Anonymous quotes: "I don't care what you know until I know that you care." "Quality healthcare is cost effective health care." "
Health care is a local activity."
And, Mark Twain, speaking through Huckleberry Finn, "Well, then, says I, what's the use you learning to do right when it's troublesome to do right and
ain't no trouble to do
wrong, and the wages is just the same?"
As a physician or patient, what is the basis of your faith that the lab and/or the pathology group you or your doctor sends specimens to will "do right"?
Why do they "care"? Do they have ethical practice arrangementst? Will the content of their
character drive them to "do right" by you (the patient) or your (the doctor) patients? Will they truly strive to go beyond some simple level of accuracy and be truly HELPFUL?
[such an overview of our group]
***WILL THEY PERFORM IN THE MANNER OF A LOCAL PROFESSIONAL "CALLING" RATHER THAN JUST A JOB?
Our Dr. Carter coined the term "Helter-Skelter" medicine in the early 1990s to describe practicing of all aspects of medicine too fast with too little time to think and interact
and with lack of focused thoroughness and attention to details of a case or an issue. This national state of affairs has come about due to two big reasons opr factors:
- Financial pressures: reduced compensation per unit of value to all medical providers by insurors & governments, has lead to physicians
being tempted into unethical activities to bring in money to keep practices profitable. It is driven by third party payors and governments who are determined that the practitioners of a
"classical, learned profession" be forced into an industrial model that rewards based on an increased rate of production of "widgets" per unit time.
- Rapid service expectations by patients: In 2009, Dr. Carter began to empasize the tremendous value of "observational medicine". In concert with 24-hour news coverage, rapidity of news & rumor dissemination within society, e-mails, texting, Twitter, Facebook, etc., patients rush in for medical care & are disappointed when the system does not immediately render a highly specific diagnosis. Timelines of a a case complaint, photographs, and details of exactly when, where & how are a tremendous help (see how patients can help themselves HERE). These are elements that help one keep from "pulling" incorrect "triggers" too soon & result in too much being done too soon (a recent example helping to avoid too much FNA10-175). "Observational medicine" & "sharing the unknown" cannot be optimally done when key components of a patient's diagnosis & management are primarily performed OUTSIDE of both (1) the geographic and (2) professional relational "point of service".
(Check this link as to the potential to be different & better in our health care district [LCHSD] & combat Helter-Skelter, especially note the end of that message). And see last sentence on this current page, HERE.
We physicians (though pathologists often speak of two classes of physicians, clinicians & pathologists) must not subdivide, even within our own specialty. Physicians must get back to emphasizing our commonalities, the positive effects of which are maximized in local communities. We must relate in such a way that we smoothly "share the uncertainties" as a case workup & management is ongoing. The efficiencies offered by technology can allow a return to focused & thorough medical practice by all physicians...to the point that they can really care again through "point of service practice". Caring comes about through relationships, and "point of service" is (1) about that network
of professional and layperson relationships that causes the local medical team to "go the extra mile" and (2) harks to that command from Jesus to "do unto others as you would have others do unto
you" (the "Golden Rule"). While utilizing distant expertise & services has always had the potential for adding value, patients are best served when such expertise occurs through
local practitioners who care (see our generalist strategy as a key to thoroughness). After all, patients must live in their local community. And the local..."point of service"...health care system must not be weakened
"hamstrung" by the primary exporting of patients, specimens from patients, or patient data from the local point of service. Otherwise, local, caring expertise will fade away (the local, intense,
non-exportable work is insufficient to provide enough dollars to competitively staff with quality). This is as equally true for the pathologist expertise needed to direct
& lead & also provide medical services to individual patients from both the clinical lab (Laboratory Medicine) as well as the anatomic pathology lab (Pathology)
[note examples...such influences as these cannot be as adequately supplied by non-pathologists or pathologists
who have inadequate judgement, don't care, or are boxed into systems which impede their caring].
We locally "care" & are hugely focused
on providing excellent point of service pathology & laboratory medicine services.
Our pathology group, Pathology
Associates of Lexington, P.A., began in late 1971 with the
opening of [then called] Lexington
County Hospital in West Columbia, S. C. Guy A. Calvert, Jr.,
M. D. was the founding pathologist. A native of Columbia,
S. C., he had been a highly effective and popular family practice physician
in Greenwood, S. C., for a decade. He left Greenwood for a pathology
residency at Bowman-Gray School of Medicine. His structuring
of the new hospital's pathology & laboratory medicine program focused on meeting the needs of local
doctors and patients...as seen through the mind of a former
family doctor. This new lab supported probably the first group of full time, community-hospital based ER doctors in S. C.
The next partners Dr. Calvert brought in were highly like-minded in
this approach to pathology lab operation...leader emphasis being
placed on each pathologist's background as regards Personal
Standard of Care. In essence, point-of-service pathology
was the emphasis...we just didn't have a name for it in the 1970s-80s.
In the early 1990's, we were affiliated with a like-minded
lab, PDL, of Florence, S. C. directed by pathologist, Louis D.
Wright, M. D. Many discussions...among all of us parties...were
had about how to maintain lab/pathology quality and appropriateness
of service locally in the face of distant, investor-owned, for-profit,
commercial megalab competition and managed care. It all boiled
down to "point-of-service medical care". Dr. Wright went on...with
prodigious tenacity and hard, long work...to found a network (our group being the first group to
be an ally) whose trademark is "Point-of-Service Pathology"...
likely to be the long-term future model for pathology and laboratory
service of the highest general quality for patients.
What does the above page title mean? Beginning in the 1960's,
near to the advent of the Federal Medicare Program, a positive paradigm shift began as well-financed
commercial businesses began to offer laboratory testing to doctors'
offices. And, such labs provided courier pickup of specimens.
Because these labs could batch-test huge loads of such specimens
in central test labs, their cost of testing fell well below
what the physician offices or local hospital labs could do.
To make it even simpler for the doctors' offices to decide to become their customers, those labs
also offered anatomic pathology (tissue biopsies and cytology...such
as pap smears...testing). These latter specimens became comparative-pricing
benchmarks for the office doctors, and they soon began being
handled as "loss leaders" by the commercial labs in order to
get/keep the more lucrative, cost-reduced lab testing.
The local pathologist (specialist physician) became dislocated
from a large percentage of local life-changing diagnoses which
were being made by distant pathologists who had no attachment whatsoever
to the general reputation or accountability of that local community
of physicians. They did not possess state licenses and were
not credentialed for practice on the local hospital medical
staff. No one in the local medical community even had any idea who they were.
And since local non-pathologist physicians were sometimes marking up the
pathology charge from the distant commercial lab into much higher charges
to their local patients, this mark-up ("client billing") arrangement became a significant
revenue source for local physicians. Against all common sense and experience we have all had with human nature & certification of expertise, quality was conveniently presumed to be universal. It was often thought that
problem cases did not exist; or, if problem cases did exist,
they could be forwarded to expert consultant pathologists, as
the need arose. Such thinking presumed correct recognition of
problem cases as actually being "a problem case" by business people in the mega-business of medicine.
"Marking up" (client billing) and many other fee-splitting and fee kick-back arrangements (pod labs, condo labs, in-house pathologist, contracted pathology services, etc.) had distorted medical practice. Direct billing to patients or their insurance by the person or entity actually performing services is
becoming more and more difficult.
When screening or diagnostic biopsies are processed in a distant lab and a final resection specimen comes afterward to the local lab, the opportunity has been cancelled for
the local pathologist to determine concordance between biopsy & definitive resection findings. So, a mixup cannot be detected. We thought we had detected a major LOCAL error in 1994 in
a prostate case [S-94-2339 & LMC-94-2841...all processed in our local lab] but were able to have DNA analysis to prove that the prostate biopsies and prostatectomy were from the same patient.
The most optimal situation for patients is when local (point
of service) pathologists (the community pathologists) are regularly and deeply involved at least with
the tissue and cytology diagnoses of the local physicians. After all, both surgical & clinical pathology services are best delivered by such specialists because
highest-quality support of local physicians happens when rendered by pathologists who have excellent judgement & care about and think in terms of the impact on local patients. They and the local
patients are both components of...the fabric of...that local community. Pathology practiced in the absence of that foremost attention to the impact on the patient is inferior (see Dr.
Ackerman's excellent book1). All
physicians are then part of an accountability network between
members of a common, local community. The pathologists become
familiar with the manner in which patients are handled in the
varying local practices. Because of these closer professional
relationships, patient-care decisions can be much more patient-specific,
rather than "general-standard-of-care" specific. [about "standard
All patients are best served when ALL medical providers are as close to...or managed basically through those closest to...the point of service as possible!
Experts: Expert (usually in a distant city of another state) pathologist consultants
may be "experts", but all community pathologists learn quickly
that "expert" does not necessarily mean diagnostic excellence
or accuracy or pertinence to a local case situation. While I mean nothing negative about expert consultants, they are not perfect; and here are just
a few examples of nationally published studies of non-agreement
- Breast cancer: Doctor Rosai...American Journal of Surgical
Pathology 15:(209); 1991: multiple cases sent to 5 experts,
and there was no instance in which all agreed on the diagnosis.
- Breast cancer: Dr. Schnitt...American Journal of Surgical
Pathology 16:1133; 1992: better agreement.
- Prostate cancer: Dr. Epstein...American Journal of Surgical
Pathology 19:873; 1995: diagnostic disagreement among 7 experts.
- Melanoma skin cancer: Dr. Farmer...Human Pathology 27:528;
1996: 10 experts disagree even on benign versus malignant,
there being unanimous agreement on only 30% of cases.
- Melanoma skin cancer: Dr. Ackerman...Human Pathology 27:1115;
1996: As part of an editorial comment about #4 "this sorry
state of affairs in histopathological diagnosis is not confined
to the sphere of melanocytic neoplasms; it exists in matters
such as cutaneous pseudo-lymphomas versus lymphomas and vexing
problems in differential diagnosis in every organ. The situation
as it exists now is unacceptable and we who bear responsibility
for patients must mobilize to rectify it, recognizing full
well that absolute concordance can never be achieved for lesions
of extraordinary difficulty diagnostically." I believe that
alliances and organizations which promote and protect point
of service medical practice counter-balance any deficiencies
due to imperfect agreement, be it expert or non-expert.
- Non-alcoholic fatty liver disease: Dr. Younossi...Modern
Pathology 11:560; 1998: 4 pathologists expert in liver biopsy
interpretation have trouble identifying key diagnostic features.
- Pap smears: Dr. Silverman...American J. of Clin. Path. 110:653;
1998: 4 expert cytopathologists reviewed slides having the
known very important diagnostic category of AGUS (which has
up to an 80% chance of being associated with a neoplastic
cervix lesion) in a group of 100 cases. In only 86% of cases
did all 4 diagnose AGUS or a comparably important diagnosis.
- Barrett's esophagus dysplasia vs. not dysplasia: 14 expert
GI pathologists cannot achieve 100% agreement on case diagnosis
even though agreeing on the criteria...Human Pathology 32:368-378,
- Thyroid cancer: follicular (implies that lobectomy suffices)
vs. follicular variant of papillary carcinoma (implies that
total thyroidectomy is needed). International panel of 8 endocrine
expert pathologists evaluate 87 cases & all agree only
on 50% of cases. Modern Pathology 16(1):106A, January 2003.
Pathology Second Opinions
"Dear Judy3: Thanks for this article about case changes due to
second opinions; I looked at it. This is deceptive in that the
TREATING institution is nearly ALWAYS going to get some additional "squeeze" out
of a "second-opinion" review because they have their unpublished
and personal experiential factors that they look for in adjusting
their prognostic advice. So, I'd like to lobby for clarification
as you write/speak/website about second opinions:
(1) "diagnostic second opinion" is when another
opinion is obtained for purposes of "is the diagnosis correct":
[a] intradepartmental opinions (we call them IPCs) may be prospectively
and voluntarily sought by the diagnosing pathologist prior to
issuing his/her report; [b] or the doctor may call and ask another
in that group to review the case and attach an opinion as an
addendum to the report. Or, the local diagnosing pathologist
may want the specific opinion of a specific expert who is extramural...located
somewhere else in the USA/world (all 3 of these are routinely
done at LMC). "Local pathologists" quickly learn to NEVER seek
a diagnostic second opinion from more than one expert...you
will often end up with "expert disagreement". Many published
studies exist attesting to the disturbing lack of concordance
among experts...even between benign and malignant!!!
(2) "referral treatment second opinion" is one
that comes about routinely as a part of tertiary-center practice...the
treating experts want the case reviewed by their own pathologist
who is especially familiar with what he wants to know about
It is a GREAT advantage to a community to have capable/good
pathologists 'at the point of care' right there in their own
communities. Sincerely," EBS 2/11/03
The Key Point
The local..."point of service"...pathologist, when (1) in possession of excellent judgement and (2) "caring", is in a better
position to make up for the above types of human deficiencies
by having a long-term interest in his/her reputation among community
physician colleagues such that his/her intensity of effort in
cases and on case quality control and case correlation in behalf
of each patient is higher and more sustained. We have no doubt
that there may be a small percentage of local pathologists who
are inept or relatively disinterested or distracted from highest
quality work. But, based on my more than 35 years in the field of pathology,
we believe that the closer a pathologist is to a patient in a
community AND the closer to that patient's physician, the harder
he/she tries to be particularly (not just generally) accurate,
"case pertinent", and "situation helpful" to that patient and his/her
doctor. This sustained intensity of effort & care is extremely difficult to imagine
coming long-term from the hireling pathologist working his shift in
a Wall Street motivated, public-stock-holder-owned reference
If the above point-of-service foundation is not in place, it
is impossible for such as a referral pathologist to catch the clue and intervene. With modern technology,
it is possible to have distant (rather than point-of-service)
doctors do all sorts of things...humans are always easily lead
to believe that some "expert" or source from afar is better
than the local medical doctors (LMDs). Two other factors are
of great importance to patients:
- GOOD DOCTOR: Your diagnosis and management decisions
and local skills must be under the care of a well-trained
and conscientious [case example] physician...a "good doctor".
- NOT HELTER-SKELTER MEDICINE: That good doctor needs to
be (by way of a wide variety of staffing and technical support
methods) relieved from the inclination (brought on by the
3rd party payment system changes and the pressures of managed-care
and a high pressured, urgent society) to practice "helter-skelter
medicine". [a case example]. Our LCHSD situation has the ability to bring that relief if the Board of Directors and top Administration will jell the will to set the stage above the level of Helter-Skelter for both (1) the MSO employed as well as (2) the closely affiliated but unemployed, hospital-based & contracted private practitioners of the organized medical staff.
- Ackerman AB, A Philosophy of Practice of Surgical Pathology: Dermatopathology as a Model, Ardor Scribendi, Ltd., 1999, 470 pages.
- Schwartz JN, "Joining in the Greater Conversation", CAP Today November 2007.
- a 2/11/2003 letter from Dr. Shaw to his good friend, Judy Kneece, a former oncology nurse who helps hospitals across the USA devise in-house breast cancer services & programs through her South Carolina company EduCare.
(posted 17 Aug. 1999; latest adjustment
10 August 2012)