology.  The key point to be made here is that the diagnosis of disease does not begin or end with a test result, but travels up and down through the various biopsychosocial strata.

Secondly, a systems approach is useful in understanding the breadth of pathology as a medical discipline.  Of necessity, most medical specialties focus their attention on one or few levels of organization.  Pathologists have traditionally functioned at the gross anatomic (organs and tissues) and microscopic level, focusing on tissues and cells, rarely, often unwittingly, entering the molecular domain through immunohistochemistry or FISH.  Laboratory medicine operates in the biochemical world.  Molecular pathology takes us one level beyond that into the new realm of molecular genetics, opening into the parallel dimensions of heredity and regulation.  In exploring this systems approach, what becomes crystal clear is that none of these organizational levels are independent, and that those who aspire to be molecular pathologists really have no choice than to pursue proficiency in the traditional areas of clinical and anatomic pathology, and even levels above that, all the way to the patient himself.  Conversely, one cannot espouse to be an anatomic or clinical pathologist today without also being a molecular pathologist. 

So what does it mean to be a molecular pathologist?  I think it is clear that molecular pathologists are pathologists¹ who have an understanding of disease processes that extends into the molecular domain.  Some of these individuals may choose to practice as surgical pathologist, others as hematopathologists, or as microbiologists, or in some other specialty area but they should all be recognized as molecular pathologists. It is useful to keep this in mind while addressing the very practical concern about what skills one needs to function in this profession, and avoid defining one’s identity simply by what techniques they use or what they do. It’s what they know and how they think that counts.

¹ I’m using the term pathologist in its most generic sense, and consider it to include all engaged in the study of disease processes.