Getting Out From Behind the Paraffin Curtain

A must-to-read Editorial on pathologist's career with a focus on the political efforts needed  to achieve a good work quality and the consideration deserved among clinician colleagues and hospital administrators. To get out from behind the paraffin curtain.

Many pathologists, especially those who maintain contracts with hospitals and other providers, possess keen political skills. They have learned how to keep clinicians happy with the accuracy and alacrity of laboratory services, administrators satisfied with efficiency and financial performance, and technical personnel content with working conditions. [...] As pathologists' careers develop, they are often called on to be leaders. Some are uncomfortable in leadership positions, their careers to date having been founded mostly on individual achievement. The reluctant leader should not be dissuaded by lack of leadership experience. Often the best leaders are those who did not seek out the position but developed their own style as they adapted to the demands of the position. [...] Other challenges include learning to delegate (and follow up on delegated tasks), providing encouragement and inspiration to team members (some of whom may be quite hard-boiled and cynical), and occasionally standing up for the team when it is under assault by powerful factions, including clinicians and other clients. This last challenge takes no small measure of courage and equanimity. [...] The pathologist/politician/leader is commonly confronted by ethical issues. We typically serve multiple masters, including patients, administrators, clinicians, and regulatory agencies. We need to be sensitive to their conflicting agendas. Medical ethics is a complex field [...]  Nevertheless, building a reputation for incorruptibility does foster trust, and trust is fertile ground for opportunity.

Edward O. Uthman (2014) Getting Out From Behind the Paraffin Curtain. Archives of Pathology & Laboratory Medicine: January 2014, Vol. 138, No. 1, pp. 12-13.

Happy New Year 2014.

Graduated Responsibility for Pathology Residents: No Time for Half Measures

The pathology community is aware of, and has not been idle on, the issue of resident deficiencies. [...] As residency progresses, “[t]he successful trainee develops a very keen sense of dedication, honesty, commitment, intellectual fortitude, integrity, and respect for both patients and colleagues.”Unlike non-pathology residents, who quickly “break the mold formed [in medical school] by being handed a large syllabus containing all of the information that they need to know for an exam and the world of multiple choice questions”… “[i]n contrast, pathology residents may fall into a passive learning style with little or no clinical responsibilities, clinical contact, or accountability…,”leading to “significant deficiencies in confidence, expertise, professionalism, and lifelong learning skills.”

“[a]s the resident progresses over time, the resident may predictate and then give the case to the attending to sign out without sitting with the attending again for sign out. This allows upper level residents to gain additional autonomy”. 

Program directors will need “a clear framework within which to ensure that residents have appropriate opportunities to take responsibility for diagnostic decisions with progressively less oversight.” [...] Program directors will be especially challenged. “[I]t takes a particular combination of high standards, creative thinking, and hard work to manage a training program”; and “time and workload management are critical.” Importantly, “competency-based learning must allow time for remediation for those trainees having inadequate performance…” and “structuring individualized programs for residents in need of remediation falls squarely on the already often overworked residency program director.”

Allen TC. Graduated responsibility for pathology residents: no time for half measures. Arch Pathol Lab Med. 2013 Apr;137(4):457-61.

Second Opinions: Pathologists' Preventive Medicine

We pathologists have long understood the significance of misdiagnoses and the value of second opinions. Second opinions of pathology diagnoses are routinely used intradepartmentally not only for immediate patient diagnostic accuracy, but also as a tool for peer review, quality assurance, and quality improvement. These may occur as consensus conferences or mandatory second opinions of initial diagnoses of cancers. These measures to assure accuracy of diagnosis are well established in many pathology departments, both private and academic. And directed peer review—selecting specific disease types or particular sites of origin—provides added benefit by targeting latent factors that contribute to diagnostic error.

Da Allen TC. Second Opinions: Pathologists' Preventive Medicine.

Bibliografia:

Allen TC. Second opinions: pathologists' preventive medicine. Arch Pathol Lab Med. 2013 Mar;137(3):310-1.

Landro L. What if the doctor is wrong?: some cancers, asthma, other conditions can be tricky to diagnose, leading to incorrect treatments. Wall Street Journal. January 12,2012 (link) Accessed March 29, 2013.

Colorectal cancer: surgical pathology practice guidelines

Caro PATHfinder,

se può essere utile, voglio passarti un piccolo contributo sul cancro del colon.

Ti allego alcuni articoli di Quirke molto didattici che spiegano qual è il metodo e l'obiettivo del patologo nella diagnosi dei tumori del retto. Due articoli spiegano molto chiaramente tutte le possibili lesioni che vanno diagnosticate; un articolo guida nel report macroscopico e microscopico, un altro spiega bene qual è il significato del margine radiale nelle resezioni del retto e come va valutato.

Penso possa essere molto d'aiuto per tutti.

Ciao

Severo Campione, MD.

Quirke P, et al. Quality assurance in pathology in colorectal cancer screening and diagnosis—European recommendations. Virchows Arch. 2011 Jan;458(1):1-19. doi: 10.1007/s00428-010-0977-6.

Vieth M, et al. Annex to Quirke et al. Quality assurance in pathology in colorectal cancer screening and diagnosis: annotations of colorectal lesions. Virchows Arch. 2011 Jan;458(1):21-30.

Maughan NJ, Quirke P. Modern management of colorectal cancer--a pathologist's view. Scand J Surg. 2003;92(1):11-9. 

Quirke P, Morris E. Reporting colorectal cancer. Histopathology. 2007 Jan; 50(1):103-12.

The Interventional Pathologist

We are observing a gradual and important change in the pathologist's profession because a new character has appeared in our daily practice: we can define this character as the “interventional pathologist.” Every day, we now spend most of our time outside of the pathology department: we help nonpathologist physicians and radiologists to solve difficult clinical cases, we aid oncologists in selecting medical procedures, and we verify the adequacy of gastrointestinal biopsies in the endoscopy room. We also discuss the best procedure for molecular characterization of neoplasms. Broadly speaking, we give an effective, direct, and crucial contribution to the patients' diagnostic and therapeutic workup. Moreover, in our hospitals, pathologists personally perform cytologic biopsies, such as thyroid or lymph node fine-needle aspiration biopsy, and histologic sampling, such as breast core needle biopsy. Therefore, we have to interact with radiologists for correct localization of target lesions. [...] This expanded approach to the practice of pathology requires a unique multidisciplinary knowledge. For example, we believe that the pathologist should have a basic knowledge of imaging, and be able to interpret radiography and ultrasound images. [...] The interventional pathologist becomes a modern and all-encompassing figure in the diagnostic process. Are we ready for this cultural revolution?

Fabio Pagni and Camillo Di Bella (2013) The Interventional Pathologist. Archives of Pathology & Laboratory Medicine: January 2013, Vol. 137, No. 1, pp. 11-12.

Bibliografia.

David N. Louis, et al “Next-Generation” Pathology and Laboratory Medicine. Archives of Pathology & Laboratory Medicine: December 2011, Vol. 135, No. 12, pp. 1531-1532.

da Cunha Santos G, et al "The petals and thorns" of ROSE (rapid on-site evaluation). Cancer Cytopathol. 2013 Jan;121(1):4-8.

The development of visual search expertise in pathology residents

As pathology is a visual specialty, it would seem that to optimize training, an understanding of  how visual perception skills develop and change as a function of experience would be beneficial.

Insomma, nel corso della specializzazione,  i giovani patologi passano gradualmente dal navigare in maniera "caotica" attraverso il vetrino fino ad arrivare, verso gli ultimi anni, a fermarsi e zoomare solo sulle aree di interesse diagnostico. E tutto questo è possibile solo con l' esposizione quotidiana a casi numerosi e diversificati, sotto una costante supervisione di seniors e professori unita ad uno studio puntuale e rigoroso. Proprio quello che avviene tutti i giorni della nostra residency...

La "semplificazione" progressiva dei movimenti oculari dal I al IV anno di specializzazione. Da Krupinski et al, Human Pathology 2013.

Bibliografia:

Krupinski EA, Graham AR, Weinstein RS. Characterizing the development of visual search expertise in pathology residents viewing whole slide images. Hum Pathol. Volume 44, Issue 3, Pages 301-450.

First, check the evidences

L' anatomia patologica dovrebbe fornire un servizio diagnostico e predittivo, in un dialogo virtuoso e alla pari con i clinici che hanno in cura il paziente. Fornire un servizio però non significa asservire, usare tecniche di laboratorio non ci trasforma automaticamente in analisti acritici. Il controllo delle evidenze scientifiche in rapporto alle sempre più pressanti richieste dei clinici rappresenta un impegno aggiuntivo ma fondamentale per il patologo moderno. Non basta ricevere una richiesta per un TestX da un collega clinico che, di ritorno da un congresso, ne magnifica l' imprescindibile utilità ai fini terapeutici. Non è sufficiente la brochure fornita da un rappresentate farmaceutico interessato a vendere un nuovo prodotto. Certo, i nuovi test richiesti o proposti possono essere davvero utili, ma vanno sempre verificate (grazie soprattutto a PubMed) le evidenze scientifiche, mettendo in conto anche la necessità di negare l' esecuzione di un test, se questo non ha solide basi cliniche. 

Idealmente poi, anche i patologi potrebbero prendere l' iniziativa,  anticipando le richieste dei clinici e   proponendo i nuovi test, sempre in seguito ad uno studio critico e aggiornato della letteratura medica corrente.

Bibliografia:

Carter AB. Clinical requests for molecular tests: the 3-step evidence check. Arch Pathol Lab Med. 2012 Dec;136(12):1585-92.

Kolata G . How bright promise in cancer testing fell apart. New York Times. July 7, 2011:A1. (Accessed Dec. 16, 2012)

The involved pathologist

The involved pathologist is a superb scientist and diagnostician. 

The involved pathologist is a physician who understands the problems of the clinician. 

The involved pathologist “makes rounds” in the doctors dining room and has lunch with his clinical colleagues. 

The involved pathologist volunteers for medical staff committees and attends the medical staff dinner dance. The involved pathologist becomes friends with the hospital administrator and participates in the hospital golf and tennis tournaments. 

The involved pathologist is visible on the hospital wards and in the operating suite. 

The involved pathologist knows the names of all of the laboratory staff and cares about them. 

The involved pathologist helps raise money for the hospital and is active in the community and in medical and specialty societies.

E tu, quanto ti senti coinvolto?

Bibliografia:

Keitges PW. The involved pathologist. Paper presented at: American Society for Clinical Pathology/College of American Pathologists Spring Meeting; April 8, 1997; Chicago, IL.

Richard E Horowitz Sorry, Doctor Glassy. Archives of Pathology & Laboratory Medicine: April 2011, Vol. 135, No. 4, pp. 415-416.

Preparing resident for the practice: An opportunity.

What is a surgical pathology rotation for a resident?

No virtual reality or simulated setting can fully replicate the complex interactive learning that is available at a surgical pathology sign-out, or in some specialties, at the bedside [...] The relationship is professional but also intellectually and psychologically personal, as it requires extended and repeated series of queries, statements, challenges, affirmation or refutations, criticisms, and compliments.

What does a resident actually learn from us at sign-out?

Although a resident may learn diagnostic criteria, a vast array of other information is transmitted [...]:  that we possess much medical knowledge;  that our dogmatic views are not entirely shared by many other equally dogmatic attending pathologists; how we deal with ignorance and uncertainty; how we deal with errors  and  how we communicate with colleagues, secretaries, and students; and much about our behavior and attitudes.  

What attitudes are expressed at sign-out?

Making a diagnosis represents both science and art. [...] The resident who sees himself/herself as a learner; eager to absorb more knowledge; curious about diseases, their pathogenesis, and natural history; [He is] grateful for the opportunity to learn [...] and will extract information from almost any situation.

What behaviors are displayed at sign-out?

Irritability, impatience, interruption of speech, exasperation, disappointment, dissatisfaction, and frustration are too often expressed, when calmness, patience, good listening, acceptance, or acknowledgement of error could add to the educational experience.  We should express frustration with work that has been done carelessly, but it should be conveyed deliberately and with a full understanding of its effect on the resident. Our behavior is also revealed in ancillary interactions. How do we handle interruptions (phone, page, or personal)? What comments do we make about clinical colleagues? How do we react when we find a typographical error? Do we have a predictable, fixed time for sign-out? Do we demonstrate respect for colleagues, residents, secretaries, and technicians? As we model a behavior, it is more likely to be adopted by the residents with whom we work.

We have the opportunity and the responsibility to shape the professional lives of our colleagues in training by how we approach this simple surgical pathology sign-out.                We can influence not only how much is taught but what is learned and how it will be used.

Zaino RJ, Abendroth CS. Preparing residents for practice. An opportunity to teach professionalism and communication skills as well as diagnostic criteria. Hum Pathol. 2010 Jul;41(7):923-6.

"...Je dois apprendre aux curieux..." 

Expédition nocturne autour de ma chambre, 

Xavier de Maistre, 1794. (http://en.wikipedia.org/wiki/Xavier_de_Maistre)

To Subspecialize or Generalize?

Dal Blog del dr. Mills un tema interessante e di attualità sui vantaggi e gli svantaggi della sub-specializzazione in anatomia patologica. Soprattuto negli anni della formazione, limitare il proprio interesse ad aree diagnostiche subspecialistiche potrebbe essere dannoso per il futuro professionale dei giovani patologi, ma non solo.
Infatti, avere in una realtà assistenziale il superesperto della patologia X potrebbe causare problemi sia economici che organizzativi (se l'esperto va in vacanza o si ammala sono guai!). 

Questo non vuol dire diventare "tuttologi", anzi. Un necessario approfondimento in determinate aree diagnostiche può, come suggerisce Mills,  creare degli "in house pathologists" di riferimento per informali e stimolanti consulenze su casi difficili.

Aspetto le vostre opinioni sull'argomento.