In the name of brevity, clarity, and data mining, it is a
current (as of about 2000) American "get on the bandwagon" vogue to reduce pathology reports into "synoptic
reports"...simple outlines with simple numerical or adjective measurements
or observations of modern...possibly momentary...interest. Its predominantly to benefit researchers..synoptics placing research interests ahead of patient care interests. In one of the
USA's finest institutions, tissue bank technicians remove samples from radical prostatectomy specimens before the pathologist or PA ever examines it!
(I [EBS] wonder whether this might be subtlely
promoted by commercial interests in order to make it appear that "quality is a given"...and latched onto by academics and researchers who are
rich in "head knowledge" and short on the practical aspects of how quality
is absolutely not a "given"...so that the commercial lab massive size gives them a
competitive advantage and their reporting requires much less effort and
attention to quality details.)
Many practices now omit gross &
microscopic descriptions in pathology reports. Is such a report content decision a reflection of "helter skelter"
THE IDEA OF BEING HELPFUL:
At its most basic, an Anatomic Pathology Report must
be (1) helpful and (2) a current-conventions accurate reflection of the patient's reality in that specimen. And, our group puts top priority on having the report speak toward the immediate benefit
of that patient (researchers, teachers, and others can benefit secondarily). Though not expressly stated in our
departmental documents, our approach visualizes a hugely different &
more comprehensive goal from that of the above synoptic
approach and is based on the Golden Rule, "Do unto others as you would
have them do
unto you." The reporting pathologist...almost never a world-class expert on even one topic...must exert his/her best efforts in thoroughness to discern the truth of the diagnosis...or diagnostic situation...rendered in that report and express it in a
way that maximally helps the doctors treating that patient select the best treatment or management plan. Attempts to optimize the written report and any associated
supplimental oral or electronic communications are highly desirable.
The following is absolutely not group policy. What follows is not a recipe for
each & every pathology report. I heard Dr. David L. Page (famous breast pathologist) respond to my question in about 1980, "I believe that pathologists vary in the degree of compulsiveness that they can execute day after day...one can personally only be so compulsive" [there may be personal limits as to sustained "thoroughness"]. We agree with Dr. Page. We also believe that a report should not attempt to be more definitive than is reasonable and that it should mention important differential diagnosis entities that the findings bring to mind...not just give a final diagnosis [S07-7320]. Our pathologists take each of these
elements into a given pathology report to varying degrees on various cases
due to the combined influences of many differing factors on a given day. The
point is that our mindset is more toward thoroughness & helpfulness in a more
comprehensive way. What follows is an undoubtedly incomplete listing of the
factors entering into the rationale for a more intense, thorough, and comprehensive approach to the reporting of Anatomic
Pathology specimens. Summary: our style is about sharing the uncertatinty...the grey zone...with the patient's physicians as we head toward excellnce in care.
- Identification: The Pathologist leadership and the
Pathologists on any particular case must assure throughout the process of
dealing with the specimen that one is working on the correct patient. Is there any discordance as to identity?
- Context: Would a family practitioner, internist, or surgeon attempt to work on
a patient without history and ancillary information? NO!! Yet, there is a
myth among many clinical physicians that if you give pathologists or
radiologists case information, it will prejudice their diagnostic
judgment. Rather than being prejudicial, historical and ancillary information
more often gives the chance to lead to a true, accurate, and helpful
Pertinent information roughly equivalent to a physician's history
and physical exam elements related to the patient need to be rendered into
(usually in the "clinical information" section). Such information may be
offered by the submitting physician. And, such is taken as a "straw in the wind" that an experienced pathologist will use to guess "what the referring physician is thinking".
The "gross" section of the report is like the physical exam of a patient. The specimen details cannot be reconstructed once the specimen id dissected and dismantled. Rather than any synoptic style, we should discribe things in such a way that a partner can reconstruct the case if you were suddenly dead.
The "micro" section findings should be concordant & logical with the "gross" so that measurements make sense in both the "macro" and "micro" realms and the integrity of the specimen identification is assured.
For example, a small dermal-based spitzoid malignant melanoma can look histologically frighteningly similar to a cellular dermatofibroma. The "discordance" that alerts the pathologist to "dig deeper" is that the experienced dermatologist who submitted the specimen gave a "clinical info" which said "r/o BCE". There is only a vanishingly slim chance that a dermatologist is going to clinically misdiagnose a DF as a BCE.
Otherwise, the pathologist on the case may
find valuable information in the electronic medical records (EMR) of the
pathology department (previous specimens & case and conference notes, etc.) or the medical-institutional EMR or paper chart. The
more context one has, the greater the likelihood of moving from skimpy and
general-bracketing, almost-generic or descriptive diagnoses to more
specific and HELPFUL diagnoses and/or guiding commentary. This
"clinical info" section of the pathology also documents what the pathologist knew about the case at the time of
evaluation and rendering of a diagnosis. The construction of the
report and placement of any subsequent information into the pathology EMR
takes into consideration whether the patient is likely in the process of a
series of surgical procedures. This gives the subsequent pathologist
helpful "heads up" alert information on the case.
During the process of workup of a case, one is encouraged to type
status notes within the report when there may be delays so that one's associates
can answer questions if anyone dealing with the patient calls when the diagnosing pathologist is away (these notes are erased or markedly abbreviated prior to final
sign-out). Also, as one investigates a case which appears to have
normal tissue, it is quite helpful to all concerned in the case if the
clinical information documents the case difficulties, disease, or complaints that lead to the removal
of what may be normal (or subtly abnormal) tissue (examples: gallbladders without stones, appendectomies without appendicitis, and obesity related sleeve gastrectomies).
- Expeditiousness: The system and patients are focused (often inordinately) on rapid TAT (turn-around time). Whether assisting in the midst of an intra-operative
or frozen section or the workup and management of a patient involving a
series of specimens, the pathologist must be intuitive as to the clinical
situation in order to know (1) when to fax or telephone preliminary
findings or updates and (2) with what rapidity the specimen needs to be processed and
interpreted into a final report. For example, a definitive cancer resection with node
dissection has a lesser demand for a rapid final report than core biopsies on an
unknown breast lesion. AND, whether you had rapid TAT from surgery to dropping your signature or not, your TAT means nothing to the treating doctor dealing wiith a patient until the information is in his/her head. So, was the specimen obtained by a person who will be talking with the patient or just by a "specimen procurer"? Do all that you can to get the managing/treating physician's name onto the report as a "copy to"!
- Usual/potential audiences for the report: Be aware that the
ordering physician is not the only person likely to read (and
struggle...?...to understand) your report. Pathology reports are
increasingly read by patients. Other physicians associated with that
patient and even kinfolk or friends who are physicians encounter our
reports. Then, within
the ordering physician's office, there are insurance clerks and nurses and
physician nurse assistants who may be involved in communication with the
patient. Insurance clerks need correct codes and phrases ("modified
radical mastectomy" is far more helpful/meaningful than "breast tissue") to describe
what was done. Such detail ultimately helps the patient gain the
insurance-claims coverage they deserve from the insurance company. After the filing of a claim, the insurance
company then has payor claims reviewers; and the industry has professional
review organization (PRO) reviewers. Then, various accreditation
agencies (CAP, JCAHO, and ACOS cancer program),
government statistics reviewers, and other organizations who collect and
review data will review pathology reports. Finally there is the scary possibility of plaintiff and
defense attorneys and their paralegals performing detailed reviews which
could then possibly get out to the general public through journalists.
It is a HELPFUL thing to attempt to have report copies go to key physicians involved in that patient's life when a report declares an important state of disease...especially if some key physicians have no access to the LCHSD EMR.
- Thoroughness: The "gross" section of the pathology report is
our usual opportunity to (1) express the condition of what was received; and
both the "gross" & "microscopic" sections are our opportunity to document (2) the thoroughness of our evaluation. Surgical operative notes...typed
soon after the surgeon's dictation...may provide valuable clarification.
Photographic documentation and sketches during the workup can be
especially helpful in avoiding confusion as the pathology team works on complex cases. Reports
can be rendered with sketches and photographs to help explain the
diagnostic situation to others. We can scan sketches into permanent electronic departmental files.
- Diagnosis: Diagnostic interpretation, especially when adequate
context is available, can be taken to various levels. At whatever
level, the diagnosis needs to be correct; and it needs to be as helpful as
possible. The refining of a
diagnosis depends on personal experience and intensity of effort in the
examination and interpretation. It may include utilization of
opinions of associates and distant experts (a comment)
. Seldom will just a descriptive
diagnosis constitute acceptable/admirable practice in our group. Physicians want our
HELP/opinions toward the resolution of their differential diagnosis
problem. In the end, the goal is
to render a correct AND helpful diagnosis...as much so as can be reasonably expected under the circumstances.
- Education: Through a component of differential diagnosis
discussion...or noting in the report the "why" of special studies done...in some reports (and telephone & hallway/lounge discussions
of the case), one has the opportunity to participate in
spreading continuing medical education to our associates & colleagues involved in the case...usually placed in the "micro" section. Photographs and sketches can
help with education.
- Sharing in uncertainty: One should never attempt to be more
certain in a diagnosis or interpretation than one is truly able to be. In a career, there will be many
instances in which the pathologist has the opportunity to impact a case
toward more advantageous management for the patient by understanding that
a case is in a "gray zone", and that the treating physician needs to have
some guiding opinion. There are many ways to diplomatically open the
door toward expressing such an opinion. In doing so, one should
remember the Golden Rule and try to be helpful toward the patient management...as if the
patient were a closely connected loved one.
- Leading the referring physician: Through subtle or direct wordings in a report, we
try to HELP the referring physician know when to do more on a case [L07-132]. Example: in
August 2005, one of us even began to try to point out high-risk factors on
colon cancer cases such that the primary doctor or surgeon might consider
sending the patient for an oncology (medical and/or radiation) consult [LMC-05-6708
& 6746], if it is indicated.
- Building relationships: "Point of service pathology" is the key to
"best care"...as to pathology factors in patient care.
In the end, as you build your career,
what will your reports tell your physician clients about you? What
will your activities leading toward a final report tell your associates
about you? What might your report tell patients or their medically savvy relatives about you? Relationship building is also the primary means toward
building a positive professional reputation. As your career lengthens, you may find that physicians
tend to come to you for an additional opinion which may have been expertly
rendered by younger (or lesser known) pathologists in the group. The reason this is done
is because relationships have been formed which lead to strong elements of
- Communication: As would be best within any medical report, our reports clearly list
our group, pathologists' names, and institution (with phone number and website) and pathologist(s) involved in the case so that it is easy for contacts to be
made with us to clarify any addendum or confusing aspect. And, we and our ancillary staff make a concerted effort to determine any other of the patient's physicians who are likely to have an interest in the case findings; and we send report copies to them.