{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,17]],"date-time":"2026-10-17T13:13:28Z","timestamp":1792242808819,"version":"4.4.0"},"reference-count":55,"publisher":"BMJ","issue":"10","content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["J Clin Pathol"],"accepted":{"date-parts":[[2026,7,19]]},"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:sec>\n                    <jats:title>Aims<\/jats:title>\n                    <jats:p>Pathology is undergoing a paradigm shift as diagnostics become increasingly multimodal and computational. Yet legacy structures, incentives and workflows have not yet evolved. This misalignment created systemic vulnerabilities that threaten diagnostic precision and the profession\u2019s future. Here, we establish a framework for the cognitive integration of rapidly evolving diagnostic innovations in pathology.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>To characterise critical inflection points and opportunities for conceptual transformation we mapped seven diagnostic scenarios: programmed death ligand 1 testing, next-generation sequencing reimbursement constraints, artificial intelligence-based triaging, integrated diagnostics, germline (pharmacogenomics) testing, trial design and emerging assurance frameworks outside traditional pathology. Our synthesis draws from peer-reviewed literature, policy analysis, institutional data, and qualitative insights to highlight where pathologists can elevate their role as integrator of clinical, morphological and molecular knowledge.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Across the seven scenarios, common patterns emerged: unintentional consequences of well-intended initiatives, commoditisation, unsustainable economic models, underleveraged efficiency gains, misaligned infrastructure, missed clinical opportunity, regulatory rigidity and erosion of diagnostic accountability. These patterns signal not only operational gaps but a cognitive crisis. A failure by pathologists to position themselves as more than an interpretative service. Pathologists must assume the role of diagnostic architects, synthesising multimodal data into structured, clinically actionable insights and engaging more directly with physicians, those organising clinical trials and patients as partners in precision medicine.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>The emerging competencies of diagnostic synthesis, systems thinking, digital fluency, and strategic presence in value-based care offer a mindset guide for both personal growth and anchoring the discipline\u2019s next transformational step to improve patient care.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/jcp-2026-210826","type":"journal-article","created":{"date-parts":[[2026,8,17]],"date-time":"2026-08-17T17:20:25Z","timestamp":1786987225000},"page":"659-668","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":1,"title":["Adapt or Become Irrelevant: the Pathologist as the new Diagnostic Architect"],"prefix":"10.1136","volume":"79","author":[{"given":"Mariano","family":"De Socarraz","sequence":"first","affiliation":[{"name":"CorePlus Servicios Clinicos y Patologicos, L.L.C, Carolina, Puerto Rico, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2434-4978","authenticated-orcid":false,"given":"Jochen K.","family":"Lennerz","sequence":"additional","affiliation":[{"name":"Pathology Innovation Collaborative Community, Medical Device Innovation Consortium, Arlington, Virginia, USA"},{"name":"Natera, Austin, Texas, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,8,17]]},"reference":[{"key":"2026091802100911000_79.10.659.1","doi-asserted-by":"publisher","DOI":"10.1038\/s41571-019-0252-y"},{"key":"2026091802100911000_79.10.659.2","doi-asserted-by":"crossref","DOI":"10.1186\/s13000-023-01375-z","article-title":"Artificial intelligence in diagnostic pathology","volume":"18","author":"Shafi","year":"2023","journal-title":"Diagn Pathol"},{"key":"2026091802100911000_79.10.659.3","doi-asserted-by":"crossref","DOI":"10.1002\/2056-4538.70049","article-title":"Computational pathology in the age of artificial intelligence - embrace not fear","volume":"11","author":"Tan-Garcia","year":"2025","journal-title":"J Pathol Clin Res"},{"key":"2026091802100911000_79.10.659.4","article-title":"Re-evaluation of the methodology for estimating the US specialty physician workforce","volume":"2","author":"Black-Schaffer","year":"2024","journal-title":"Health Aff Sch"},{"key":"2026091802100911000_79.10.659.5","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2020.10648","article-title":"Reevaluation of the US Pathologist Workforce Size","volume":"3","author":"Robboy","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2026091802100911000_79.10.659.6","doi-asserted-by":"crossref","first-page":"578","DOI":"10.5858\/arpa.2024-0114-RA","article-title":"A New Generation of Pathologists: Addressing Modern Curriculum and Educational Scholarship for Pathology Educators and Trainees After the End of the COVID-19 Pandemic","volume":"149","author":"Schukow","year":"2025","journal-title":"Arch Pathol Lab Med"},{"key":"2026091802100911000_79.10.659.7","doi-asserted-by":"crossref","DOI":"10.1186\/s13000-024-01590-2","article-title":"The current troubled state of the global pathology workforce: a concise review","volume":"19","author":"Walsh","year":"2024","journal-title":"Diagn Pathol"},{"key":"2026091802100911000_79.10.659.8","doi-asserted-by":"crossref","first-page":"83","DOI":"10.1007\/s00292-024-01396-5","article-title":"Key considerations when implementing new diagnostic technologies in routine practice","volume":"45","author":"Lennerz","year":"2024","journal-title":"Pathologie (Heidelb)"},{"key":"2026091802100911000_79.10.659.9","doi-asserted-by":"publisher","DOI":"10.1016\/S1470-2045(19)30154-8"},{"key":"2026091802100911000_79.10.659.10","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1038\/s41581-026-01047-3","article-title":"Sustainable AI in medicine: balancing benefits and environmental costs","volume":"22","author":"Schmitz","year":"2026","journal-title":"Nat Rev Nephrol"},{"key":"2026091802100911000_79.10.659.11","unstructured":"CHAI . Blueprint for trustworthy AI implementation guidance and assurance for healthcare. 2023."},{"key":"2026091802100911000_79.10.659.12","doi-asserted-by":"crossref","first-page":"1061","DOI":"10.1001\/jama.2024.1084","article-title":"Health AI Assurance Laboratories","volume":"331","author":"Stead","year":"2024","journal-title":"JAMA"},{"key":"2026091802100911000_79.10.659.13","doi-asserted-by":"crossref","first-page":"2335","DOI":"10.1038\/s41591-026-04417-3","article-title":"Unintended consequences of legacy oversight in digital medicine","volume":"32","author":"Lennerz","year":"2026","journal-title":"Nat Med"},{"key":"2026091802100911000_79.10.659.14","doi-asserted-by":"crossref","DOI":"10.1002\/2056-4538.12366","article-title":"Closing the loop - the role of pathologists in digital and computational pathology research","volume":"10","author":"Rau","year":"2024","journal-title":"J Pathol Clin Res"},{"key":"2026091802100911000_79.10.659.15","doi-asserted-by":"crossref","first-page":"100657","DOI":"10.1016\/j.modpat.2024.100657","article-title":"Making Pathologists Ready for the New Artificial Intelligence Era: Changes in Required Competencies","volume":"38","author":"Vos","year":"2025","journal-title":"Mod Pathol"},{"key":"2026091802100911000_79.10.659.16","doi-asserted-by":"publisher","DOI":"10.1097\/PAP.0000000000000161"},{"key":"2026091802100911000_79.10.659.17","doi-asserted-by":"crossref","first-page":"1399","DOI":"10.1016\/S1470-2045(20)30592-1","article-title":"How current assay approval policies are leading to unintended imprecision medicine","volume":"21","author":"Salgado","year":"2020","journal-title":"Lancet Oncol"},{"key":"2026091802100911000_79.10.659.18","doi-asserted-by":"publisher","DOI":"10.1634\/theoncologist.2013-0392"},{"key":"2026091802100911000_79.10.659.19","doi-asserted-by":"publisher","DOI":"10.1016\/j.jmoldx.2023.09.012"},{"key":"2026091802100911000_79.10.659.20","doi-asserted-by":"crossref","first-page":"1062","DOI":"10.1016\/j.jval.2018.06.011","article-title":"From the Past to the Present: Insurer Coverage Frameworks for Next-Generation Tumor Sequencing","volume":"21","author":"Trosman","year":"2018","journal-title":"Value Health"},{"key":"2026091802100911000_79.10.659.21","doi-asserted-by":"crossref","first-page":"e407","DOI":"10.1016\/S2589-7500(20)30159-X","article-title":"An artificial intelligence algorithm for prostate cancer diagnosis in whole slide images of core needle biopsies: a blinded clinical validation and deployment study","volume":"2","author":"Pantanowitz","year":"2020","journal-title":"Lancet Digit Health"},{"key":"2026091802100911000_79.10.659.22","doi-asserted-by":"crossref","DOI":"10.1016\/j.jpi.2024.100378","article-title":"Validation and three years of clinical experience in using an artificial intelligence algorithm as a second read system for prostate cancer diagnosis-real-world experience","volume":"15","author":"Santa-Rosario","year":"2024","journal-title":"J Pathol Inform"},{"key":"2026091802100911000_79.10.659.23","article-title":"Artificial intelligence in medicine: mitigating risks and maximizing benefits via quality assurance, quality control, and acceptance testing","volume":"1","author":"Mahmood","year":"2024","journal-title":"BJR Artif Intell"},{"key":"2026091802100911000_79.10.659.24","unstructured":"AMA . Appendix S - artificial intelligence taxonomy for medical services and procedures. 2025."},{"key":"2026091802100911000_79.10.659.25","doi-asserted-by":"crossref","DOI":"10.1148\/radiol.240335","article-title":"Administrative Alignment for Integrated Diagnostics Leads to Shortened Time to Diagnose and Service Optimization","volume":"312","author":"Bredella","year":"2024","journal-title":"Radiology"},{"key":"2026091802100911000_79.10.659.26","doi-asserted-by":"crossref","unstructured":"Balogh E , Graig L , Wizemann T , et al . Incorporating integrated diagnostics into precision oncology care: proceedings of a workshop. Washington, D.C: National Academies Press (US), 2024.","DOI":"10.17226\/27744"},{"key":"2026091802100911000_79.10.659.27","unstructured":"CPIC . CPIC\u00ae guideline for fluoropyrimidines and DPYD. 2024. Available: https:\/\/cpicpgx.org\/guidelines\/guideline-for-fluoropyrimidines-and-dpyd"},{"key":"2026091802100911000_79.10.659.28","doi-asserted-by":"crossref","DOI":"10.1111\/cts.70466","article-title":"Global Investigation of Clinical Implementation Strategies for DPYD Testing to Guide Fluoropyrimidine Therapy","volume":"19","author":"El Rouby","year":"2026","journal-title":"Clin Transl Sci"},{"key":"2026091802100911000_79.10.659.29","doi-asserted-by":"crossref","first-page":"80","DOI":"10.1097\/FPC.0000000000000581","article-title":"Leveraging implementation science to enhance the adoption of DPYD testing","volume":"36","author":"Tuteja","year":"2026","journal-title":"Pharmacogenet Genomics"},{"key":"2026091802100911000_79.10.659.30","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1002\/cpt.911","article-title":"Clinical Pharmacogenetics Implementation Consortium (CPIC) Guideline for Dihydropyrimidine Dehydrogenase Genotype and Fluoropyrimidine Dosing: 2017 Update","volume":"103","author":"Amstutz","year":"2018","journal-title":"Clin Pharmacol Ther"},{"key":"2026091802100911000_79.10.659.31","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMoa1910549"},{"key":"2026091802100911000_79.10.659.32","unstructured":"FDA . In vitro diagnostic immunohistochemistry (IHC) test for detection of PD-L1 in formalin-fixed, paraffin-embedded (FFPE) human tissue sections. 2015. Available: https:\/\/www.accessdata.fda.gov\/cdrh_docs\/pdf15\/P150013B.pdf"},{"key":"2026091802100911000_79.10.659.33","doi-asserted-by":"publisher","DOI":"10.1016\/j.jtho.2016.11.2228"},{"key":"2026091802100911000_79.10.659.34","doi-asserted-by":"publisher","DOI":"10.1016\/j.jtho.2018.05.013"},{"key":"2026091802100911000_79.10.659.35","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2023.26930"},{"key":"2026091802100911000_79.10.659.36","unstructured":"Joint Commission . Joint Commission and Coalition for Health AI (CHAI) release initial guidance to support responsible AI adoption across U.S. health systems. 2025. Available: https:\/\/www.jointcommission.org\/en-us\/knowledge-library\/news\/2025-09-jc-and-chai-release-initial-guidance-to-support-responsible-ai-adoption"},{"key":"2026091802100911000_79.10.659.37","unstructured":"EMA . EMA recommendations on DPD testing prior to treatment with fluorouracil, capecitabine, tegafur and flucytosine. 2020. Available: https:\/\/www.ema.europa.eu\/en\/news\/ema-recommendations-dpd-testing-prior-treatment-fluorouracil-capecitabine-tegafur-and-flucytosine"},{"key":"2026091802100911000_79.10.659.38","unstructured":"FDA . Good machine learning practice for medical device development: guiding principles. 2025."},{"key":"2026091802100911000_79.10.659.39","unstructured":"FDA . Guiding principles of good AI practice in drug development. 2026."},{"key":"2026091802100911000_79.10.659.40","unstructured":"Nass S , Wizemann T , Graig L , eds. Incorporating integrated diagnostics into precision oncology care: proceedings of a workshop. Washington, DC: National Academies Press (US), 2024."},{"key":"2026091802100911000_79.10.659.41","unstructured":"CMS . National coverage determination (NCD) 90.2 next generation sequencing. 2020. Available: https:\/\/www.cms.gov\/medicare-coverage-database\/view\/ncd.aspx?NCDId=372"},{"key":"2026091802100911000_79.10.659.42","doi-asserted-by":"crossref","first-page":"165","DOI":"10.5858\/arpa.2013-0561-CP","article-title":"Ordo ab Chao: framework for an integrated disease report","volume":"139","author":"de Baca","year":"2015","journal-title":"Arch Pathol Lab Med"},{"key":"2026091802100911000_79.10.659.43","doi-asserted-by":"crossref","first-page":"521","DOI":"10.1586\/14737159.2016.1146593","article-title":"Toward clinical genomics in everyday medicine: perspectives and recommendations","volume":"16","author":"Delaney","year":"2016","journal-title":"Expert Rev Mol Diagn"},{"key":"2026091802100911000_79.10.659.44","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2025.5785","article-title":"Claim Denials for Cancer-Related Next-Generation Sequencing in Medicare","volume":"8","author":"Kang","year":"2025","journal-title":"JAMA Netw Open"},{"key":"2026091802100911000_79.10.659.45","doi-asserted-by":"publisher","DOI":"10.1200\/JCO.24.00372"},{"key":"2026091802100911000_79.10.659.46","unstructured":"UCSF . Coordinating center for diagnostic excellence. 2025. Available: https:\/\/codex.ucsf.edu\/about-codex"},{"key":"2026091802100911000_79.10.659.47","doi-asserted-by":"crossref","first-page":"3","DOI":"10.1016\/S1470-2045(17)30905-1","article-title":"Tumour infiltrating lymphocytes in breast cancer: increasing clinical relevance","volume":"19","author":"Salgado","year":"2018","journal-title":"Lancet Oncol"},{"key":"2026091802100911000_79.10.659.48","article-title":"Clinical Utility of Rapid EGFR Genotyping in Advanced Lung Cancer","volume":"2018","author":"Dagogo-Jack","year":"2018","journal-title":"JCO Precis Oncol"},{"key":"2026091802100911000_79.10.659.49","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1200\/OP.23.00031","article-title":"Integrated Radiology, Pathology, and Pharmacy Program to Accelerate Access to Osimertinib","volume":"19","author":"Dagogo-Jack","year":"2023","journal-title":"JCO Oncol Pract"},{"key":"2026091802100911000_79.10.659.50","doi-asserted-by":"crossref","DOI":"10.4103\/jpi.jpi_53_18","article-title":"Artificial Intelligence and Digital Pathology: Challenges and Opportunities","volume":"9","author":"Tizhoosh","year":"2018","journal-title":"J Pathol Inform"},{"key":"2026091802100911000_79.10.659.51","doi-asserted-by":"publisher","DOI":"10.1093\/oncolo\/oyac134"},{"key":"2026091802100911000_79.10.659.52","doi-asserted-by":"crossref","DOI":"10.1016\/j.jpi.2025.100542","article-title":"Applications and challenges of utilizing digital pathology and AI-enabled workflows in clinical trials","volume":"20","author":"Sebastian","year":"2026","journal-title":"J Pathol Inform"},{"key":"2026091802100911000_79.10.659.53","doi-asserted-by":"crossref","unstructured":"Tizhoosh HR . Beyond the failures: rethinking foundation models in pathology. arXiv 2025. doi:10.1038\/s41551-026-01696-6","DOI":"10.1038\/s41551-026-01696-6"},{"key":"2026091802100911000_79.10.659.54","doi-asserted-by":"crossref","unstructured":"Kuhn TS . The structure of scientific revolutions. 4th edn. University of Chicago Press, 2012.","DOI":"10.7208\/chicago\/9780226458144.001.0001"},{"key":"2026091802100911000_79.10.659.55","doi-asserted-by":"crossref","DOI":"10.3390\/diagnostics15182308","article-title":"The Rise of AI-Assisted Diagnosis: Will Pathologists Be Partners or Bystanders?","volume":"15","author":"El-Khoury","year":"2025","journal-title":"Diagnostics (Basel)"}],"container-title":["Journal of Clinical Pathology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/jcp-2026-210826","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,18]],"date-time":"2026-09-18T09:11:12Z","timestamp":1789722672000},"score":1,"resource":{"primary":{"URL":"https:\/\/jcp.bmj.com\/lookup\/doi\/10.1136\/jcp-2026-210826"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,17]]},"references-count":55,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2026,9,18]]},"published-print":{"date-parts":[[2026,10]]}},"alternative-id":["10.1136\/jcp-2026-210826"],"URL":"https:\/\/doi.org\/10.1136\/jcp-2026-210826","relation":{},"ISSN":["0021-9746","1472-4146"],"issn-type":[{"value":"0021-9746","type":"print"},{"value":"1472-4146","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,17]]}}}