A Dream Fulfilled: The Plan, the Journey, and the Promises
The inauguration of Canadian Journal of Pathology
Jagdish Butany, MBBS, MS, FRCPC
Jagdish Butany, MBBS, MS, FRCPC, is a consultant cardiovascular pathologist, director of autopsy services, and a professor at the University of Toronto, and director of the Division of Pathology, Department of Laboratory Medicine and Pathobiology, University Health Network/Toronto Medical Laboratories, Toronto General Hospital, Toronto, Ontario. He is also the president of the Canadian Association of Pathologists and co-editor-in-chief of Cardiovascular Pathology. E-mail: jagdish.butany@uhn.on.ca.
A journey of a 1000 miles begins with a single step.
− Lau Tsu, Vietnamese Philosopher
All of us have heard the phrase, “It was the best of times, it was the worst of times.” It never seems an appropriate time to start a new venture. There will always be yea-sayers and naysayers. What matters is to plan, do your homework, meticulously work hard, confer with those concerned, heed advice, and take the plunge after having considered all the pros and cons.
The Dream
Happy 60th Birthday Canadian Association of Pathologists!
The CAP’s birthday gift to its membership is the newborn Canadian Journal of Pathology! To all our members: Come and join us in Halifax as we celebrate these great events!
It has long been a hope of CAP to have a journal of its own, and this inaugural issue of the Canadian Journal of Pathology (CJP) is the culmination of a long-standing desire, a commitment, and the fulfillment of a promise. The present CAP executive has worked toward this goal, for at least 2½ years, and the issue that you hold in your hands is testimony to their efforts (please see Tables 1–3). This issue of Canadian Journal of Pathology is special, with messages from some very exceptional people, from the past and the present. It will surely be followed by many more such issues under the guidance of the incoming editor-in-chief, Dr. Godfrey Heathcote, and the new executive, which will follow later this year.
The journal will be the official voice of Canadian pathology. It is the desire of our executive committee – as well as many of our members – that it be a meeting point in pathology, where knowledge and ideas are exchanged and where each pathologist is able to publish material specific to his or her domain and milieu. It will publish original work and reviews as well as guidelines and committee reports that, although set in Canada, will nevertheless be of value to pathologists everywhere.
The past few years, especially the past few months, have been difficult ones for pathology. (I use the word pathology generically to refer to all of laboratory medicine.) Today, economic times are difficult. Our tomorrows will be different, and the future offers many tantalizing possibilities of keeping this dream alive and doing more for our specialty with our journal. For now, today is the moment we live in, and we must make the most of it.
Table 1. Executive Committee of the Canadian Association of Pathologists 2008–2009
President Jagdish Butany
Vice-president Laurette Geldenhuys
Past-president Donald Cook
Secretary-treasurer Bruce Burns
Assistant secretary-treasurer Avrum Gotlieb
Member-at-large Emina Torlakovic
Member-at-large Iakovina Alexopoulou
Continuing professional development Joan Sweet
Newsletter editor Martin Bullock
Resource development chair TBD
Web editor Tadaaki Hiruki
Table 2. Journal Implementation Committee
Chair Maire Duggan
Members Sylvia Asa
Martin Bullock
Jagdish Butany
William Chapman
Runjan Chetty
Donald Cook
Bertha Garcia
Laurette Geldenhuys
Avrum Gotlieb
Richard Hegele
John Maguire
Jean Michaud
Marciano Reis
Mike Shkrum
Martin Trotter
John Veinot
Valerie White
Table 3. Ad Hoc Subcommittee for the Selection of the Editor-in-Chief
Chair John Maguire
Members Sylvia Asa
Martin Bullock
Jagdish Butany
Laurette Geldenhuys
Avrum Gotlieb
Marciano Reis
John Veinot
Valerie White
Never let a day pass that you will have cause to say,
I will do better Tomorrow.
− Brigham Young
Opportune Times
The current human resource issues mean that many pathologists across the country are working longer and harder, with an unfortunate decrease in the time available for continuing professional development (CPD). But pathology is in a resurgence, and residency programs are attracting increasing numbers of Canadian medical graduates. The improvement in reimbursement, changes in our attitudes, and developments in working conditions, among other things, have led to the rising student interest in pathology. At the same time, some provinces have taken steps to increase residency positions for international medical graduates (IMGs), creating additional positions for which the IMGs compete. Together, these should lead to a significant increase in the availability of trained pathologists to fill vacant positions across the country over the next few years. It takes many years to turn an MD into an experienced expert pathologist; while pathology is a science, it is also an art, and artists take time to mature.
Celebrate!
CAP was launched at the 1949 Annual Meeting of the Canadian Medical Association (see the cover photo and Table 4). The few pathologists who were there had the vision to launch CAP, nurture it, and make it grow. Today, CAP counts most Canadian pathologists as its members.
The past few years have also seen a significant surge in interest in laboratory medicine, particularly in regard to automation, new tests, testing modalities, the requirement of more detailed analysis of all specimens, and more detailed tumour reporting and diagnoses. The net result has been a significant increase in the complexity of case reporting, which further necessitates CPD at all levels, starting with the technologists, pathologists’ assistants, and pathologists.
The availability of quality CPD programs – those geared to the maintenance of quality standards in test performances and test reporting – has not kept pace with need and demand in all parts of the country. The CPD committee of CAP is focused on filling this gap with contemporary technologies, in the immediate future, a process begun by Dr. Laurette Geldenhuys and now in the hands of Dr. Joan Sweet.
Table 4. Pathologists Who Launched the Canadian Association of Pathologists, in Saskatoon, 1949
John Adams, Saskatchewan
John Duffin, Alberta
John Hamilton, Ontario
Joseph E. Josephson, Newfoundland
W. Stewart Lindsay, Saskatchewan
Thomas L. Linn, Saskatchewan
R.A. Mackeen, New Brunswick
William Magner, Ontario
Lola McLatchie, Alberta
Norman G. McLetchie, Saskatchewan
Donald F. Moore, Saskatchewan
Daniel Nicholson, Manitoba
Joseph J. Ower, Alberta
Robert C. Riley, Alberta
Lorne Whitaker, Ontario
Source: Data from A History of the Canadian Association of Pathologists, 2nd Edition. 1994.
A Great Time to Be a Pathologist
Pathology results are the basis for clinical diagnosis in over 70% of cases and play a part in patient wait times. The number of tests required is rising, as is the number of tests available. New tests, such as the ER/PR and HER2/neu for patient management (class II immunohistochemistry [IHC] tests), ensure that pathologists’ involvement in prognostication and the decision-making process regarding the type of therapy to be given is also critical. It is, all things considered, a great time to be a pathologist. One is sobered by the realization that with this demand comes a tremendous responsibility – to make sure that we get things right, every time, in time.
National Immunohistochemistry Standards
It is disturbing to realize that for some of these tests, such as the estrogen/progesterone receptor, there were no internationally accepted, universal gold standards for either the performance of the test or particularly its interpretation. It is worth noting that several provinces have excellent laboratory accreditation and laboratory quality assurance/improvement processes in place. These standards must be extended to all parts of the country to ensure that all Canadians have the benefit of the same high and dependable standards of laboratory test results. CAP took the step to set up a National Standards Committee, chaired by Dr. Emina Torlakovic, to ensure that we develop our standards and offer them to all laboratories across the country. At this time, the process is geared to the ER/PR test but is being expanded in the future to include other IHC tests. The recommendations of this and future similar committees will be published in CJP.
Forensic Pathology
In light of the difficulties we have faced and the media attention focused on forensic pathology over the past 10 years, the Royal College of Physicians and Surgeons of Canada has started the process of subspecialty certification in forensic pathology. The first fellows are being trained and will have their RCPSC examinations in the near future. CAP formed a section of forensic pathology 2 years ago, with the help of Dr. Michael Pollanen (chair of the CAP Section of Forensic Pathology), which is offering excellent continuing medical education in forensic pathology.
New Specialties
These are perhaps the most challenging times to be physicians in our country, equally so for pathologists. It is also a time of great opportunities for those willing to grab them. Life expectancy is increasing, and the aging segment of the population is generating its own surge in demand, with an increasing burden of age-related disorders such as cardiovascular degenerative and neoplastic diseases. Add to that the increasing population of our country, exploding medical knowledge, rising patient expectations, and the need for pathologists to keep abreast of advances in medical research, and the demands on pathologists’ time are greater than ever before.
These changes are creating new specialties for the future, such as regenerative medicine, personalized medicine, and molecular pathology. We must continue to explore new specialties and be the drivers of change as well as the professionals who maintain the quality of these initiatives.
Our knowledge of the role of genetic and environmental factors, their interaction, and their influence on human health and life, is growing exponentially. Their impact on the cell, on molecular structures as well as on tissues, manifesting as morphological/pathological changes is becoming increasingly evident. More innovative diagnostic modalities and tests continue to appear as well as special training, specialization, and CPD, merely to stay current with the tests and their application. This rapid progress from “bench to bedside” will drive laboratories even further toward specialization/subspecialization and pathologists further toward becoming an active part of the patient management team. We must participate in applied molecular testing and be the ones interpreting the results. With relatively limited application today, the role of molecular testing is increasing and will continue to do so in the years ahead. We must be part of the change, among those who help maintain the standards of test quality and their consistent interpretation.
Change always comes bearing gifts.
− Price Pritchett
Pathologist the Consultant: Out of the “Basement”
For too long, pathologists have been merely the providers of test results to clinical colleagues. As tests become more complex and critical to decisions regarding therapy for patient prognosis, it will be increasingly important for pathologists to be the consultants explaining the tests, results, and their applied value. We are the providers of the results, and we must be the ones who actively participate in their conversion to patient management and prognostication. Without this “leap,” we will forever remain in the “basement,” unheard, unseen, and forgotten. The recent media attention has been less than savory. We must ensure that the public is aware of our specialty changes.
One step toward this education is the publication of Canadian Journal of Pathology. It is critical to make this journal the voice of Canadian pathology, for each of us to participate in its running, as necessary, and to make sure that we submit manuscripts to the journal for the education of all pathologists and laboratorians in our country.
With these opportunities come many challenges. With the need for genetic research comes the demand for human tissues for this research, which raises ethical, legal, and other issues that pathologists must confront, learn about, and discuss with our peers, ethicists, and, when necessary, patients. Pathologists must maintain control of tissues and tissue banking, not for hegemony but for the greater good.
Personalized Medicare
There is considerable focus on the much-used term personalized medicine. Hopefully, genetic and molecular studies will lead to the further refinement of diagnoses and personalizing of therapy, leading to improved outcomes, especially survival.
At this time and in the future, it must be pathologists and laboratory physicians who illuminate the results of the tests on which personalized health care rests. We must begin to interface with patients directly, individually or as part of a team. We must boldly step into this emerging world of personalized medicine, together and with the appropriate skills, those than can only be obtained from ongoing CPD.
As new information emerges about the origins/etiopathogenesis of disease, and as the laboratories receive more advanced technology, we must remain at the cutting edge of these technologies, be the people who provide the results on which treatments will be based and those who help plan patient management. We must become more specialized and widen our horizon into clinical epidemiology, education, ethics, and management and, in brief, embrace the full spectrum of our CanMEDS role.
This is an appropriate time to launch our new journal; 60 years ago, CAP was launched at the 1949 meeting of the Canadian Medical Association, in Saskatoon. The foresight of those few pathologists who were at that meeting led to the Canadian Association of Pathologists of which we are all proud members. Your CAP has grown, and we continue to welcome all pathologists (in fact all laboratorians), in practice or in training, to join us!
As we take this next step in CAP’s journey to becoming the voice of pathology in Canada, I thank everyone who has helped us achieve this goal, every member of the CAP, all of our administrative staff, and all those who have promised to contribute content to the Canadian Journal of Pathology. And last, but by no means least, I thank Mr. John Birkby of Andrew John Publishing Inc. (Dundas, Ontario) for having had the patience to work with us and agreeing to publish our journal. Now, let’s make CJP succeed, grow, and flourish!
As is your Pathology
So is your Medicine.
− Sir William Osler
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