The future for histopathology: protectionism or prudence?BMJ 1994; 309 doi: https://doi.org/10.1136/bmj.309.6951.417 (Published 06 August 1994) Cite this as: BMJ 1994;309:417
- T G Ashworth
As a consultant histopathologist, I am concerned for the future of my specialty. Despite an increasing volume of work, our departmental budget has been steadily eroded over the years. We have modified many of our work practices and become more efficient but the drive for economies continues. From the beginning of 1994 our NHS trust hospital has to save another £4.4m. Some of this has already been borne by our department. Voluntary redundancies having not proved sufficient, early retirement and compulsory redundancies are now taking effect.
Have we reached the end of the road in our battle with the budget? Yes, if protectionism holds sway; no, if prudence allows us to recognise that changes are necessary before more unacceptable measures are imposed on us. Throughout the developed world, health services are being subjected to similar pressures.
Protectionism may be a dirty word to some, but it is what every group in society strives for to a greater or lesser extent. Ever since pathologists achieved recognition in their own right and promoted professional standards, we have been fostering this protectionism. Instead of looking at alternative strategies in the face of increasing output, we respond by demanding more resources. With market forces ruling the NHS, aspects of current professional practices show every sign of being overridden. The alternative to protectionism is prudence, embodied in the new buzz phrase “skill mix.” Hiding under the shibboleth of “preserving standards” we have justified our determination to maintain the status quo. Demarcation lines between the medical and technical have been kept as sacrosanct. Are we, in all honesty, using the two groups appropriately?
For over 50 years our laboratory has entrusted tissue selection for embedding and microscopy to senior medical laboratory scientific officers (MLSOs), who also help train junior medical staff. This activity is professionally regarded as the responsibility of the medically trained. Although initially concerned at this practice, it did not take me long to realise that it was done better than I could have done it. More importantly, it gave the MLSOs an intellectual stimulus otherwise denied them. We have been complimented on the quality of our gross descriptions and I know of no instance where this practice has led to a diagnostic error. In the present climate of the NHS surely any practice that enhances job satisfaction and staff morale is to be encouraged.
“Any practice that enhances job satisfaction and staff morale is to be encouraged.”
There is another aspect of current practice that needs re-examination. It is incomprehensible to me that as a highly paid consultant I should spend hours at the microscope pronouncing on lesions that could safely be reported on by someone less expensive to the NHS. All histopathologists know the lesions to which I am referring, those that require simple objective answers and which can be easily verified.
So long as there is proper training and a system of audit, there is no reason why we should not accept responsibility, as we always have done with our junior medical staff, for reports from MLSOs. Skills in histopathology rely largely on recognising patterns. Interpretation is necessary in a minority of cases. I entrust my eyes to an optician, paramedical ambulance crews perform a whole range of specialist duties when confronted with an emergency, and nurse anaesthetists are widely used on the continent. There are many other examples where the non-medically trained perform tasks regarded as the preserve of doctors. We rely on cytology screeners to separate the normal from the abnormal; MLSOs are the first to recognise an undiagnosed leukaemia or a potentially fatal malarial parasite. With the reduction of work hours of junior medical staff, nurse practitioners are inevitably going to become responsible for more of the erstwhile duties of doctors. We are in the process of joining with other European countries where the practice of histopathology (anatomical pathology) is far less constrained by protectionism than is the case in Britain.
Are there other areas where our skills could be used more beneficially in a true consultatory capacity? Many years ago it was mooted that prosectors (technical staff) should be used to perform postmortem examinations under guidance. I am unsure whether this is a good idea or not but it certainly merits consideration.
Should the degree of responsibility be regarded as something to be measured solely on a graph of educational or professional attainments? Professor Roger Dyson quotes the example of a Spanish professor of pathology who employs widows with large families to cut his sections because they are used to cutting thin slices. In Britain this task has been preserved for well trained MLSOs with the equivalent of a BSc qualification. This group has been persuaded to look to medical laboratory assistants to replace some of their duties. They suffer from protectionism just as much as we do but they have reluctantly agreed to changes in long established work practices. I have seen no suggestion that histopathologists should also think about modifying their traditional roles.
All is not doom and gloom. There is a future for our breed. As doctors first and pathologists second, interpretation still has a vital role to play in a variety of medical conditions. Audit of a hospital's performance depends largely on patient outcome. If the clamour from the royal colleges for more postmortem examinations for deaths in hospital is to be heeded pathologists must play an increasingly important role. We may not be able to justify more consultant posts, but we should at least be able to stop the possibility of retrenchment or redundancy, which is a much more likely event.
I know I will incur the displeasure of some of my peers for expressing these opinions but they represent a view held for many years. Our college has drawn up guidelines as to how many surgical specimens we should examine and how many postmortem examinations we should perform each year. I see these guidelines becoming increasingly irrelevant in the face of financial and market forces. Our new NHS executives are right to question the assumption that more work needs more staff. In many other walks of life this equation has taken a tumble. It behoves us to look at all possible alternatives.