A Brief History of the Formation and Transformation of the College of American Pathologists House of Delegates

The College of American Pathologists (CAP) was officially founded in Chicago on December 13, 1946, during the second day of a 2-day ad hoc meeting of about 140 board-certified pathologists. They had assembled largely by the efforts of Frank W. Hartman, MD, who was elected the CAP's first president.From the beginning, the CAP adopted the following as one of its official objectives: “To foster the highest standards in education, research, and the practice of Pathology.” The record suggests, however, that the primary moving force behind the CAP's founding was increasing dissatisfaction among pathologists with their lowlier status— in terms of both prestige and financial compensation— when compared with other medical practitioners. Pathology had only been affirmed to be the practice of medicine by the American Medical Association in 1943, and members of the profession still struggled against the misunderstanding and undervaluing of their work by both the public and their medical colleagues. This situation was further exacerbated by the advent of third-party payment systems, notably Blue Cross and Blue Shield, just before and during World War II. Because payment for laboratory services was made to hospitals, and not to individual physicians, third-party payment introduced additional friction into the relationships between hospital-based pathologists and the institutions in which they practiced.Other organizations, principally the American Society of Clinical Pathologists (ASCP), which was founded in 1922 and was later renamed the American Society for Clinical Pathology, found themselves fielding an increasing flood of complaints concerning economic arrangements between hospitals and practitioners. These complaints were generally bounced back to local, state, and regional pathology societies, with results that were often, by the explicit admission of the ASCP leadership, less than effective. Against this background, there began a grassroots movement looking toward the establishment of a separate “Academy of Pathology” that might deal with such issues more successfully.Initially, this effort received concrete support from the ASCP. Dr Hartman had enjoyed considerable success as chair of a committee of the Michigan Pathology Society that was charged with improving the socioeconomic status of pathologists in that state and on that basis was appointed chair of the ASCP Committee on Hospital and Public Relations to spearhead a similar effort of national scope. But, curiously enough, the ASCP Executive Committee announced only a few months later that “the Society would favor such an organization, but would not take an active part in promoting it.” Undeterred by this setback, Dr Hartman felt, as he recalled in a 1961 letter, that “so much ground work had already been done … that I continued alone …” in the efforts that led to the December 12–13, 1946, organizational meeting of the CAP in Chicago.The original constitution and bylaws of the CAP provided for a system of geographical regions and regional committees, to be appointed by the Board of Governors, whose primary purpose was to organize and present seminars on scientific subjects—a difficult task, given that long-distance travel was still a formidable undertaking in the 1940s and 1950s. The regional committees were also, however, expected to serve as a grassroots network of liaisons to bring matters of local and regional concern to the attention of the CAP's leadership. Confusingly, the regional councilors of the ASCP (who were similarly selected on a geographic basis) were at first relied on for this purpose as well, despite the fact that not all the councilors were even members of the CAP—a circumstance that rapidly and predictably raised misgivings about possible conflicts of interest. Meanwhile, the regional committees were proving to be an entirely mixed bag in terms of effectiveness, with some being extremely active and others existing only on paper. By the mid-1950s, this combination of circumstances was giving rise to a search for an alternative and more broadly based mechanism of grassroots representation for the CAP membership.It was against this background that the concept of an Assembly was born. To ensure broad geographical representation, the body was to consist of 1 elected delegate for every 50 fellows of the CAP in a given state; the Canadian provinces and the armed services were also represented. The duties previously assigned to the regional committees and to the ASCP councilors were now to be assumed by the new Assembly.The establishment of the Assembly was approved by the Board of Governors in February 1957. The stated purposes of the Assembly were to improve communication between the Board and the membership, to identify members who could be potential governors or committee members, to involve more members in activities of the CAP, and to strengthen the regional educational programs. This lofty language was nonetheless deemed objectionably vague by at least one fellow of the CAP, who remarked at the time, “I nowhere see that the Assembly has any duties or responsibilities. …” Possibly, this failure to define the Assembly's functions more concretely was not entirely accidental; despite having approved its formation, the Board of Governors remained considerably skittish about the possibility of the Assembly becoming sufficiently autonomous to relegate the Board of Governors to merely a judicial role. It was surely for this reason that, at the outset, the CAP president was designated as the presiding officer of the Assembly “to maintain control of the activities of the Assembly. …”The first meeting of the Assembly, led by newly elected speaker, H. Russell Fisher, MD (Figure 1), was held at the Roosevelt Hotel in New Orleans in conjunction with the fall 1957 joint meeting of the CAP and the ASCP. The editor of the College Bulletin, S. E. Gould, MD, opined at the time, “With perfecting of the organization of this representative group of pathologists, one may confidently expect that the work of the College will gain in efficiency and in speed of accomplishment.” In fact, rumor had it that the materials sent to the assemblymen in preparation for the meeting had gone largely unread, a circumstance that hardly enhanced the efficiency of the proceedings. It did become immediately clear, however, that the Assembly did not take kindly to the notion of being presided over by the president of the CAP.Other conflicts between the new Assembly and the CAP's officers and Board also surfaced in due course. The rules of procedure for the first meeting of the Assembly had been set by the Board. In June 1958, however, the Board delegated the task of drawing up a protocol for the future operation of the Assembly to the regional committee chairs, while the compilation of the agenda for the 1958 meeting was entrusted to the chair of the Assembly Steering Committee, Richard F. Birge, MD. That agenda was to include the election of a speaker and a vice speaker, but the election was subject to a specific proviso that in effect required the officers of the CAP to also be the officers of the Assembly, and that allowed the speaker—even though elected by the Assembly—to preside only at the discretion of the president of the CAP.The relationship between the Assembly and the existing regional committees was hardly less muddy. Despite the once-expressed intention of transferring the functions of the regional committees to the Assembly, the regional committees continued to function for more than a decade later, resulting in a situation whereby 2 parallel grassroots organizational networks existed within the CAP—the Assembly and the regional committees. An effort was made to harmonize the two by providing representation for the regional committees in the Assembly and by requiring at least one member of the Assembly to be named to each regional committee. The older regional committees, however, had been accustomed to reporting directly to the Board of Governors and bridled at being asked to report to the upstart Assembly instead.The problem, in a nutshell, was that several crucial operational questions about the exact role of the Assembly had been left unanswered. These questions included: Should the CAP committees report to the Board of Governors or to the Assembly? Should the Assembly appoint its own reference committees? Should the Assembly have the prerogative of setting policy or should it play a purely advisory role? The Board of Governors suffered continuing misgivings about whether it might have given birth to a sort of Frankenstein's monster over which it would eventually lose control—to the extent, heaven forbid, that the Assembly might even want to elect both the CAP governors and officers (this procedure was actually proposed in 1989, after the Assembly had been converted to the House of Delegates, but was never adopted). Eventually, in 1960, some of the fog was cleared when the CAP's constitution and bylaws were finally amended to provide for an Assembly—at which point, as CAP historian Loyd R. Wagner, MD, pithily observed, “The bastard child had been made legitimate!”Legitimate or not, the Assembly still remained something of a mischievous child, at least from the Board's point of view, with questions about its role and operations continuing to command much of the Board's deliberations during the early 1960s. As early as 1962, as well as on several occasions thereafter, proposed resolutions called for the conversion of the Assembly into a House of Delegates with explicit legislative powers to be “similar to [those of] the American Medical Association in its duties and functions,” including (at least in the 1962 proposal) the power to elect the CAP officers. This far-reaching proposal proved to be extremely controversial; the outcome was the formation of “an ad hoc committee … to study and recommend methods and procedures to be followed in the relationship of the Assembly to the Board of Governors.” Although the record is not entirely clear, it was probable that this committee drafted a proposed written charter and bylaws for the Assembly—a document that turned out to be barely recognizable by the time the Board of Governors had finished rewriting it early in 1963. It was on this occasion that Assembly speaker, and future CAP president, William J. Reals, MD, accused the Board members of operating “in the stratosphere” and talking “only to each other and … not … to the [CAP] membership” (Figure 2).Somehow this crisis was weathered in time for a final charter and bylaws to appear in the agenda book for the fall 1963 Assembly meeting, and from this point onward the operations of the Assembly slowly evolved. Terms of office and election procedures were codified for the speaker, vice speaker, secretary, and a steering committee. Assembly reference committees began to receive formal reports from CAP officers, the chief executive officer, and the councils and commissions; to hear pro and con testimony on the various issues; to make recommendations for action by the entire body on proposed resolutions; and to accept or reject reports (although the latter action, if ever taken at all, was exceedingly rare).In 1970, the Assembly was converted to a House of Delegates at the spring interim CAP/ASCP meeting at the Shamrock Hotel in Houston. At this stage, its policy-generating function was finally made explicit in a set of objectives that read, in part: “The House is identified as a body within the College which formulates policy so that the actions and policies of the College of American Pathologists may reflect the needs and wishes of its fellows. The House of Delegates … shall act as a legislative body of the College, initiating business, considering the reports of the College's Officers, Executive Director, Councils and Committees, and the Officers and Committees of the House, passing such actions on to the Board of Governors.” The term formulate is a key one in these objectives, because official policy-making authority remained vested in the Board of Governors. In practice, however, House resolutions and recommendations transmitted to the Board of Governors have, with few exceptions, received favorable consideration and have been adopted as policy statements.To enhance communication between the House and the Board of Governors, the speaker and vice speaker of the House began attending meetings of the Board as guests. In 1971, only a year after its establishment, the House requested voting membership for the speaker on the Board. Partial fulfillment of this request came about with ex-officio Board membership being granted to the speaker in 1972. Nevertheless, dissatisfaction with House-Board relations continued, as evidenced in a 1978 House “position paper,” which stated that “the impact of an orderly flow of information between the Board of Governors and the House of Delegates would be far-reaching …,” thus implying that such an “orderly flow of information” was not taking place at the time. The paper further recommended that “[a] prospective review of new programs and membership services should be undertaken by the House before consideration by the Board of Governors.” There is scant evidence that this particular recommendation was put into practice. The speaker of the House was finally granted a vote on the Board in 1984, and an additional proviso allowed the vice speaker to serve as an alternate in the absence of the speaker. In 1989, the vice speaker was also granted ex-officio membership on the Board. These arrangements served to enhance ongoing communication between the House and the Board and to ensure that the views of practicing pathologists were more fully presented to the Board of Governors, thus bringing the House's function as the true grassroots voice of pathologists closer to reality. (Figure 3 illustrates a typical meeting of the House of Delegates.)During the 1990s, the role of the House of Delegates continued to evolve with the inauguration of an orientation program for new Delegates in 1990. The House also assumed a greater role on the scientific front, formally evaluating proposed CAP Practice Guidelines drafted for submission to the Board of Governors for action.Even before the discontinuation of the Practice Guidelines in 2002, however, the House had entered a period of ferment and experimentation with various aspects of its operations. In 1999, the previous custom of meeting in 2 sessions 2 days apart was abandoned in favor of holding those 2 sessions on successive days. At the fall 2000 meeting, a consent calendar was adopted to streamline consideration of noncontroversial items of business. At the following meeting in the spring of 2001, the meeting format was condensed even more radically; reference committees were not convened, and the 2 business sessions were held on the same day. The dissatisfaction resulting from this procedural change extended to the topmost ranks of the CAP leadership, prompting then-president Paul Raslavicus, MD, to devote his entire “President's Column” in the April 2003 issue of CAP TODAY to the function and future of the House.1 President Raslavicus observed, “The potential energy in our House has clearly been permitted to disperse. … With the newly curtailed House meeting schedule, reducing meeting time to less than a day, we seem to have given up the fight.”Dr Raslavicus then went on to present a series of proposals originally generated by the CAP Strategic Planning Committee and subsequently embodied in a House Steering Committee document entitled “Strategic Tactics for Revitalization,” which was the subject of a half-day's debate at the spring 2003 meeting of the House. The items embodied in this document includedOne immediate result of these recommendations was the appointment of an Ad Hoc Committee on Delegate Selection. Some other recommendations proved to be more challenging to implement, owing to the demise of the spring interim CAP/ASCP joint meeting, which was discontinued after 2003. In 2004 and 2005, the House of Delegates met in conjunction with the meeting of the United States and Canadian Academy of Pathology, and the spring meeting was not held in 2006. Nonetheless, the drive toward reform of the House continued to gain momentum, with the return of reference committees and a 2-day meeting format in the spring of 2004. At this meeting, the House also adopted the formal slogan, “You create pathology's future today.” At the subsequent fall meeting, the House adopted several changes to its rules, notably returning the House to an entirely elected body. Under the new rules, all Fellows of the CAP can nominate themselves for candidacy and stand for election by the fellows in their state. State pathology societies still have the opportunity to endorse candidates and to add them to the slate.These changes helped produce a record turnout at the fall 2005 meeting, with 40% of the 162 attending delegates having been newly elected. At the subsequent fall 2006 meeting, the first resolution brought to the floor was entitled “Discussions on the Function and Structure of the House of Delegates.” This resolution was passed and, as a result, most of this meeting was spent carrying out the resolution. Four special reference committees, one of which is illustrated in Figure 4, were convened to consider 4 core functions ranked as most important in a survey of all House and Board members and a random sampling of CAP committee members. The 4 core functions for the House of Delegates were determined to be:Delegates discussed the meaning and value of each of the 4 functions and developed ideas on how the House could fulfill them. Three ad hoc committees were appointed to build on the results from the meeting, with recommendations from the committees to be brought to the spring 2007 meeting of the House of Delegates for discussion. The spring meeting was reinstated in response to a fall 2005 resolution conveyed from the House to the Board of Governors. A new, more interactive, and less formal meeting format was pilot-tested at this meeting, including round-table discussions and an open question-and-answer session with the Board. This new format met with high praise from the delegates who were present.In sum, ongoing efforts during the past decade seem to give promise to the House of Delegates. There is still determination to “wake the sleeping giant” to a new day of even greater involvement and service to the CAP during its second half-century.The College of American Pathologists House of Delegates celebrated its 50th anniversary on September 29, 2007, during the CAP '07 meeting held in Chicago.This brief of the House of Delegates is based on materials by the A considerable of information on the early of the House of Delegates was also from the In of The College of American of American which was and by Loyd R. Wagner, MD, and other to the book enhanced the and of the College, which the of the College's past brief a during the past 50 of the formation of the original Assembly and its subsequent and into the House of Delegates. to the and support of CAP members and during the preparation of this

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