FSB Author Article
The "Doctors' Doctor"
Coping With Pathology Reports
By Laura Nathanson, MD
Author of What You Don’t Know Can Kill You
HarperCollins, May 8, 2007
Pathologists are often referred to, and often refer to themselves as “The Doctors’ Doctor.” This is because a Pathology Study, such as a biopsy (tissue sample), is often the ultimate step in deciding which of several possible diagnoses is accurate.
Pathologists don’t examine or interact with patients -- only with physicians trying to diagnose the patient. It is up to these clinical physicians to interpret the Pathologist’s rendition of his findings and to judge whether it meets the standard of medical care.
Even for fellow physicians, judging a given pathology report can be a daunting task:
1. There are no guidelines mandating ordinary clarity of a report. The only mandated guidelines involve the details of highly technical procedures.
2. Until recently, pathologists were trained to use narrative dictation for their reports. This format more easily allows ambiguity and subtle qualifications. Newer “synoptic” formats, computer based, may help diminish this problem.
3. The vocabulary of pathology reports is very arcane because of the highly technical nature of their subject matter. (To learn more, try www.thedoctorsdoctor.com )
Pathologists themselves are faced with many challenges:
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They are dependant on clinical physicians to give them background information about the patient and about previous tests, such as MRIs. Sometimes this information is incomplete, inaccurate, or missing entirely.
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They depend on the surgical skills and academic training of the doctor performing the biopsy to give them a valid specimen of the tissue.
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They must decide in every case whether they have an appropriate specimen to study.
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They need to decide which tests to perform -- in which diagnostic direction to go. If they have little or no useful clinical information, but only the name of the biopsied tissue, they have to start from scratch: The Pathologist must perform the entire previous diagnostic investigation. This takes extraordinary medical knowledge and experience and is extremely time consuming, at best.
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If initial tests do not give a perfectly clear answer, they must decide whether to pursue further “special” testing, refer for a second opinion, obtain another specimen, or make a diagnosis based on “the most likely clinical entity.”
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The more special the study (such as “immunohistochemical stains”) the more expensive it is, the more time it takes, and the more vigorously the pathologist must defend the position of “further investigation” to the lab or hospital bureaucracy.
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Modern medical care is rushed. Guidelines from the American College of Pathology (which are not mandated) state that an individual pathologist should not be asked to “read” more than 100 slides in each working day -- about 14 minutes per slide. This may be plenty of time for some diagnoses, but not nearly enough time for complex, rare, or ambiguous cases.
Given this, it is possible that Pathologists would welcome some help from the the Patient’s Helper (or Sentinel, as I call it in my book.)
The Sentinel would:
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Try to have the biopsy performed and read at a hospital that is certified by the Joint Commission on Accreditation of Healthcare Organizations (www.jcaho.org.)
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Furthermore, try to find a JCAHCO accredited hospital in which the lab has been certified by The American College of Surgeons Committee on Cancer (ACS COC). This Committee works with the College of American Pathologists (CAP) to ensure lab safety, accuracy, training credentials, and so on.
If your hospital is accredited and certified, this is good insurance that your biopsy is being handled, analyzed, and reported with accuracy and care. Only 25% of the 1400 hospitals in the United States and Puerto Rico have been approved for accreditation.
The easiest way to find out whether your lab is accredited is to call the laboratory itself and ask. The best way to find an accredited hospital in your area is to go to the Home Page of the American College of surgeons: www.cancer.org/asp/search/ftc/ftc_global.asp.
Before the biopsy is taken, the Sentinel can make sure that the Pathologist does have clinical information on the patient -- at the very least, a list of the possible diagnoses suggested by the other doctors involved.
After you have the biopsy report in hand, the Sentinel might check that it includes that these are in order:
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Correct patient name and date of birth
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The correct tissue was biopsied
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A statement as to whether any clinical information has been provided, and if so whether that information is, indeed, complete
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A statement about the quality of the biopsy -- any limitations on how adequate it might be
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A definite diagnosis OR
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A list of possible diagnoses, with suggestions for further testing.
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Treatment options, if indicated.
If your report is in the “narrative” form, search it (as I discuss in my book) for Red Flags.
Discuss any concerns with your clinical doctor.
An alternative option is to order a “translation into English.” For $200 a report, either of the following websites will perform this task for you:
Finally: if you ask for a second opinion, make sure that you understand what you are asking for. If only the slides are sent off, the Second Opinion will only determine whether the tests that were done were read correctly. This is NO assurance that the correct tests were done in the first place. For this, you need a second biopsy.
Good Luck!
Copyright © 2007 Laura Nathanson
Author
Dr. Laura Nathanson is the author of What
You Don't Know Can Kill You (Published by Collins; May 2007;
$15.95US/$19.95CAN; 978-0-06-114582-7) and The
Portable Pediatrician, as well as several other books. She has
practiced
pediatrics for more than thirty years, is board certified in pediatrics
and peri-neonatology,
and has been consistently listed in The Best Doctors in America.
For more information, please visit www.lauranathansonmd.com.