I think that Dickens got it right. As the pandemic has unfolded over the course of many months, I've continually been drawn to remembrances of my high school reading list which included Dickens' Tale of Two Cities (which frankly I didn't like much at that time, but appreciate more right now). As Dickens aptly described, it has been the best of times, the worst of times, and everything in between – though our own contemporary and bizarre version of the tale has included far more than just two cities.

I therefore couldn't help but paraphrase Dickens in my reflections for a virtual panel discussion on “Lessons Learned in the Time of COVID-19” during the American Society of Cytopathology's Annual Meeting. I thought that I'd share these thoughts in my blog this month, since who knows what more is to come and how these lessons may continue to be helpful.

  • “It was the best of times…” Clearly the pandemic has been a terrible event with too much tragic loss of life – but as I've shared before in this blog, this unprecedented crisis has highlighted the irreplaceable role of the specialty of pathology and laboratory medicine and clinical labs in general. The public's clamor for more COVID-19 testing has demonstrated that diagnostic testing is more fully appreciated as a pivot point in health care decision-making. We are all so proud that our laboratory brought up testing so quickly and that we emerged early as a local and national leader in the fight against COVID-19.
  • “It was the worst of times…” We could have been even better prepared, as could have clinical laboratories nationwide. Prior to the emergence of COVID-19, clinical laboratories were frequently under-resourced. The resulting shortcomings in the US capacity for diagnostic testing were highlighted in an article in National Geographic which noted that lack of preparedness began years before the novel coronavirus emerged in China.
  • “It was the epoch of incredulity …” OMG – who? Us?? Accustomed to being behind the scene and ancillary, we are incredulous that we are now major players. Catharina Boehme, CEO of Foundation for Innovative New Diagnostics, a medical nonprofit based in Geneva, Switzerland noted in the above National Geographic article “Diagnostics are the forgotten small brother of pandemic response. When it all goes right, they're almost invisible. COVID-19 has shown the world the importance of diagnostics.”
  • “It was the season of Light…” We have found our place in the spotlight — in fact we are basking in it.
    • Leadership lesson #1: Use the spotlight to your advantage – or as Winston Churchill said, never let a good crisis go to waste. In an Association of Pathology Chairs' Town Hall session on the COVID-19 experience which I moderated in July, chairs throughout the country noted that they have seized the opportunity to ask for long-needed resources and have received everything that they have asked for – more people, more equipment, more everything. This has also been the case in our laboratory too – we have not been shy about asking for more resources and it has been gratifying to see our requests approved so quickly and readily, including those not directly related to COVID-19 testing. It has also been gratifying to see the recognition that we have received, including the Josie King Hero Award which honored our amazing molecular laboratory team.
  • “It was the age of wisdom…”: The world has learned a lot about diagnostic testing and clinical laboratories during the pandemic – but we have also learned a lot about ourselves. One attribute that we always recognized in ourselves is that laboratorians love the comfort of careful planning and well-thought out policies and procedures. But every well-prepared plan – like our carefully considered multi-platform COVID-19 testing plan with phased implementation — is inevitably made to be broken due to the emergence of unforeseen challenges, like our many supply chain shortages. The frequent and rapid pivots to new approaches and spin-off projects created some confusion and occasionally some tension among others who wanted to “stick with the plan”. This tension between process vs. flexibility brought to mind one of my favorite articles from Harvard Business Review regarding different operational cultures in the armed forces. The Navy and Air Force are very process-driven and have a culture of precision because they operate large and expensive equipment like aircraft carriers which cannot easily change direction and where a deviation from process can create errors which are expensive and life-threatening. In contrast, the Army and Marines are down on the ground with small modular equipment and have more operational independence – they need to respond quickly and spontaneously in order to meet their mission and preserve lives. I see laboratorians as analogous to the Navy/Air Force — similarly process-driven with frequent dependence on complex and expensive equipment like automated analyzers, and with a similar culture of precision since patient care depends on accuracy. In contrast, faculty (especially those with research backgrounds) and administrators may be more like the Army/Marines since they may be more accustom to making quick mid-course changes to respectively address experimental challenges or to meet budget targets.
    • Leadership Lesson #2: Know your team: Awareness of differences in operational culture regarding flexibility vs. process is a valuable perspective which can help groups come together more effectively as a team, especially during a crisis. This should allow the team to achieve the necessary operational “sweet spot” to meet their goals, as happened with us.
  • “We had everything before us, we had nothing before us…”: Clinical laboratories are clearly enjoying unprecedented attention and recognition as leaders – but can we sustain this? Is our place in the spotlight already slipping away?
    • Leadership Lesson #3: Don't rest on your laurels. Diagnostic testing has suddenly become “sexy” and everyone wants to do it – and lots of folks think they can because we do our jobs so well, we make running a lab look easy. The FDA's emergency use authorization (EUA) has allowed research labs to develop and offer COVID-19 tests, and many are doing this nationwide. Thankfully, these efforts have expanded the US test capacity and taken the heat off of established clinical labs — a blessing in many ways. But — after the dust settles and the pandemic subsides from crisis-level — is this EUA a slippery slope? Should research labs and others continue to do clinical diagnostic testing permanently, if they desire? What would these mean for quality of testing? Most research labs are not involving pathologists or clinical laboratorians to ensure the process-driven culture of precision and adherence to quality standards that have made clinical laboratories trusted as high-quality providers. How can we demonstrate the added value of our profession – and how can we partner with research labs and others to ensure high standards at all testing sites? These questions and more will be discussed at an upcoming Town Hall panel discussion which I will be moderating, sponsored by the Association of Pathology Chairs on November 13, 2020. Our own Ralph Green will be sharing the positive example of his involvement as a pathologist in bringing up several “pop-up” labs, including in Nobel laureate Jennifer Doudna's research lab at Berkeley's Innovative Genomics Institute and at our own UCD Genomie Center.

So bottom-line, as I mentioned at the start, I think that Dickens got it right – and clearly, everything I needed to know about pandemic response, I learned in high school, though in English class not biology. I think William Fremd High School in Palatine, Illinois would be proud – I should tell them to be sure to keep A Tale of Two Cities in the curriculum. We'll see how the pandemic goes and how these lessons continue to apply – stay tuned.