J Clin Pathol 1992;45:845-849

Occasional articles

The changing practice of pathology

N K Shinton

The beginnings of pathologyPathology is the study of deviation fromnormal health. It has been studied from thetime when man first began to reason on thedisorders which affected him. Its separationfrom medicine in general began with enquiryinto the causes of disease and the early historyof pathology has been described by Long.'During the 5000 years of Egyptian dynasties

around three quarters of a billion humanbodies were embalmed but no anomalies wererecorded. Later, during the fourth and fifthcenturies, BC, the Greek school of Hippo-crates developed a philosophy of humoralpathology, which suggested a mechanistic con-cept of disease in place of mythology. VariousRoman doctrines of pathology followed in thefirst century, BC-the pneumatists, the meth-odists, and the eclectics. These early ideas ofdisease were formed at a time when dissectionof the body was regarded as a desecration andnot permitted.A total change of outlook came with the

Renaissance when necropsies were permittedand printing vastly widened the disseminationof knowledge. In the 18th century pathologywas a branch of anatomy-morbid anatomy,most gross anatomical lesions being simplydescribed.The microscope was invented in the 16th

century but was not sufficiently refined fortissue to be studied until the early 19thcentury. This was associated with new tech-niques of fixation, embedding, microtomecutting, and staining. Cellular pathology wasthus established.

Bacteriology developed in parallel, allowingthe pathogenic process to be recognised andchemistry, previously a fundamental science,also came to be applied to medicine alongsidephysiological concepts of disease during the19th century.

This is an abridged versionof the Presidential Addressgiven by Professor N KShinton to the Associationof Clinical Pathologists,London, 3 October 1991.

School of PostgraduateMedical Education,The University ofWarwick, CoventryCV4 7ALN K ShintonCorrespondence to:Emeritus ProfessorN K Shinton.

Accepted for publication13 January 1992

Early pathology practiceGreat advances in the science of pathologywere made in the latter half of the 19thcentury, but there was little demand for theservices of pathologists outside university cen-

tres where necropsies were regularly per-formed as part of the teaching curriculum.2 Inmost hospitals at this time, simple chemicaltests on urine and microscopic examinationof blood and urine were performed in wardside-rooms by clinicians. Clinical pathologylaboratories were being developed at the turnof the century. The range of tests was limited to

blood cell counting, chemical analysis and cellcounting of urine, bacterial staining and cul-ture of urine, sputum, cerebrospinal fluid,swabs, stools and blood, and the serologicalWassermann reaction for syphilis. Clinicalpathologists performing this work earned theirliving as clinicians in medicine by privatepractice from consulting rooms, which oftenincluded a small laboratory staffed by a labo-ratory assistant. Specimens were either col-lected on site or posted and a reportdispatched, together with a bill for the appro-priate fee. A good deal of time was also spenton allergy testing, desensitisation, and vaccina-tion. This was the subject material for a play byGeorge Bernard Shaw, The Doctor's Dilemma.3Large hospitals were soon to appoint paidlaboratory directors.

Towards a national pathology serviceIn 1911 the Lloyd George National InsuranceAct whereby 15 million workers became enti-tled to "free" medical services was passed."Panel" patient pathology was performedeither by: venereal disease clinics; CountyCouncil laboratories; insurance committeearrangement with hospital pathology-for (a)payment by patient, (b) lump sum payment;arrangement with general practitioners forsupply of vaccines (paid by the NHI) plusinvestigations; commercial laboratories (path-ology institutes).

After the First World War there was littlechange in pathology practice. Pathologistseither worked in university departments; aspart-time hospital pathologists making a livingfrom a mixture of hospital pathology, publichealth work, coroners' post-mortem examina-tions and private practice: or exclusively inprivate practice. Their standing with theirconsultant colleagues was low. Ledingham,chief bacteriologist at the Lister Institute,described pathologists as "hewers of wood anddrawers of water".4 A leading article in TheLancet at the time condemned "slot-machinepathology" and "sending things down the roadand having answers back on pieces ofpaper".5

However, pathologists were making pro-posals. Delepine suggested in 1921 that thereshould be a large national laboratory forpreparation of standard reagents and antisera,a network of public health laboratories andhospital clinical pathology laboratories.2Dyke emphasised that efficient diagnostic

pathology for the patient could only be ach-

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ieved by the closest possible contact betweenpatient and pathologist and also between theclinician and the pathologist.6 To achieve thisevery general hospital required a clinical labo-ratory on site and a trained pathologist to runit. The range of work under discussion was stillmainly bacteriological diagnosis, but now withthe addition of blood sugars and glucosetolerance tests, following the introduction ofinsulin in 1925. The diagnosis of perniciousanaemia and its treatment with liver in the dietsoon required red cell sizing, gastric analysis,serum bilirubin and reticulocyte counting.Surgical biopsies were also entering routinepractice.The most important deficiency was an orga-

nised body to represent hospital pathologists.To correct this, The British Pathologists' Asso-ciation was formed, later to become the Asso-ciation of Clinical Pathologists (ACP). Theheads of university departments were approa-ched but they were satisfied with their statusquo. The aims of the new Association were "todevelop the application of pathology in relationto medicine and to protect the interests ofthose engaged in its study and practice".One external event changed the organisation

of pathologists in the 1930s-the Local Govern-ment Act of 1929. This transferred the poorlaw hospitals from boards of guardians to thelocal authorities. The London County Councildecided that each hospital should have its ownclinical laboratory.The onset of the Second World War brought

about striking changes in the practice ofpathology. In preparation for bacterial warfareor widespread epidemics from overcrowding,the government, through the MedicalResearch Council, planned an emergency pub-lic health laboratory service which became thePublic Health Laboratory Service (PHLS). Inaddition, a nationwide pathology servicebecame part of an Emergency Medical Serv-ice. This was the critical turning point forclinical pathology in the United Kingdom. Thecountry was divided into twelve regions andthe professors of pathology in provincial uni-versities became Honorary Regional Advisersin Pathology. Purpose-built and convertedclinical laboratories staffed by pathologists andbiochemists were developed. Many cliniciansand most general practitioners were henceprovided with a pathology service that they hadnever known before. In Dyke's words "anational service in clinical pathology".7Another war-time consequence was the emer-gence of a National Blood Transfusion Serv-ice.

Pathology in the National Health ServiceAfter the War, the foundation of the NationalHealth Service (NHS) resulted in Britishpathology being differently organised from thatin Europe and America. In accordance withthe NHS Act consultant pathologists had equalstatus, with the same terms and conditions ofservice, including salary, as any other consult-ant. Clinical pathology became "a growthindustry" with a 10% increase per annum in

staff. Most new consultant pathologists optedfor whole time contracts which avoided con-straints from clinical colleagues wanting aspecial service for themselves. Furthermore,consultants were contracted to a regionalhealth authority and so were independent oflocal influence. Apart from some large uni-versity hospitals, histopathology and clinicalpathology (bacteriology, haematology, and bio-chemistry) were linked within a single depart-ment, often in a converted building, usuallyunder a director. Departments of biochemistryemerged in all large hospitals with either aclinical pathologist or a non-medical scientistat its head. Another important developmentwas the emergence of the Journal of ClinicalPathology in 1947 under the editorship ofGordon Signy (fig 1).8A great stimulus for the expansion of pathol-

ogy practice was the ever increasing range oflaboratory tests. These included detection ofRhesus and other blood group antibodies bythe Coombs' test with compatibility testingbefore blood transfusion; the one-stage pro-thrombin time to monitor anticoagulation;protein electrophoresis; andWhitfield's flexibletube which allowed samples for analysis to beseparated by an air bubble. This latter develop-ment became the forerunner of the automatedmethods for estimation of urea, glucose, andhaemoglobin. This automation allowed for amuch larger number of estimations to be madeeach day and removed drudgery from technicalstaff. Blood counting, however, continued tobe by hand, with emphasis on the blood film.Histopathology and bacteriology continuedmuch as before, with improved staining tech-niques.

The Golden Age of British pathologyThe foundation of the College of Pathologistsin 19622 was to have a profound influenceon the practice of pathology in the UnitedKingdom, and indirectly, in Commonwealthcountries. The inception of the examinationinevitably indicated the areas of training with

Figure 1 Dr Gordon Signy, from Trends in clinicalpathology: Jrournal of Clinical Pathology.

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The changing practice ofpathology

an ongoing effect on practice. At that timemost pathologists were general pathologistspractising all four branches-chemical pathol-ogy, haematology, microbiology and morbidanatomy with histopathology so that traineeshad to gain experience in all four branches.An important development was the recogni-

tion of haematology as a laboratory specialty.Until the post-war era, haematology hadlargely been a subspecialty of clinical medicinebut the new investigations vastly increased itslaboratory aspect. Dacie (fig 2) proposed "apipe-dream wild and impractical-a depart-ment of haematology in each hospital" withlinking oflaboratory and clinical haematology.9It followed that when the RCP moved torecognition of specialty training in 1972,haematology was included within the JointCommittee for Higher Medical Training.'0 Itwas anticipated that both chemical pathologyand medical microbiology would follow butthis did not occur.Towards the end of the 1960s, the then

Ministry of Health issued a number of reportsconcerning the practice of pathology. That onthe Organisation of medical work in hospitals"established the Division of Pathology, with anelected chairman, in each large hospital. TheZuckerman report to the Department ofHealth and Social Security (DHSS) on Hospi-tal Scientific and Technical Services establishedthe place in hospital medicine of the non-medical scientist.'2 The place of the patholo-gist was confirmed in a subsequent HealthService circular (HSC (IS) 16) whichestablished the principle that the head ofdepartment must be a medical consultant ornon-medical scientist of equivalent standing. 13Another development from the Zuckermanreport was the introduction of regional scien-tific committees, with an executive Regional

_ .... ...aN : . . .: ::sB . : . : ...... :: ::.. : " . ,, ... ...... . , _ My;. . ^w :: . . i ... :: ^ ..... ::S . ..... S { .o S ......... .....Figure 2 Sir 3tohn Dacie.

Scientific Officer (RSO), which led to plannedregional development of pathology with raisedstandards of practice. Another outcome of theZuckerman report was the formation by theDHSS of a Laboratory Equipment andMethods Advisory Group (LEMAG), theforerunner of the Laboratory DevelopmentsAdvisory Group (LDAG). Much ofthe work ofthese committees comprised evaluation exer-cises at selected centres ofnew equipment andreagents. LDAG also supervised the introduc-tion of data processing to clinical chemistryand haematology. Other outcomes of theZuckerman report were the Supra-regionalAssay Services (SAS) funded centrally for theperformance of assays required infrequently,and the National External Quality AssessmentSchemes. In 1975 a Joint Committee betweenDHSS and the professional bodies agreed thatquality assessment in pathology must be aneducational exercise. Persistently poor perfor-mers were, however, identified by organisers ofschemes and the results forwarded to anadvisory panel for each discipline. A 95%laboratory participation rate was establishedand annual reports showed considerableimprovement in analytical results. The variousschemes were subsequently brought togetherunder the Advisory Committee for the Assess-ment of Laboratory Standards (ACALS).Pathology was well ahead of other medicalspecialties in quality assurance.While these administrative changes were

taking place, the technology of clinical chem-istry and haematology was changing. Theintroduction of plastic bags for donor bloodpermitted separation of platelets and plasma.This increased the safety from contaminationbut sadly increased the transmission of as thenunknown viruses. Automation of most clinicalchemistry analytes and of blood countingpermitted the introduction of screening fordisease and of profile testing. When a patientwas seen in outpatients or admitted to hospital,specimens for an agreed test profile werecollected routinely-opportunistic screening. 4This increased the number of venepuncturesresulting in the army of "vampires" descendingon the wards every morning-the phleboto-mists which swelled the numbers of laboratorystaff requiring supervision. The NHS, in paral-lel with the Civil Service, developed laboratorystaff grading from senior technicians to chieftechnicians ending at the top in a principaltechnician if more than 65 staff were beingsupervised. The urge to increase staff wasinherent in the system, so instead of decreasingnumbers with automation they expanded. Thenew staff required training so there was aburgeoning of courses in pathology at technicalcolleges which was good for the disseminationof knowledge of pathology.The 1970s saw a great expansion in hospital

building, the district hospital programme, eachwith its own laboratory. Building guidelines forpathology were developed by the Ministryaided by Gordon Signy as chairman of acombined college/ACP committee. This wasbased on the four disciplines (chemical pathol-ogy, haematology, histopathology and micro-

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biology) with some common services. Thecollege structure was being built in bricks andmortar.

Decline of the national pathology serviceIn 1974 the NHS was due to undergo its firstmajor reorganisation with the introduction ofdistrict health authorities and new manage-ment structures.'5 16 One effect on pathologywas the appearance of large district scientificcommittees.But the Golden Age of pathology was

ending. The workload had vastly increasedwith the workforce necessary to cope with theload. The clinical pathologist became lessinvolved in the bench while at the same timeincreased automation led to increasing bore-dom of the technical staff. The laboratory wasbecoming a factory. Haematologists becamemore interested in clinical matters, chemicalpathologists in administration, while micro-biologists and histopathologists trudged onwith an increasing labour intensive workload.Many technicians were overtrained for theirjob and expressed their irritation by requestingmore control of laboratories. In an attempt toassuage their frustration the Governmentintroduced the title medical laboratory scien-tific officer, but this was not sufficient to satisfythe militants. While all laboratories were tosome extent involved in these matters, it wasthose who had an "absent landlord" whosuffered most. Pathologists who understoodthe frustrations and were sympathetic with theMLSO movement made appropriate inter-departmental changes by the introduction ofan embryo form of line management.

Associated with the discontent was a realisa-tion of the danger attached to working inhospital laboratories. Tuberculosis in the mor-tuary was followed by outbreaks of hepatitis Bin departments of haematology and clinicalchemistry and of salmonellosis in microbiol-ogy. A DHSS committee chaired by Sir JamesHowie (fig 3) prepared A Code of Practice forPrevention of Infection in Clinical Laboratoriesand Post Mortem Rooms"7 which led to internallaboratory procedures being reviewed withchanges to safer automatic equipment prac-tices and the provision of special rooms orcabinets for handling infectious material.The management revolution of the 1980s

speeded the decline of British pathology, dis-trict, and unit managers seeing the laboratoryas an expensive resource. Stratified guidelinesby which efficiency could be judged were setup with financial budgeting of departments.This led to numerous management prob-lems. 8 Methods of measuring workload wereintroduced followed by a series ofperformanceindicators to compare the efficiency of labo-ratories. Financial restrictions led to reductionin laboratory staff, amalgamation, rationalisa-tion and in a few instances, laboratory closure.Regional capital budgets, which allowedpathology to be developed on a planned basis,were devolved to districts and by them tohospital units with overall reduction in pur-chase of equipment.

Figure 3 Sir James Howie. "Portraits from memory":British Medical J7ournal.

Another important change in the 1980s wasthe introduction of dry-stick methods withdesk-top analysers.'9 This resulted in anincrease in private laboratories with a narrowrange of tests, and minimal consultant avail-ability. Retrenchment of pathology in Britainwas underway.

PIathology practice in Europe andAmericaWhile dramatic changes in clinical laboratorypractice had occurred in Britain, comparativelylittle change in the organisation of pathologypractice had occurred in Europe and Amer-ica.'' Apart from funding, the principaldifference was the continued separation ofanatomic pathology, which included histopa-thology, cytopathology, and necropsy pathol-ogy, from clinical pathology, usually termed"laboratory medicine" or in France "clinicalbiology". Clinical pathology organisation dif-fered from country to country and in somefrom one region to another depending onhistorical, cultural, economic and politicalvariations.

University and large hospitals had, as inBritain, monospecialty departments usuallywith associated research activities. Small hos-pitals, of which there were many, had multi-disciplinary clinical pathology departments. Insome countries-Finland, Holland, Denmark,Sweden, and to a lesser extent, Germany,laboratory haematology was a subsection ofclinical chemistry, with haemastasiology as aseparate discipline. Clinical haematology heremainly dealt with haematological malignan-cies, linked in Germany and the USA eitherwith oncology or as part of internal medicine.Immunology was split between clinical chem-istry, clinical microbiology, or in Scandinaviawith transfusion medicine. Outside the hospi-tals many clinicians ran their own small labo-ratories attached to their office (consulting

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room). In addition, private laboratories were

often run by non-medical scientists or inFrance by "pharmacists". These could be largecommercial organisations, offering at low cost,a wide range of analyses with a specialisedcommunication facility but without a medicaladvisory service. In large departments,requesting, analysis, and reporting was com-

puterised, the whole process being dividedbetween "star" testing (about 35%) and "whenpossible", the bill taking the difference intoaccount. The staff worked in shifts with analy-ses being performed day and night on the sameequipment. The laboratory had become a

reporting or "informatics service" and regar-

ded as a "cost centre".25But the major difference from the United

Kingdom was the source of funding. In theUSA, particularly, laboratory income depen-ded entirely on the volume of work beingperformed, this in turn being controlled by therequesting physician with a budget controlledby diagnostic-related groups.26 The "billing"aspect of laboratories required high computer-isation with appropriately high clerical staffing.Due to the number of private laboratories,accreditation and licensing by the College ofAmerican Pathologists (CAP) became essen-

tial. Satisfactory quality assurance becamecompulsory for licensing in France, Germany,and the US. With expensive privatisation a highlevel of litigation followed.

Harmonisation of pathology practiceThe 12 countries of the EC agreed in 1987that movement of goods and personnelthroughout the member countries should bepossible after 1992.27 For this purpose direc-tives aimed at essential requirements for thisharmonisation have been or are being drawnup. The effects of these on pathology practiceare likely to be slow, bearing in mind the widedifferences in current practice.Widespread changes consequent on UK

government policy embodied in Working forPatients28 are already changing British pathol-ogy practice more profoundly than anythingover the past 40 years. The ethos is to changethe NHS from a centrally planned service intoa competitive internal market. This has accel-erated budgetary management, with deskillingof staff from the highly trained MLSO to themedical laboratory assistant (MLA) whorequires training only for specific repetitiveprocedures. Laboratories are expected to pricetheir tests, enter into contracts with cliniciansand general practitioners, and to compete witheach other. Large central laboratories are likelyto emerge similar to those in Europe andAmerica, with numerous small laboratoriesnear the patient-ward side-rooms, consul-tants' private offices, and general practitionersurgeries. Pathology practice in Britain willsoon be so similar to that in Europe and the USthat mandated harmonisation will not be nec-

essary.

ConclusionsPathology by its nature is and always will be a

part of life itself. Knowledge of its state andprocesses have developed from observation bythe ancient Egyptians through Greek andRoman doctrinal thought, to early investiga-tion by necropsy at the Renaissance. Theadvent of the microscope brought cellularpathology and microbiology, followed bychemical analysis of blood fluids. Applicationto medical diagnosis has been largely a 20thcentury practice, its organisation outside uni-versities and research centres being largelycommercial. Some countries like Britain andSweden have attempted a planned nationalservice, but with altruism being replaced bymonetarism this may be seen in the future asan idealistic experiment. Whither pathology? isfor crystal-ball gazing but cyclical pointersfrom the past suggest that the current moves toa competitive market in pathology will befollowed by government intervention towards aplanned service for patients. And so the prac-tice of pathology will continue to change.

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2 Foster WD. Patholoqy as a profession in Great Britain and theearly history of the Royal College of Pathologists. London:Royal College of Pathologists, 1982.

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4 Ledingham JCG. Discussion on the present position ofpathology and bacteriology in this country. Br Med J

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17 DHSS. Code of Practice for the prevention of infection in clinicallaboratories and post mortem rooms. London: HMSO,1978.

18 Pennington GW Crystal ball gazing and the effects of fate.I Clin Pathol 1988:41:1141-7.

19 Nanji AA, Poon R, Hindberg I. New patient testing usingdesk-top analysis. Comparison of performance by nurses,physicians and medical office personnel. J Clin Pathol1988;41:223-5.

20 Shinton NK. Pathology across Europe: differences andsimilarities 1. Haematology. J Clin Pathol 1990:43:613-5.

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22 Berry CL. Pathology across Europe: differences and similar-ities 3. Histopathology. J Clin Pathol 1990;43:796-9.

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24 Ferns GAA, Austin D. Laboratory medicine-An Americansystem: discussion paper. J Roy Soc Med 1990;83:502-5.

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26 Fetter RB, Shin Y, Freeman JL, Averil RF, Thompson JD.Case mix definition by diagnosis-related groups. MedCare 1980;18 (suppl):1-453.

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