Address at the Royal College of Pathologists of Australasia (RCPA) State Dinner 2023 | AMA (WA)


Royal College of Pathologists of Australiasia (RCPA) State Dinner 2023

Address at the Royal College of Pathologists of Australasia (RCPA) State Dinner 2023

Tuesday November 28, 2023

Dr Michael Page, AMA (WA) President

AMA (WA) President Dr Michael Page was recently invited to give an address at the Royal College of Pathologists of Australasia (RCPA) State Dinner. In his speech, he emphasised the importance of advocating as a doctor for all doctors in his role as president, the centrality of pathology to medicine in general, and the importance of challenging outdated perceptions of his specialty.

It was a real honour to be invited to speak at this dinner, especially having been to a number of these now and having seen the high calibre of speakers the event has historically attracted. I should also add that as a member of the College’s WA State Committee, I was an apology at the meeting where it was decided I’d be doing this talk – which is usually how speakers “volunteer” for this gig.

As I understand it, I’m the first pathologist since Dr Keith Shilkin AM in the early 1980s to be an AMA (WA) President. I’ve thought a lot about how to approach this very broad role of medical leadership as a member of one of the, dare I say, less prominent specialties, within which I work in a subspecialty that is in fact entirely obscure within medicine, let alone to the general public.

So, as I pondered whether the President role was one that I wanted to take on, I’ll admit this crossed my mind. I thought about all the surgeons, GPs, obstetrician/gynaecologists and other publicly relatable specialties that have been in the role, I thought about my predecessor, plastic surgeon Dr Mark Duncan-Smith in the newspaper in a theatre cap and scrubs and wondered whether me standing with my hand on a Siemens auto-analyser or staring at ULTRA on a computer screen would carry the same impact with the public.

Indeed, when I took on the role and did my media training session, the trainer said to me “lose the grey suit – you need to be wearing scrubs or at least have a stethoscope around your neck.” But of course, I said no, I’m not going to pretend to be something that I’m not, in front of our members who’ll see me as inauthentic, and especially in front of our pathologist members who then lose the opportunity for me to perhaps raise the profile of pathology in its own right.

Nonetheless, the role is one of leadership for the entire profession: junior, senior, every specialty, no specialty. And the public-facing persona of the role, whether I’m speaking on vaccination, vaping, energy drinks, farm safety, hospital waiting lists or any other topic of public health importance is simply of a doctor speaking to the public. It’s all about clear, well-informed and authoritative communication, which is what we as pathologists do every single day. I might not have deep expertise in any of these topics, so it’s just about obtaining, synthesising and presenting the expert view.

If I go before the media to talk about mosquito-borne viruses as I did today, for example, I’m in no better a position than an orthopaedic surgeon, neurologist or sexual health physician to speak on this topic. But I am sometimes surprised by how broadly applicable many aspects of my basic medical training, early clinical years and even specialty training in chemical pathology can be when interpreting and filtering information that I provide publicly or use in advocacy behind closed doors.

I’m sure , others could give far better insights into where pathology is headed in this country than I can, but I do want to speak about a couple of the issues we’re facing now and that we will continue to face, and why it is that a broadly united medical profession is important; why we are not going to be able to solve our problems in isolation from the broader profession and health community.

Firstly, we are all well aware that health expenditure as a proportion of GDP only continues to increase, and governments and private insurers are doing everything they can to rein in spending on health. This is a result of amazing new therapies, inflation, the ageing population, labour shortages and other factors. We know that GPs have been underfunded by successive federal governments. This is incredibly well known; the public knows it, other doctors know it, it’s no secret. It’s a factor in the significant competition between private pathology providers to secure collection premises in general practices, without which, it is often said, many general practices would simply not be viable. It’s what’s permitted many bulk-billing general practices to continue operating as they have only until very recently, when we’ve seen many GPs change their approach to bulk billing in order to remain viable by charging patients gaps. Ultimately, this is the fault of federal governments for underfunding general practice, and at times publicly chastising GPs for not bulk billing enough.

What’s less well-known amongst doctors and the public, but well-known in this room, is that Medicare rebates to pathology have also stagnated, and in fact have not been indexed in nearly three decades. The assumption by government that this is OK because market consolidation and automation continue to drive overheads down in pathology ignores the erosion of pathology margins by rental competition, increasing labour costs, and the reality that quite clearly some pathology businesses are actually doing it pretty tough.

So where should this be going? A fight between general practice and pathology to get the last remaining Medicare money, like some gangs fighting over precious petrol in the post-apocalyptic world of Mad Max?

The fact is that we need to work with our colleagues from other specialties like general practice to make governments understand the issues and importantly, especially for pathology, which flies very much under the public’s radar compared with general practice, to bring the public along, to have the public understand what we do and why it should be valued.

It’s true that we made some ground in that regard during the COVID-19 pandemic, when clinical microbiologists came out of the disgusting urine-scented part of the laboratory and became some of the stars of the pandemic, bringing the broader pathology industry into the limelight. But the world moves along more quickly than ever now, and with the pandemic seemingly a distant memory for many, and RAT testing (or no testing) well and truly supplanting the role of PCR testing in the vast majority of suspected cases, that’s faded, and we need to find ways to remain in the public consciousness.

In fact, I’d argue that RAT tests, whilst no doubt a useful tool for the public health response to this particular infectious disease, might do more than just short-term harm to the bottom line of pathology services by largely replacing laboratory-based PCR testing. I believe that it’s opened the door to increased consumerism of pathology testing. Right now, in the United Kingdom you can go into a Boots pharmacy and buy home test kits for thyroid function, B12, iron studies, HbA1c to test for diabetes, HIV, other STIs, vitamin D and a few other things. You get a little box which for the blood tests contains a finger prick collection device which you then mail in and get your results back in a few days.

Closer to home there are many third-party providers that facilitate non-Medicare, self-requested pathology tests. Now, I’m not going to argue either way as to whether this is a good thing or a bad thing. No doubt there are many instances in which it is plainly inappropriate. Clearly the Bayesian process of refining a diagnosis by taking a history and examining the patient before ordering pathology or radiology tests goes out the window, increasing the likelihood of false positive results and inappropriate tests being performed. If thyroid function tests are sold directly to consumers as a first-line approach to see why you’re tired when there are 100 other causes, it’s very unlikely to be a cost-effective approach to diagnosis.

But it’s not as though patients taking an interest in their own health is a new phenomenon. We’ve talked about patients consulting Dr Google for decades now, but even before that there were home health manuals that savvy homemakers would have on the shelf to troubleshoot the family’s ailments before consulting the family GP. But Dr Google as we think of it is surely giving way to Dr ChatGPT and many manifestations of AI-driven self-directed care. AI-driven chatbots could in fact reintroduce a more Bayesian approach to test selection for a patient seeking their own pathology testing, and perhaps interpretation too.

As is always the case with new trends, we as pathologists, pathology scientists and administrators will have choices to make around the degree to which we participate. Even if we don’t ourselves directly participate in enabling consumer-driven pathology testing, if our laboratories are doing it, what do we understand about the medical governance of those tests? If we provide an interpretative comment, who is it directed towards? I’m not aware of many pathologists who as yet are tailoring interpretation of results towards patients. Should we be?

What about medically requested tests with a copy to the patient? What about the fact that irrespective of “copy to patient” being written on the form, nearly all tests could end up on MyHealthRecord, and there’s an increasing push towards removing or reducing the delays between test reporting to the doctor and the results also being available directly to the patient on MyHealthRecord? Is there an opportunity, in this, to raise the profile of pathology’s clinical dimension directly to patients and the public?

We of course also need to raise the profile of pathology to medical students and junior doctors. Many of the barriers and their solutions are well known, it’s just the execution that’s incredibly difficult.

Clearly direct experiential learning of pathology through rotations during medical school, internship or residency would be very useful, but there are significant issues with the capacity of pathology laboratories to supervise juniors, when there is a very steep learning curve for the junior to be able to contribute to service delivery.

But more broadly, do we have an image problem and if we do, how do we address it? Personally, I don’t see value in even acknowledging some of the negative stereotypes about pathologists that might be out there. I see that approach often — acknowledging the stereotype then trying to debunk it. “Pathologists are often seen as basement dwellers, but did you know that most of us come out of the basement to buy a coffee twice a day?” I think we’re on the back foot the moment we do it. If they are incorrect stereotypes, then we shouldn’t give them any airtime.

Let’s model and demonstrate what we know we are — medical specialists with excellent communication skills because they are necessary to our jobs; deep linkages with many other clinical specialities; broad medical backgrounds; and an incredibly rich and detailed understanding of disease processes. As an AMA President, when I do media or meet with the Health Minister or whoever else, I identify as a doctor representing all other doctors. I can’t afford in this role to pay any attention to public misperceptions or misunderstandings about what a pathologist is or does. I’m extremely proud to be a pathologist, and once again thank you for the enormous honour of having me to speak this evening.