| Handling Our
Anatomic Pathology Workload
SITUATION: We are a group of 8-10 pathologists dedicated to "going the extra mile" in case thoroughness, point of service attitude, and favoring adequate lifestyle benefits (rather
than maximized income) and intending to do so by having sufficient "manpower" who
can "handle/manage" all situations well. Understaffing is long-term incompatible with thoroughness. One clinical physician (as of
June 2001) has recently demanded that only 3
of us deal with his group's skins. This again focuses the issue of whether to be a
group of generalists with unofficial special interests vs. specialists.
If specialists, we'd be more pressed to significantly reduce annual
leave (so that the specialists are more often on site), an undesirable move for a group intending long stable careers of thorough case handling at the point of service, productive of superior judgement & that includes older, wise associates.
Here is our compromise that sounds complicated but is easy
when everyone resolves to "make it work".
GOAL: To maintain the above "generalist" broad capability to "handle" a/any
case, yet have our reports not only be accurate but reflect a type of extra "authoritativeness" as
they assure that (1) either "members with a special interest" have
reviewed the case or (2) it has gone to one of our selected, recognized experts
for an "expert outside consult". The above demand on skin specimens prompted our need
to institute change. Starting very soon thereafter, we needed...when short-staffed...to have skin cases initially
spread out among the group as everyone's part of the "workload assignments".
Then, if the diagnosis is "slam dunk" straight-forward and easy, ANYONE
might go ahead and sign the case out. Less than an open-and-shut diagnosis, the
case MUST AT LEAST be carefully IPC'ed by any or all of the 3.
It is unwise for biopsies
of inflammatory dermatoses to be FINALIZED without IPC by one of the 3 (all or any of the 3 who are present that day), the IPC comment to nicely synthesize the
opinions if there is not a strong consensus. Skin lymphoids ought to include
a hematopathbology IPC. Alternatively, the initial pathologist on a skin case can just execute a written
case transfer to one of the 3. IPC's and case transfers need to use the forms (they
are our proof of process), even if just to note: "we double-scoped, benign" or "check
voice mail comment, favor dysplastic nevus". FINALLY, the path report needs
to stop using the abbreviations, "IPC": followed by pathologist's
initials, as these are meaningless to referring doctors and patients. I'd suggest
something like, "The case has also been reviewed by doctors Carter, McMaster,
and Armstrong; and all 4 of us agree with the diagnosis rendered below".
The "point" is to assure the dermatologists and their patients (who
both read the path reports) that we have done the best that we can within the
group and have included those that the docs recognize as our group's "special
interest in skin" people (or even an expert consultant). This will be OK with docs and evens the SP load back
among us. As to possibly extending the concept:
SKIN: Dermatologists nationally (and locally)
are in a panic such that one might hear a generic quote such as, "All
derm cases should be read out by board-certified dermatopathologists;
Fred, I can't believe that you're still using general pathologists!!" We
can do the above IPC/in-house-special-interest reviews or lose skins to other providers. We have seen far too insufficient performance by dermatopathologists just in the adequate diagnosis of melanoma to change our generalist strategy, even in skins. Some dermatologist clients think
that the above 3 are most helpful with skin cases. This would institute "the
PROSTATE BIOPSIES: With (in 2001) Dianon,
Urocorp, P-RMH (disguised as Lab Corp) and others' sales reps pounding
regularly on urologists' office doors and promising "the
world," we've kept this VERY CHALLENGING part of our practice
with only 5 of our pathologists in a very tight and parameter-filled
format. In about 2004, we lost all but 2 of the urologists in Columbia Urology as the two Palmetto Health hospital pathology groups merged and offered a regular clinicopathology conference in uropathology. In 2007, out-of-state illegal "client billing" cost us one account and a temporary part of another.
MARROWS: One of our group is the hemepath-boarded, clinically
heme-onc-acknowledged, midlands of SC hemepath expert; so, we
have marrows signed out only by that person, another (a product VERY
strong heme residency program and active med school professorships
in heme/coag), and a third (product of a hemepath fellowship).
GIs: Since Jan. 1st 2001, there has been
a steady flow of calls from the big GI group and from others
for one of us to review cases with diagnoses of dysplasia and
presence (yes/no) and type of colitis and type of hepatitis (liver...especially could it be AIH...based on old/new lab test data).
Sometimes the request is for expert 2nd opinion (not infrequently
a patient request)...we send it to an outside expert. CRC oncology is getting increasingly complex as of 2004, and we are meeting that need nicely.
GYN: The clinical docs continue to feel
mounting medicolegal pressure for greater sensitivity, precision,
and accuracy...much of it fueled by the ThinPrep high-pressure
marketing of the late 1990s. Concern about HPV. The P-RMH surgical oncologists
are now independent of P-RMH and are members of S. C. Oncology Associates'
master group. Therefore, most of the malignant cases that get a diagnosis from us will have treatment elsewhere. All of our group handles equally proficiently.
BREAST: Women are more and more knowledgeable,
and the envelope is being pushed closer and closer to the edge
for us to interpret as much usable data as possible out of a
case exam. Thoroughness is critical. This has become powerfully evident during
the years since formation of our hospital's multidisciplinary breast program in about 2000 and special attention to the weekly breast
conference. This continues to be a challenging
area which all of our group handles equally proficiently.
THYROID: This continues to be a challenging
area which all of our group handles equally proficiently.
CNS: Very challenging and one of our group has taken
special interest and been responsible for much of the lead in this topic. An expert consultant is often used.
Cytology, especially non-GYN: We have two
of our group with fellowship training ( and one board certified).
|CONCLUSION: Our group's approach in all of the above areas
is somewhat like the skin cases "concept" & will be
done as we identify those in our group who have special interest
and/or are clinically perceived as our group experts and give cases
the benefit of our best when that is useful. Telepathology will become an additional link to prompt help. But outside expert opinions continue to be a great and prompt help on tough cases (Fed Ex can have our slides delivered to any USA expert "next day", and their opinion is back to us promptly by telephone, FAX, or e-mail...promptness related to our communication of degree of urgency).
| (4 June 2001; latest update 20 September 2008; typo correction 6/10/2013)
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