Original research in pathology: judgment, or evidence-based medicine?

Pathology is both a medical specialty and an investigative scientific discipline, concerned with understanding the essential nature of human disease. Ultimately, pathology is accountable as well, as measured by the accuracy of our diagnoses and the resultant patient care outcomes. As such, we must consider the evidence base underlying our practices. Within the realm of Laboratory Medicine, extensive attention has been given to testing accuracy and precision. Critical examination of the evidence base supporting the clinical use of specific laboratory tests or technologies is a separate endeavor, to which specific attention must be given. In the case of anatomic pathology and more specifically surgical pathology, the expertise required to render a diagnosis is derived foremost from experience, both personal and literature-based. In the first instance, knowledge of the linkage between one's own diagnoses and individual patient outcomes is required, to validate the role of one's own interpretations in the clinical course of patients. Experience comes from seeing this linkage first hand, from which hopefully comes wisdom and, ultimately, good clinical judgment. In the second instance, reading the literature and learning from experts is required. Only a minority of the relevant literature is published in pathology journals to which one may subscribe. A substantial portion of major papers relevant to the practice of anatomic pathology are published in collateral clinical specialty journals devoted to specific disease areas or organs. Active effort is therefore required to seek out the literature beyond the domain of pathology journals. In examining the published literature, the essential question then becomes: Does the practice of anatomic pathology fulfill the tenets of 'evidence-based medicine' (EBM)? If the pinnacle of EBM is 'systematic review of randomized clinical trials, with or without meta-analysis', then anatomic pathology falls far short. Our published literature is largely observational in nature, with reports of case series (with or without statistical analysis) constituting the majority of our 'evidence base'. Moreover, anatomic pathology is subject to 'interobserver variation', and potentially to 'error'. Taken further, individual interpretation of tissue samples is not an objective endeavor, and it is not easy to fulfill the role of a 'gold standard'. Both for rendering of an overall interpretation, and for providing the semi-quantitative and quantitative numerical 'scores' which support evidence-based clinical treatment algorithms, the Pathologist has to exercise a high level of interpretive judgment. Nevertheless, the contribution of anatomic pathology to 'EBM' is remarkably strong. To the extent that our judgmental interpretations become data, our tissue interpretations become the arbiters of patient care management decisions. In a more global sense, we support highly successful cancer screening programs, and play critical roles in the multidisciplinary management of complex patients. The true error is for the clinical practitioners of 'EBM' to forget the contribution to the supporting evidence base of the physicians that are Anatomic Pathologists. Finally, the academic productivity of pathology faculty who operate in the clinical realm must be considered. A survey of six North American academic pathology departments reveals that 26% of all papers published in 2005 came from 'unfunded' clinical faculty. While it is likely that their academic productivity is lower than that of 'funded' research faculty, the contribution of clinical faculty to the knowledge base for the practice of modern medicine, and to the academic reputation of the department, must not be overlooked. The ability of clinical faculty in academic departments of pathology to pursue original scholarship must be supported if our specialty is to retain its preeminence as an investigative scientific discipline in the age of EBM.