Bit of a rant...anyone have a similar experience?

[pianoguy05]

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I work (academic subspecialist) with a malignant narcissist who has effectively trained our oncologists that any pathologist who doesn't order at least IHC on a given case is incompetent (slight exaggeration, but not too far off the mark). Generally this hasn't effected me too much...usually can fend off stupid requests for IHC from clinicians ("can you please run ER/PR on this papillary thyroid carcinoma?").

Yesterday, I get a case of met colon CA to a lymph node. Patient had a colectomy with colon CA ~2 months ago...now with diffuse abdo-pelvix lymphadenopathy. LN is to prove met for chemo. I get the core...it's slam-dunk 100% 1st-yr-resident-can-diagnose-it colon CA. I sign it as such.

An hour later, oncologist emails: "Thank you for reading this. I'd like to exclude lung adenoCA. Can you please order CK7, CK20, CDX2 and TTF1? I know this is probably colon CA, but would feel more comfortable with IHC."

Is it just me, or is this a seriously unprofessional thing to do? I mean, I would never waltz into an onc clinic and question a treatment plan, and ask for an oncologist to try a different chemo regimen...

Apologies for the rant.

 

[BamaAlum]

That sort of thing pisses me off as well. What happens when everything except the CDX-2 is negative? CK20 negative colon Ca happens occasionally. Sensitivity for TTF-1 and lung CA is certainly not 100% and varies depending on the clone. Like other specialties we are trained to appreciate the nuances of IHC. It is not as formulaic as some clinicians believe.

I had an old school GYN attending pathologist who was completely awesome, but never ordered IHC. I asked him once why he never felt the need to stain anything. His reply was “IHC just colors what I don’t know brown.” Sometimes H&E just trumps IHC.

There is another saying that applies as well:“see a little, see a lot. See a lot, see nothing.” As most of us know, sometimes you can go down a diagnostic death spiral if you overthink and overuse IHC. Those of us who have practiced for a while understand this, which is why we should be the ones dictating what needs to be stained and what doesn’t.

Practically, depending on the politics of your institution and how much clout pathology has you may have to suck it up and stain it, but that doesn’t mean that it is right or necessary.

 

[Guest8]

I work (academic subspecialist) with a malignant narcissist who has effectively trained our oncologists that any pathologist who doesn't order at least IHC on a given case is incompetent (slight exaggeration, but not too far off the mark). Generally this hasn't effected me too much...usually can fend off stupid requests for IHC from clinicians ("can you please run ER/PR on this papillary thyroid carcinoma?").

Yesterday, I get a case of met colon CA to a lymph node. Patient had a colectomy with colon CA ~2 months ago...now with diffuse abdo-pelvix lymphadenopathy. LN is to prove met for chemo. I get the core...it's slam-dunk 100% 1st-yr-resident-can-diagnose-it colon CA. I sign it as such.

An hour later, oncologist emails: "Thank you for reading this. I'd like to exclude lung adenoCA. Can you please order CK7, CK20, CDX2 and TTF1? I know this is probably colon CA, but would feel more comfortable with IHC."

Is it just me, or is this a seriously unprofessional thing to do? I mean, I would never waltz into an onc clinic and question a treatment plan, and ask for an oncologist to try a different chemo regimen...

Apologies for the rant.

Unfortunately we're in the customer service industry, and the onocologists are our customers. Since I'm in private practice I'll do more useless IHC when they request it - it's free money. Yes, it does get annoying being told how to do my job. But that extra IHC beer money eases the pain a bit 😉

 

[deleted314957]

Depends on how long you have been around and how you are perceived. I am sure it is more of an academia thing. I would just tell them it was not needed/ appropriate, etc. and never had a problem. Your example would have been met with” it is colon cancer, not lung”. As a group, we need to learn how to convey conviction, believevability and certainty.
One of my favorite responses to “ are you sure it is XYZ?” would be to say “ if it’s not, I will eat the slide”. That seemed to make them happy and I never ate a slide.

 

[SunBakedTrash]

Agree that this is a service specialty and it is definitely a team sport. Why not make the oncologist feel better about treatment? Sure it might require a BS comment if the staining is funny, but 99% of the time, you will be right and look like a rockstar. If you are wrong, at least you did your due diligence and no can argue you were negligent.

 

[deleted314957]

Agree that this is a service specialty and it is definitely a team sport. Why not make the oncologist feel better about treatment? Sure it might require a BS comment if the staining is funny, but 99% of the time, you will be right and look like a rockstar. If you are wrong, at least you did your due diligence and no can argue you were negligent.

One big reason I got to the point where i did not do useless stains was BamaAlum’s point of the immuno diagnostic death spiral. Been there, done that. I learned my lesson.
Plus it is a matter of principle. As in the ( properly run) military, give me an objective. Don’t tell me how to achieve it.

 

[Med Director New England]

I work (academic subspecialist) with a malignant narcissist who has effectively trained our oncologists that any pathologist who doesn't order at least IHC on a given case is incompetent (slight exaggeration, but not too far off the mark). Generally this hasn't effected me too much...usually can fend off stupid requests for IHC from clinicians ("can you please run ER/PR on this papillary thyroid carcinoma?").

Yesterday, I get a case of met colon CA to a lymph node. Patient had a colectomy with colon CA ~2 months ago...now with diffuse abdo-pelvix lymphadenopathy. LN is to prove met for chemo. I get the core...it's slam-dunk 100% 1st-yr-resident-can-diagnose-it colon CA. I sign it as such.

An hour later, oncologist emails: "Thank you for reading this. I'd like to exclude lung adenoCA. Can you please order CK7, CK20, CDX2 and TTF1? I know this is probably colon CA, but would feel more comfortable with IHC."

Is it just me, or is this a seriously unprofessional thing to do? I mean, I would never waltz into an onc clinic and question a treatment plan, and ask for an oncologist to try a different chemo regimen...

Apologies for the rant.

Honestly this stuff doesn’t bother me too much. If the requested stain / work up is entirely off base I just subtly slip in the addendum that it was ordered as a clinician request.

If a oncologist wants to know a mutual patients pancreatic cancer ER / PR status who cares - just order it

 

[deleted314957]

Honestly this stuff doesn’t bother me too much. If the requested stain / work up is entirely off base I just subtly slip in the addendum that it was ordered as a clinician request.

If a oncologist wants to know a mutual patients pancreatic cancer ER / PR status who cares - just order it

Legit therapeutics is one thing. That’s their bailiwick. Diagnostics, that’s another matter.

 

[pianoguy05]

This is where I'm at. They give me a random paper to run an unnecessary predictive marker, fine - I'll humor them.

Asking me to do a panel to confirm my diagnosis - which I rendered on a slide which they haven't seen and upon which they are unqualified to opine - that's the equivalent to me as saying "I don't trust your ability to diagnose".

I'm sure there's a "trust is earned" argument to be made here somewhere, but this just seems ridiculous.

The CDX2 was positive, incidentally 🙄. The malignant narcissist I referred to earlier actually ordered it on my case and reported it without me knowing, and after the oncologist complained that I didn't do it. I don't even know where to begin with that bull****.

 

[caffeinegirl]

I feel your pain pianoguy05. I think that the root cause of this is not just the malignant narcissist but the pathology department as a whole. If the attitude of the department is to roll over and just provide a "service", then other specialists will take authority over the the field and diagnoses. If, however, the pathology leadership in the department also projected that it's not just service but expertise that is provided, then that would help. But this shift in authority and leadership doesn't happen overnight, and when such mindset is entrenched not just in the pathologist but also the ordering physician, then it is very hard to change.
I was frustrated very early on in my career with similar requests, and tried very hard to show and explain my expertise - and to provide value to the health system as a whole. But it rocked the boat, and it's not too good of a look for a junior physician.
Just peruse the replies to this thread and heed the advice - just follow what the ordering physician says and don't cause too much of a ruckus, because at the end of the day pathologists cannot survive without specimens provided by them. It doesn't matter if it's a slam dunk case, it doesn't matter where you trained, it just doesn't matter. "We are beholden to our masters."
Tread carefully with this malignant narcissist - you already have one complaint against you, and could generate more.

 

[Spikebd]

This is where I'm at. They give me a random paper to run an unnecessary predictive marker, fine - I'll humor them.

Asking me to do a panel to confirm my diagnosis - which I rendered on a slide which they haven't seen and upon which they are unqualified to opine - that's the equivalent to me as saying "I don't trust your ability to diagnose".

I'm sure there's a "trust is earned" argument to be made here somewhere, but this just seems ridiculous.

The CDX2 was positive, incidentally 🙄. The malignant narcissist I referred to earlier actually ordered it on my case and reported it without me knowing, and after the oncologist complained that I didn't do it. I don't even know where to begin with that bull****.

Too bad you have a colleague like that.

 

[deleted314957]

Too bad we have pathologists who check their spine at the door.

 

[PATHDOCNYCNJ]

Every place I have been, with rare exceptions, sees the pathologist as the clinician’s dog or glass slide scut monkey. As a resident, I was essentially the secretary for the pathology attendings. And the sub specialty sign out you had to endure made you feel like a glorified scheduler. In my adult life, I’ve had colleagues at those “consensus conferences “ tell me get more levels, get more stains, get more IHC etc” and you were duty bound to do it because the “consensus book” becomes a legal document. Until I found that the reason why some pathologists did that to others was to increase their turn around time, which was a major benchmark for the evaluation of a pathologist as incompetent. If the clinician didn’t like the way you worded your diagnosis, the chairperson would be called, who would then show up in your office to reprimand you.

A lot of medicine today and the top down command structure of medicine forces you to be a salaried drone of the hospital and just be happy you’re getting a paycheck. I already saw at one point a 15-year hospital job go down the toilet when the hospital administrator fired all the pathologists upon merging with Big Name MedicalConglomerate across the East River.

 

[Allegri]

At least try to retain some self-respect and tell the clinician OK, we can do immunostaining but the right panel in this situation is XXX, and then add another 5 markers to exclude every other remote possibility.

 

[WEBB PINKERTON]

More stains=more money. Be thankful.

Our oncologists are ordering Guardant360 on every MFer that walks in the door.. Talk about waste.

Remember when pathologists were supposed to act as gatekeepers? Good luck with that.

 

[Med Director New England]

Honestly Piano - the most unprofessional person in your story is your fellow pathologist. Ordering stains on someone else case w/o asking is crossing a line.

Your colleague also probably fed the suggested IHC work-up to the oncologist, you think they came up with that by themselves.

Your story is annoying but really is driven by your own dept / your senior pathologist.

Input from clinical colleagues in my experience can be valuable & I’ve seen vague diagnoses improved after input from a clinician and even mis-diagnoses discovered (with no adverse clinical outcome) b/c of a clinician request.

Just don’t forget your on the same team as your clinics colleagues..

 

[deleted314957]

Honestly Piano - the most unprofessional person in your story is your fellow pathologist. Ordering stains on someone else case w/o asking is crossing a line.

Your colleague also probably fed the suggested IHC work-up to the oncologist, you think they came up with that by themselves.

Your story is annoying but really is driven by your own dept / your senior pathologist.

Input from clinical colleagues in my experience can be valuable & I’ve seen vague diagnoses improved after input from a clinician and even mis-diagnoses discovered (with no adverse clinical outcome) b/c of a clinician request.

Just don’t forget your on the same team as your clinics colleagues..

Re: the team. Sure, we all work with and value the input of most of our colleagues. I’m taking about the snarky wastes of time delivered with uninformed pronouncements and unnecessary skepticism. Those I blew off. I once worked with a marginally competent oncologist( who had path boards by the way, and knew NOTHING about path) who asked me to go to a small satellite hospital to do a marrow on some poor old guy with metastatic brain small cell CA. When asked “why” she said it was for staging. I told her I was not her g.d. resident and she never, ever gave me any more s***. (n.b. community hospital where I was chief). She could never even grasp the TNM classification/ criteria. God she was a piece of work. Just go torture the poor patient for no reason.

 

[WEBB PINKERTON]

You guys need to get some thicker skin and just roll with it. Without waste, we don't need that many doctors.

"The point is, ladies and gentlemen, that WASTE, for lack of a better word, is good."

 

[gbwillner]

You guys need to get some thicker skin and just roll with it. Without waste, we don't need that many doctors.

"The point is, ladies and gentlemen, that WASTE, for lack of a better word, is good."

Gold swimming pools don't build themselves, right?

 

[deleted314957]

I would have rather retained my status as the diagnostic authority on my particular medical staff than cave to b.s. Didn’t need the money THAT bad. And, you add up all the waste throughout the system, it is a problem.

 

[WEBB PINKERTON]

Fight for bundled payments would be the way to go I guess.

 

[The Professional]

NO pathologist should ever be treated this way. We should not be treated like the serfs of other physicians. Because of the rampant oversupply and commoditization of the field, we are treated like a useless IHC stain. I am very sorry for your situation.

 

[Lagunamonster]

I work (academic subspecialist) with a malignant narcissist who has effectively trained our oncologists that any pathologist who doesn't order at least IHC on a given case is incompetent (slight exaggeration, but not too far off the mark). Generally this hasn't effected me too much...usually can fend off stupid requests for IHC from clinicians ("can you please run ER/PR on this papillary thyroid carcinoma?").

Yesterday, I get a case of met colon CA to a lymph node. Patient had a colectomy with colon CA ~2 months ago...now with diffuse abdo-pelvix lymphadenopathy. LN is to prove met for chemo. I get the core...it's slam-dunk 100% 1st-yr-resident-can-diagnose-it colon CA. I sign it as such.

An hour later, oncologist emails: "Thank you for reading this. I'd like to exclude lung adenoCA. Can you please order CK7, CK20, CDX2 and TTF1? I know this is probably colon CA, but would feel more comfortable with IHC."

Is it just me, or is this a seriously unprofessional thing to do? I mean, I would never waltz into an onc clinic and question a treatment plan, and ask for an oncologist to try a different chemo regimen...

Apologies for the rant.

Maybe it is just me but I would totally have confirmed metastatic colon cancer in that scenario above. I have seen way weirder **** than that in my day. And maybe the oncologist knows something you don't, like the patient is a lifelong smoker and has a funny nodule on imaging or some **** like that.

Don't trip and don't take things personally because they aren't meant to be. Sometimes we order **** on our cases where there is almost no ****ing way it will be positive but we do it because the idea popped in our heads. Maybe that idea popped in his head and he just wants it totally eliminated. Or maybe the patient is worried about lung cancer because some person they know died of it. Don't trip. Just order the stains and bill for that ****.

 

[deleted314957]

Maybe it is just me but I would totally have confirmed metastatic colon cancer in that scenario above. I have seen way weirder **** than that in my day. And maybe the oncologist knows something you don't, like the patient is a lifelong smoker and has a funny nodule on imaging or some **** like that.

Don't trip and don't take things personally because they aren't meant to be. Sometimes we order **** on our cases where there is almost no ****ing way it will be positive but we do it because the idea popped in our heads. Maybe that idea popped in his head and he just wants it totally eliminated. Or maybe the patient is worried about lung cancer because some person they know died of it. Don't trip. Just order the stains and bill for that ****.

And then when you have ordered a bunch of unnecessary bs because you can’t/didn’t communicate with the clinician about the “ lung cancer” in some guy riddled with metastatic colon ca, see how you feel when the payor has to tell you it is unnecessary bs and you are stuck.

Believe me, if I was given any legit reason why that guy in the prior example had lung cancer i would have taken steps to address it. Eg. someone with lobular breast ca. marrow positive for what looks all the world like metastatic lobular ca. That’s it ( at least it was 8 years ago).

 

[cmz]

And then when you have ordered a bunch of unnecessary bs because you can’t/didn’t communicate with the clinician about the “ lung cancer” in some guy riddled with metastatic colon ca, see how you feel when the payor has to tell you it is unnecessary bs and you are stuck.

As long as you document explicitly what you're doing and stating the medical necessity, I don't see why you'd get the shaft from a carrier. I guess it is left up to chance depending on the carrier (and we all know that certain carriers are worse than others), but. for the most part, I would think that 3-4 IHC are no big deal as long as appropriate documentation is provided. If you start reaching into the stratosphere and ordering 10-12 IHC... then some computer algorithm is going to take pause and deny everything. If you have a lax billing department/company and they don't know how to appeal cases, then I guess you're SOL.

 

[deleted314957]

Well, i’ve been s.o.l. too many times with payors for lesser reasons and I always had better use of my time than responding to bs with more of my time and effort and needless documentation of the unnecessary bs. Maybe that’s why doing 10000+ surgical / yr. wasn’t a problem for me time wise. Since I never got sued over my career or had 1 medical staff complaint, I guess it worked. And, it is almost a phantasm to think you can practice in FL for any length of time and not get sued. I’m not saying i’m such a great diagnostician, it’s just what worked for me for a loooong time. I think clinical background and 4 years path attending experience prior to PP afforded me some street cred.

 

[gbwillner]

As the billing party you are responsible that there is medical necessity for the service rendered. Make sure the record reflects the justification for the service.

 

[ScubaV]

I tend to be somewhat conservative with ordering stains, but I'm in a group that orders a lot so depending on how many "scary" cases have popped up recently I'll wax and wane with what I order. I'm employed so I get no monetary benefit and I do try to be mindful of million dollar workups for the patient's sake. But if you need twenty stains over two or three rounds for the diagnosis, then you gotta do it.

That said, if a clinician asks for something on a case I've already signed out, I usually humor them and put "at the clinician's request" in the addendum. Having a colleague do stuff to your cases without asking first is terrible though. We actually had that happen a couple times here and it was likely heading to a confrontation, but the person responsible left the group for unrelated reasons.

 

[cmz]

I tend to be somewhat conservative with ordering stains, but I'm in a group that orders a lot so depending on how many "scary" cases have popped up recently I'll wax and wane with what I order. I'm employed so I get no monetary benefit and I do try to be mindful of million dollar workups for the patient's sake. But if you need twenty stains over two or three rounds for the diagnosis, then you gotta do it.

That said, if a clinician asks for something on a case I've already signed out, I usually humor them and put "at the clinician's request" in the addendum. Having a colleague do stuff to your cases without asking first is terrible though. We actually had that happen a couple times here and it was likely heading to a confrontation, but the person responsible left the group for unrelated reasons.

What you're doing is correct. If you think that "ordering more" is going to help your group out... it may in fact hurt your group (especially if they are the ones doing the TC).

You would be surprised to find out that a lot of carriers will flat out deny the claims submitted to them by your group's billing company just because a certain case has exceeded the number of MUEs (Medically Unlikely Edits | CMS). It's then up to the billing company to appeal (and a lot of them won't bother or will only bother to a certain extent).

 

[deleted314957]

What you're doing is correct. If you think that "ordering more" is going to help your group out... it may in fact hurt your group (especially if they are the ones doing the TC).

You would be surprised to find out that a lot of carriers will flat out deny the claims submitted to them by your group's billing company just because a certain case has exceeded the number of MUEs (Medically Unlikely Edits | CMS). It's then up to the billing company to appeal (and a lot of them won't bother or will only bother to a certain extent).

Indeed! There is always a GS6 at CMS who is very eager to help you out with immunohistochemical evaluation of complex tumors. They are your friends in the govt. And, if there are questions they will readily consult with their GS7 expert supervisor.