Practicing pathology through multiple hospitals at multiple sites. Practice management issues.

OBJECTIVE: To describe a successful method of management for pathologists to use in an environment of hospital consolidation and managed care. DESIGN: This article draws on the experience of a large, pathologist-owned regional laboratory in applying management principles needed for practice in the future. SETTING: A group of 20 pathologists, with 19 affiliated pathologists (multiple groups) practicing in rural and urban areas of five states in the Southern Plains. PRINCIPAL FINDINGS: Planning, personnel management, organizational structure, finance, and information systems are necessary keys for pathology management in a dispersed system. CONCLUSION: The opportunity exists for a professionally and economically satisfying practice in the medical environment of the future.

Resource allocation and the cost of quality.

The costs of producing quality medical care and the proper allocation of resources to assure quality are major contemporary concerns. Minimalists attempt to improve quality and lower costs through the application of the theory, "less is more." Bureaucracies make the same attempt through the denial of payments for "unnecessary" services. Governments and insurers try to "improve quality" by impeding the flow of new technology so that costs will be restricted (presumably allowing society better access to current care modalities). All impose regulations and requirements on medical practice. Each of these approaches is examined individually and substantial problems with their application in actual practice are illustrated. Genuine quality is not a cost or resource allocation problem. Quality is free.

Changing technologies and the practicing pathologist.

Rapid, dramatic technologic change is occurring in almost all areas of current pathology practice, while a changing environment for pathology provokes the question, "What is the future of pathology as technology emerges?" A review of the types of technologic change and the forms of environmental forces suggests great opportunities for pathology if critical actions by individual pathologists and organized pathology are taken.

Pathology and the corporate transformation of American medicine.

Corporate medicine is a cultural response to increasing medical costs, a transformation made possible by an oversupply of physicians. The independence of physicians is being curtailed. Nonetheless, corporate needs for medical efficiency, low costs, and good outcomes match the capabilities of pathology and assure that the specialty will have a major corporate role. Pathologists as individuals may face sharply different outcomes. Those pathologists who own laboratories, who are good managers, who a extremely productive, or who are excellent clinicians have good opportunities, as do a few individuals with highly developed technical or subspeciality skills, Eventually, hospital chains are likely to be replaced by physician-owned or -controlled corporations, further strengthening pathology's role. Pathologists in academic and independent laboratory settings are likely to do well. Pathology organizations must take a leadership role in preparing pathologists for what can be a bright future.

What are your practice alternatives?

The possibilities for the future of the practice of pathology have never been brighter, the author says. He explains how pathologists can be successful in alternative practice arrangements, and what these alternatives are.

Analysis of mammography: a blind interpretation of BCDDP radiographs.

An ROC curve analysis of mammography is presented. This study is based on a blind interpretation of radiographs of patients who underwent screening during the Oklahoma Breast Cancer Detection Demonstration Project (BCDDP). In particular, we evaluated the accuracy of mammography based on 38 incidence cancer cases. Incidence cases are those that develop in a patient after an initial visit and at least one additional annual visit before a biopsy is performed. Using 40 normal subjects, a sensitivity of 72% was attained at a 28% false positive rate. We also evaluated the contribution of viewing radiographs of both breasts (right and left) simultaneously as compared with viewing radiographs of the individual breasts singly. In cases on the threshold of detectability, the breast that did not result in the cancer diagnosis was occasionally identified as the most suspicious for cancer. When mammograms of the two breasts were compared, the false positive rate was lower. These results can be used to assess various screening strategies and to yield a more realistic accuracy estimate of mammography on a rescreened population than is currently available.

Irradiation injury to the ureter and surgical tolerance. An experimental study.

An attempt was made to produce damage to the ureter of the dog with external irradiation in the high therapeutic ranges in the absence of surgery or cancer. No significant changes were apparent on excretory urography and only minimal changes were seen on histologic study. In another series of dogs, one ureter was reimplanted before the administration of maximal irradiation and the other ureter was reimplanted after the irradiation. The reimplanted ureter tolerated later irradiation very well. The postirradiated ureter tolerated similar surgery very poorly.