confocal microscopy and future of biopsies

SDN Members don't see this ad. (About Ads)

From what I hear, this technology has potential to reduce, but not replace, biopsies. In a sense, clinicians will be able to obtain a more targeted biopsy of the gi tract, bronchus, etc at endoscopy by screening for dysplastic areas and not taking biopsies of obviously benign areas.

While there may be positive aspects to this, I think any and all anatomic pathologists should be somewhat concerned as to how this may shape future practice. Yes, difficult cases make our jobs interesting but the run of the mill TA vs. HP cases are the reason we can make a decent living. Take these away, and most of us are out of a job.

What I want to know are the opinions of others out there as to how much of an impact such new technology will make on our jobs as we know it, and when (5 yrs, 30 yrs, etc).

While this technology sounds good in theory, will clinicians embrace it anytime soon if there is extra training required, extra liability, decreased volume for their pod labs, and, as of now, no formal reimbursement?

I wouldn't lose sleep over this issue. If you want to worry about something (not that I recommend it), worry about bundled payments (especially if you're considering private practice).

How would confocal microscopy affect whether or not a clinician takes a biopsy, given that you have to biopsy material before it can be submitted for processing and eventual evaluation on a confocal microscope?

Originally Posted by Sulfinator

How would confocal microscopy affect whether or not a clinician takes a biopsy, given that you have to biopsy material before it can be submitted for processing and eventual evaluation on a confocal microscope?

I assumed confocal microscopy was the real-time endoscopic imaging they did to see if something was, for example, Barrett's or not, ala a few 2012 RISE questions that I had no idea the answers to...

Maybe that's something else

Confocal microscopy is a form of in-vivo imaging done at endoscopy. It will essentially allow clinicians to answer the question of "is this dysplastic or not." I believe that biopsies will still be done for a number of purposes, but this can eliminate all of the random biopsies used for screening in barretts and ibd, many polyp resections (why excise HPs unless they may be SSP), etc--specimens which comprise a lot of volume for many surg path labs.

Anyways, this and related techniques have been in the literature for a number of years now, and I am curious to know if this is becoming more common at other institutions and how clinicians view such technology

Did a quick search on NCBI and came across a few recent articles touching on confocal laser endomicroscopy (CLE), which I think is the technology you're referring to. The term 'confocal microscopy' is confusing because that term also refers a technology that has been around several years and is basically just a suped up version of a traditional fluorescence microscope and is used almost exclusively in research contexts.

Anyway, I looked at the CLE stuff and I'm not all that impressed. I mean, it's a nifty idea, but it seems pretty rudimentary right now and I really wouldn't bother with worrying about whether or not this particular technology will suck away pathology jobs (I doubt that it will).

Like Tissue said, if you want to worry about something, there is definitely lower hanging fruit out there. But, personally, I really try not to worry too much about anything. 99% of the time I think it's just counterproductive.

There has been some progress on the reimbursement for this test:

http://www.ama-assn.org/resources/do...ns-feb2012.pdf - See tab #23
They have just recently approved CPT codes for this to be implemented 1/1/2013.

THere is an article in the recent archives about urologists using this for bladder lesions.

This, like all new medical advancements, will just continue to drive up the cost of medicine.

The gastroenterologits and urologists will be able to bill for those new CPT codes and then they will biopsy everything anyway to collect the TC off making the slides and then pay some dupe pathologist 25 cents on the dollar to sign it out for him.

Originally Posted by pathbot

From what I hear, this technology has potential to reduce, but not replace, biopsies. In a sense, clinicians will be able to obtain a more targeted biopsy of the gi tract, bronchus, etc at endoscopy by screening for dysplastic areas and not taking biopsies of obviously benign areas.

While there may be positive aspects to this, I think any and all anatomic pathologists should be somewhat concerned as to how this may shape future practice. Yes, difficult cases make our jobs interesting but the run of the mill TA vs. HP cases are the reason we can make a decent living. Take these away, and most of us are out of a job.

What I want to know are the opinions of others out there as to how much of an impact such new technology will make on our jobs as we know it, and when (5 yrs, 30 yrs, etc).

While this technology sounds good in theory, will clinicians embrace it anytime soon if there is extra training required, extra liability, decreased volume for their pod labs, and, as of now, no formal reimbursement?

The bread and butter specimens are gonna disappear due to technology. Most of the surviving pathology labs will be specialty labs for specific areas, offering very sophisticated testing that you wont be seeing with the "town pathologist". How long it will take is hard to say but if I were a new pathologist, I would be saving/investing like crazy. Make your money and GTFO. Since pathology is so full of introverts, very few people have any desire for the field to go interventional, which is the only way it has much of a future.

Given the litigious nature of American lawyers/public and the cover-one's-ass at all costs mentality that is permeating medicine these days, I feel like all it will take is one or two lawsuits against a gastroenterologist or urologist who didn't biopsy and/or remove something that "looked normal/benign" with their in-vivo imaging and turned out to be a sneaky malignancy or pre-malignant lesion. Maybe we'll end up getting less "random" biopsies of essentially normal tissue, but I don't know if these new technologies will actually make that big of a difference.

Originally Posted by WEBB PINKERTON

The bread and butter specimens are gonna disappear due to technology. Most of the surviving pathology labs will be specialty labs for specific areas, offering very sophisticated testing that you wont be seeing with the "town pathologist". How long it will take is hard to say but if I were a new pathologist, I would be saving/investing like crazy. Make your money and GTFO. Since pathology is so full of introverts, very few people have any desire for the field to go interventional, which is the only way it has much of a future.

My question is:

If all xrays have to be read by a radiologist, why shouldn't all microscopy have to be read by a pathologist.

It doesn't take a radiologist to read a normal chest xray, but they all must do it even if a clinical physician does it too. Why can't you apply that standard to microscopy as well?

Originally Posted by Substance

My question is:

If all xrays have to be read by a radiologist, why shouldn't all microscopy have to be read by a pathologist.

It doesn't take a radiologist to read a normal chest xray, but they all must do it even if a clinical physician does it too. Why can't you apply that standard to microscopy as well?

You can, but

a) as WEBB mentions, unless pathologists get their heads out of their b-hinds and create something like "interventional pathology", it will be up to others to do it for us.

b) look at ultra-sonography. It's used in real-time in a lot of settings that completely bypasses the radiologist. So too it will be with these technologies.

Originally Posted by Substance

My question is:

If all xrays have to be read by a radiologist, why shouldn't all microscopy have to be read by a pathologist.

It doesn't take a radiologist to read a normal chest xray, but they all must do it even if a clinical physician does it too. Why can't you apply that standard to microscopy as well?

True, but theoretically, the clinician will only take biopsies of the areas they feel are abnormal, and these will have to be confirmed by the pathologist. If an area looks benign, biopsies wont be taken to confirm that they are normal by the pathologist - unless- as pointed out there are clinicians who will still take random biopsies for fear of missing something, or because they are making money by the biopsies themselves. In essence, volume for path labs will drop due to less random biopsies.

In terms of polyps, I feel that if the lesion is diagnosed by the endoscopist as TA, it still has to be removed and will still come to the lab (right?) rather than being discarded. So, I would imagine that we wouldnt lose all 88305s on polyps. Even with HPs, clinicians may remove some of these and say "r/o SSP". There will be some straight up HPs, but from what I understand, even currently, clinicians do not remove what they feel may classic HP (i.e. clusters of small, minute polyps in rectosigmoid).

While I think this technology will be employed well before many of our careers are over, I find it difficult to predict how it will affect the typical surgical pathologist

Originally Posted by Substance

My question is:

If all xrays have to be read by a radiologist, why shouldn't all microscopy have to be read by a pathologist.

It doesn't take a radiologist to read a normal chest xray, but they all must do it even if a clinical physician does it too. Why can't you apply that standard to microscopy as well?

Obstetrical ultrasounds and echocardiography aren't read by radiologists most of the time.

Originally Posted by thebouque

Obstetrical ultrasounds and echocardiography aren't read by radiologists most of the time.

Sure, but all ER xrays and ICU films are.

Microscopic tissue diagnosis is the primary domain of the pathologist, and if your field has any foresight, you should be trying to keep it that way.

There is a turf war on the horizon, whether you notice it or not. You guys will probably lose given the above attitude, which seems to be de rigeur of most pathologists. It's ok though, you will always have autopsies - glorious procedures that provide valuable information and that every other specialist wishes they could do.

I swear. The Dark Report has an article painting a grim future for biopsies almost every week.

http://www.darkdaily.com/duke-univer...cer-50712#more-

"Of course, there would still be the need for anatomic pathologists and medical laboratory scientists to confirm positive findings and conduct additional molecular and genetic tests as needed to develop therapeutic options for additional patients."

If we just sit by and do nothing, the future pathology jobs will only be at specialty labs doing all these molecular and genetic tests. The number of practicing pathologists will be NOWHERE near as many as we have now. So we have two options, sit back and watch the field contract or go interventional. Considering the prevalence of learned helplessness in lab medicine, I have a feeling it will be the former. Save/Invest and GTFO my friends.

Originally Posted by WEBB PINKERTON

I swear. The Dark Report has an article painting a grim future for biopsies almost every week.

http://www.darkdaily.com/duke-univer...cer-50712#more-

"Of course, there would still be the need for anatomic pathologists and medical laboratory scientists to confirm positive findings and conduct additional molecular and genetic tests as needed to develop therapeutic options for additional patients."

If we just sit by and do nothing, the future pathology jobs will only be at specialty labs doing all these molecular and genetic tests. The number of practicing pathologists will be NOWHERE near as many as we have now. So we have two options, sit back and watch the field contract or go interventional. Considering the prevalence of learned helplessness in lab medicine, I have a feeling it will be the former. Save/Invest and GTFO my friends.

So I take it by your "Save/Invest and GTFO" suggestion, you are going to take part in the learned helplessness as opposed to helping advance the profession?

Originally Posted by Substance

Sure, but all ER xrays and ICU films are.

As are all glass slides for pathologists, save some derms. I don't see anyone lining up to look at other types of tissues.

Originally Posted by Substance

Microscopic tissue diagnosis is the primary domain of the pathologist, and if your field has any foresight, you should be trying to keep it that way.

There is a turf war on the horizon, whether you notice it or not. You guys will probably lose given the above attitude, which seems to be de rigeur of most pathologists. It's ok though, you will always have autopsies - glorious procedures that provide valuable information and that every other specialist wishes they could do.

If a turf was is looming, as you portend, do you think that GIs and GUs, for example, are going to start cross-training in tissue pathology? There is no incentive to do it, given how cheap path labor is. Perhaps, we better get back to focusing on the oversupply issue, rather than tilt at imagined windmills.

But ok, I'll bite, how do we do that? What Webb suggests? Get trained in "interventional" approaches like endoscopy? Start doing CEL? Ok, why not. I nominate you to spearhead the effort.

Btw, who's to say that Rads won't try to steal autopsies from us too? Minimally invasive autopsies exist and would probably be more acceptable to families of the decedents... Oh yeah, right, again, no incentives.

Originally Posted by rollwithit

So I take it by your "Save/Invest and GTFO" suggestion, you are going to take part in the learned helplessness as opposed to helping advance the profession?

Yep. I'm catching learned helplessness from all those around me. A year ago, we finally get rid of client billing in my state and I swear on a stack of bibles the first reaction of the other pathologists was "Oh dear, what will the offices do without that revenue?". It was a great victory and they all had ominous looks on their faces and couldnt enjoy it. I said "Screw em. They never should have been billin for the technical component on surgicals and paps anyways."

Maybe the next generation wont put up with this crap. Or maybe the expectations of the field will be so low they wont care. All that learnin just to go slave for Ameripath, may be OK for people if thats what they know they are getting into.