Peer-to-Peer, Featuring George Lundberg

Ivan Damjanov interviews George Lundberg

George Lundberg has a long and storied history not only in pathology, but also in medical writing. He spent 17 years as the editor of the Journal of the American Medical Association (JAMA), followed by a further decade as the editor of Medscape. Never shy of controversy when he believes it will further the cause of pathology and laboratory medicine, he has seen plenty of career ups and downs and has emerged with his faith in the discipline intact. Here, he speaks with pathologist Ivan Damjanov about his career, his accomplishments, and his advice for those who wish to follow in his footsteps.

What’s the closest you’ve come to the goals you set as a junior pathologist?

As a pathology resident in San Antonio in about 1961, I was told by a staff pathologist that I had the potential to become chair of a medical school’s pathology department. I felt flattered and intrigued, and I immediately established that as a career goal. When I assumed that role at the University of California, Davis in 1977, I felt fulfilled – and wildly energized.

As an associate professor at the University of Southern California, my chair told me that I had the ability to become the president of the American Society for Clinical Pathology (ASCP) and that I should think about it. As a result, I began to climb the ladder in organized pathology, serving on committees for both ASCP and the College of American Pathologists (CAP). My work with ASCP led to a position on the board of directors; my work with CAP did not. When I did ultimately become ASCP’s president in 1990, I felt gratified and tried to do a good job – but the heavy lifting, and the major impacts of my work, took place on the way up, not at the top.

Would you do it the same way again?

For the most part, yes; it has been a great ride! Other than deciding to become a physician at the age of five, I have done no specific career planning. The medical school I attended was the only one that both accepted me and was affordable. Internship in the Army was a preemptive strike to avoid the doctor draft, but it led to an 11-year career in Vietnam-era military pathology. My choice of a pathology residency in Texas came as a result of my need to be closer to my father (who had had a coronary) and mother (who was rattled by his illness).

My professional life has largely been shaped by being open to opportunities and taking advantage of them as they appeared. I have rarely applied for jobs; most often, jobs found me and sometimes even convinced me to change career directions. My advice is to be flexible, open-minded, and alert to unforeseen opportunities – and don’t be afraid to make choices by intuition.

Do you feel that you have had an impact on pathology?

William Boyd taught us in medical school that cause and effect are very difficult to determine with certainty. Most outcomes are a result of myriad different forces. That said, I would like to think that my contributions had at least a small effect on the evolution of US pathology. These are specific actions I took that may have been impactful:

1. The 1975 book, “Managing the Patient-Focused Laboratory,” aimed at helping to organize laboratories based on test turnaround times – not only because of technical capability, but also the need for the result to benefit clinical decision-making using patient focus committees.
2. The 1975 introduction of clinical algorithms to medicine via the regular “Toward Optimal Laboratory Use” column that ran for decades in JAMA and even resulted in a 1983 book called “Using the Clinical Laboratory in Medical Decision-Making.”
3. The 1969 invention of the critical value concept of laboratory reporting that rapidly became a worldwide standard.
4. Coining the phrase “the brain-to-brain loop” for laboratory testing in 1971 to describe a global concept that is still updated 40 years later. This concept called attention to the critical pre-and post-analytic phases.
5. Placing pathologists in a position to guide physicians about what lab tests should (and should not) be ordered, and the meaning of the results, while simultaneously demanding an outcomes agenda for lab tests.
6. I first used computers in pathology in 1963, placed them into a clinical laboratory in 1966, and chaired the CAP Computer Committee throughout the 1970s – an undertaking whose effects should be obvious in today’s digital age.
7. I started working in drug abuse in San Francisco in 1963. Media personality Art Linkletter’s daughter died in 1969 as a result of a fall – it’s believed that she jumped from a sixth-floor window in Santa Monica while high on LSD – and, at the same time, my colleagues and I were seeing up to 70 patients a day in the ER with suspected drug-related illnesses. We asked the Board of Supervisors to fund a 24/7 clinical toxicology laboratory, which became a model for the field.
8. Many of the issues we took on in my 17 years at JAMA affected the evolution of pathology. For instance, a public focus on the often-dreadful quality of physician office labs led directly to CLIA. We also led the national public health charge against tobacco and played a leading role in the international physician movement to prevent nuclear war. We converted peer review from an art into a science via the quadrennial International Congress on Peer Review in Scientific Publishing; we printed literally hundreds of articles about HIV and AIDS in the early days of the crisis; we launched the National Patient Safety movement; and we even invented open-access medical journals.
9. At JAMA in 1995 and Medscape after 1999, a group of us invented Internet medicine. Shortly thereafter, we conceived the webcast video editorial – concurrent text, audio, and video on the same web page. This was before YouTube, but everybody on the Internet uses this model now.
10. In 2010, at CollabRx, we built molecular disease models for melanoma and lung cancer and converted them into diagnostic and therapeutic decision tree web apps. In 2014, those became mobile apps ideal for use in patient-physician shared decision-making – applied precision oncology.
11. As editor-in-chief of JAMA, a position I held from 1982 to 1999, I had editorial responsibility for all the AMA journals. They wanted to discontinue Archives of Pathology and Laboratory Medicine because it was a money-loser. I fought to keep it. It was a free membership benefit for AMA members and very little money came from paid subscriptions or advertising revenue, so I convinced CAP, which did not have a journal, to subsidize the Archives and make it a CAP membership benefit. That satisfied the AMA for a few years – but some CAP leaders still wanted their own journal, so I convinced the AMA to sell the Archives to CAP for a dollar and convinced the leaders of CAP to take it over rather than found a new competitor. That arrangement is still in place today.
12. I am currently the President and Chair of the Lundberg Institute. We enjoy a terrific board of directors and advisory board and have presented a stellar annual lecture in collaboration with the Commonwealth Club of California in San Francisco for the past eight years. But we could do so much more. We have not engaged in succession planning; perhaps we should.

People entering pathology must recognize the vast and diverse career opportunities it offers. At one point, a pathologist was editor-in-chief of JAMA, another was editor-in-chief of the New England Journal of Medicine, another the Director of the National Library of Medicine, and others Deans of medical schools at Stanford and the University of Chicago. Think big!

Tell us about The Lundberg Institute…

The Lundberg Institute (TLI) was founded in 2009 during the one “gap year” of my life. WebMD had laid off all the staff of the Medscape Journal of Medicine on its 10th birthday, declaring the end of a successful experiment in medical publishing (1). We had proven that it was feasible to create and sustain an exclusively electronic, open-access, primary-source, peer-reviewed general medical journal. It was the first such journal indexed in PubMed, Medline, and PubMedCentral – the debut of the medical Internet.

During my non-compete year, I needed to busy myself – and out of that gap came TLI. Our goal was to promote the patient-physician relationship and facilitate shared decision-making informed by the best possible evidence. The not-for-profit 501(c)(3) organization was founded by me, my spouse and former ASCP Publisher Patricia Lorimer Lundberg (who remains the CFO), Kathryn Watson (who remains the Secretary), and Peter Jensen (who remains a member of the Board of Directors). All early members of both boards were notable, and most remain to this day. Unfortunately, the initial lofty plans of TLI were truncated shortly after its founding by my taking on two serious and time-consuming jobs exactly one year after my Medscape Journal of Medicine buy-out.

The Board of Directors agreed that TLI should focus on educating the public about our mission by establishing an annual lectureship. Patti Lundberg developed relationships that opened the door to a nine-year (and counting) collaboration with the highly influential Commonwealth Club of California to host the annual lecture in San Francisco. We aim high for speakers and achieve consistent excellence: names like Don Berwick, Atul Gawande, Elliott Fisher, Leana Wen, and Ken Kizer grace the list. Who’s next? As Yogi Berra famously said, “Predictions are hard to make, especially about the future.” Never is that truer than when discussing TLI!

You’ve been in medicine for nearly seven decades. What has changed over time?

There are still buildings, patients, healthcare workers, equipment, supplies, power struggles, successes, failures, harassment, drug abuse, and administrative “processes” – but pretty much everything else has changed.

In the early 1950s, terms like “quality control” and “quality assurance” were absent. Those concepts and entities were invented and applied over the following half-century. Everything was cheap when I entered the world of medicine; there was no Medicare or Medicaid and not much private insurance. Technology was primitive and has now become overwhelmingly complex. Licensure, certification, inspections, and medical subspecialization existed, but were very early in their conception. Since then, a massive bureaucratization – both governmental and professional – has evolved. Vast riches have flowed in and been consumed by the most effective resource-trapping device ever invented: the voracious American medical-industrial complex.

Relatively small amounts of money were invested in every element of the enterprise. Over time, those dollar numbers soared. Were there population health benefits? Absolutely – but they were not proportional to the money invested. Not even close.

The notion of “medical ethics” as something distinct from common sense, the “golden rule,” or other guides to behavior hardly existed. The impact of the Nuremberg War Crimes Trials had not yet entered common parlance. The Tuskegee syphilis experiment was underway. Human experimentation was common, without anything like “informed consent.” This has all changed with masses of ethical writing and public laws and regulations about almost every detail of possible individual or organizational behavior. Is it now cumbersome and overwrought? Yes. But is it better? Certainly – for our patients, for us, and for our discipline.

Where are we heading?

The field of pathology will continue to be “under the gun” economically, because purchasers and payors generally do not understand our value. Pathologists also tend to be soft-spoken scientist types who are not given to activism or aggressive bargaining. And, sometimes, frankly, what pathologists do may not be worth much money in the eyes of a bottom-line MBA business type – and those people tend to hold a lot of the cards – at least in American medicine. I think it would help if pathology and laboratory medicine were more visible and attractive to the next generation of physicians. To accomplish that, we need a more aggressive mindset. Don’t be afraid to toot your own professional horn. If you’ve earned the attention, take it.

Is pathology a good career for current medical students? If they like science, the laboratory, data, diagnosis, quality assessment, quality assurance, patient safety, teaching, writing, managing people, truth-finding, truth-telling, are interested in any of the myriad subspecialty options our discipline encompasses, and have a high tolerance for administrative ambiguity, then absolutely. But just look at all those caveats…

To existing pathologists and laboratory medicine professionals, I say: be clinically relevant. Make a difference. Help clinicians help their patients. Encourage direct interaction with patients when it would be helpful. Help institutions do fewer, but more useful, lab tests. Be open to noting the clinical outcomes of performing lab tests, recognizing that most clinical lab tests do not need to be done; the results are either normal, negative, or unchanged from the previous test.

On a scale from one to 100, how optimistic are you about pathology’s future?

About 80. There is so much science of disease yet to be learned, and then applied, to improve the human condition. Pathology is at the fulcrum of all those challenges and opportunities.

I am more worried about clinical medicine in the US than I am about pathology. The forced economic industrialization of medical practice has de-professionalized medicine into almost a pure business. That condition must be temporary, because of the human need to trust learned professionals with their very lives. People know that they cannot trust businesses in the same way, which makes the present day an enormously threatening time for American physicians.

Do you think pathologists participate enough in public life and the media?

Definitely not. During my time as an ASCP leader, we did organized outreach mentoring and taught lecture, radio, and TV communication skills. I am not sure whether it did any good – maybe for a few – but we should have ways to encourage pathologists and laboratory medicine professionals to reach out. We should do more role modeling and incentivize outreach.

First, though, we must endure this rough patch in the current American anti-science, anti-truth political and social environment. We can get through it by being among the leaders in speaking truth to power as our society bottoms out, recognizing the constant risk of scorn and ridicule. We can become health science advisors to our clubs and to school, town, county, state, and federal organizations. Be active in social media; become a blogger; have your own website; be available to your local public media; weigh in on discussion boards; help your local coroner’s office; become an expert witness; run for elective offices; speak out; care!