neurosurgery and neuropathology

[Enkidu]

Hey, I was wondering about the neurosurgical perspective on neuropathology. Is there generally a good rapport, or is it a lot of conflicting expectations? My interest is in path and I just want to get a view of the field from the surgeons perspective.

---

Members don't see this ad.

 

[kitsunepixie]

Our neuropathologists give us a lecture twice before our boards but we usually never see them. They call us with the results of frozen specimens but that's it with our interaction. We used to go down to bring biopsies to them and sometimes stuck around to see what the specimens looked like under the scope w them but not since our pathologists moved their lab to a big fancy building separate from the hospital a few years ago.

 

[Enkidu]

Our neuropathologists give us a lecture twice before our boards but we usually never see them. They call us with the results of frozen specimens but that's it with our interaction. We used to go down to bring biopsies to them and sometimes stuck around to see what the specimens looked like under the scope w them but not since our pathologists moved their lab to a big fancy building separate from the hospital a few years ago.

Wow. Not the most collegial relationship then. Would you prefer more interaction? Must not be too much neuropath on neurosurgery boards, I guess.

 

[kitsunepixie]

Wow. Not the most collegial relationship then. Would you prefer more interaction? Must not be too much neuropath on neurosurgery boards, I guess.

I'm pretty indifferent. I enjoyed pathology as a med student and am friends with some of our pathology residents since med school, but they seem to rarely come out of the lab and we're far too busy to travel outside our hospital over to them...plus if we do want to see the specimens ourselves (and some of our staff do for curiosity's sake), then we follow the circulating nurse when she takes it over to the mini lab for the lab tech to process, scan, upload, and send the images to the pathologists, we can see them before the pathologists do. We usually have a pretty good idea of what the diagnosis is before we even take the biopsy from the clinical history and radiographic characteristics of the lesion and how the specimens look under the scope isn't nearly as important for us to know. We have far more interaction with our interventional neuroradiologists who we consult for angiograms and coils/embolizations...plus they often come to our weekly didactics that are scheduled earlier than when the path residents are probably even awake. Our clinical decisions, especially in emergent situations, are highly dependent on our patients' exam and scans, which we read and intrepret on our own before the neuroradiologists even have the chance to view them. That's probably why a good percentage of those who leave neurosurgery for other fields often choose neuroradiology.

I don't think that we interact with neuropathologists any more or less than any other specialty of medicine interacts with pathology. And I don't think I know what you mean by conflicting expectations.

 

[Enkidu]

I don't think that we interact with neuropathologists any more or less than any other specialty of medicine interacts with pathology. And I don't think I know what you mean by conflicting expectations.

Thanks for sharing your perspective.

I'm asking if there are conflicts about things like frozen sections. Maybe pathology values precision over timeliness and neurosurgery prefers timeliness. From the pathology side there is often insufficient tissue to make a diagnosis or inappropriate frozen sections being ordered that leave less diagnostic tissue for permanent sections.

I don't know how much most surgeons interact with pathology, but since the bulk of pathology practice is surgical pathology I would think that surgeons might have cause to talk to the pathologists about their patient's diagnosis.

Do you have a sense that there is a cultural gap between surgery and pathology that limits their sense of collegiality? I've gotten the impression in pathology conference that surgeons aren't always viewed as full colleagues. Sometimes they are viewed in the way that I suppose most physicians view their patients. If things are as you describe, with minimal interaction outside of frozen sections and two didactic sessions, then this may be partly responsible for that cultural disconnect.

 

[kitsunepixie]

I'm asking if there are conflicts about things like frozen sections. Maybe pathology values precision over timeliness and neurosurgery prefers timeliness. From the pathology side there is often insufficient tissue to make a diagnosis or inappropriate frozen sections being ordered that leave less diagnostic tissue for permanent sections.

We value the same thing--getting a precise and timely diagnosis to best treat the patient in a timely and effective manner. It's the nature of obtaining biopsies that some of the tissue samples are not going to be diagnostic--say a piece obtained for frozen that shows nothing but necrosis. That's why we do frozens, with the expectation that we may have to take more tissue. We want to obtain diagnostic samples for the pathologists but not at the expense of the patient by being kept under anesthesia or grabbing more tissue than what is necessary .

I don't know how much most surgeons interact with pathology, but since the bulk of pathology practice is surgical pathology I would think that surgeons might have cause to talk to the pathologists about their patient's diagnosis.

Yes, we do--with results on the frozens, and if it's taking an exceptionally long time (over 5 working days) to get the results of a permanent and oncology is getting antsy, we call the lab to see what they have.

Do you have a sense that there is a cultural gap between surgery and pathology that limits their sense of collegiality? I've gotten the impression in pathology conference that surgeons aren't always viewed as full colleagues. Sometimes they are viewed in the way that I suppose most physicians view their patients. If things are as you describe, with minimal interaction outside of frozen sections and two didactic sessions, then this may be partly responsible for that cultural disconnect.

Sure, just like there is a cultural gap between surgery and medicine. Some services, like Gyn-Onc at my center, have time to do things like tumor board in which surgery, oncology, rad-onc, path, and radiology are all there and I get the inkling that you'd like something like that--and honestly, I love those kinds of conferences too, but our time is pretty well sucked up by our weekly spine, skull base, vascular, & m & m conferences. Plus it's hard to organize all those different specialties around a neurosurgeon's schedule--we're only available late in the evening or in the wee hours of the morning and our pathology colleagues aren't particularly enthusiastic about that and I think that's why we haven't had tumor board this year--there's a huge cultural gap, due to lifestyle issues, right there! Case in point--Gyn-Onc does theirs at noon with lunch served once a week, and we usually aren't even guaranteed a 10 minute lunch break, even though my program is considered quite "cush" for neurosurgery.

 

[kitsunepixie]

Additionally about tumor boards...I think that really Rad Onc and Onc are the most interested in what the pathologists have to say about the specimens since it influences THEIR next step in patient care more than it does ours, except when the permanent is say a surprise and the patient is primarily on OUR service (ie we are shocked to find it's a lymphoma and not a meningioma, or it's a high grade meningioma)--then we obviously have to refer the patient to the next appropriate physician to take over their care after their surgery if they're still on our service; otherwise we're consultants to medicine and oncology who coordinate their care if it's say a patient who comes in with mets to the brain with an unknown primary. When we discuss tumors pre-operatively in conferences, say in Skull Base, it's between radiologists and fellow surgeons (ENT), and our focus is a) radiologically what is the most likely diagnosis and b) technically how should we go about getting it out and minimize damages.

 

[Enkidu]

Additionally about tumor boards...I think that really Rad Onc and Onc are the most interested in what the pathologists have to say about the specimens since it influences THEIR next step in patient care more than it does ours, except when the permanent is say a surprise and the patient is primarily on OUR service (ie we are shocked to find it's a lymphoma and not a meningioma, or it's a high grade meningioma)--then we obviously have to refer the patient to the next appropriate physician to take over their care after their surgery if they're still on our service; otherwise we're consultants to medicine and oncology who coordinate their care if it's say a patient who comes in with mets to the brain with an unknown primary. When we discuss tumors pre-operatively in conferences, say in Skull Base, it's between radiologists and fellow surgeons (ENT), and our focus is a) radiologically what is the most likely diagnosis and b) technically how should we go about getting it out and minimize damages.

Interesting. Thanks a lot for your insight.