Clinicians wanting to read their own biopsies?

[yaah]

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Wanted to share a PM I got from a current medical student:

I a interested in a gastroenterology fellowship (through general medicine, e.g.). With a fair amount of biopsies from the colonoscopies, I couldn't help but wonder 'what if.'

Do you think it would be feasible to get training during such a residency or afterwards to read the slides of only colon biopsies? I believe it would be quite the service to biopsy and read in the same day for a patient to eliminate the multi day waiting period for results. I also did my undergrad in microbiology and have an affinity for the microscope (the origin of my question). So I was wondering if in this I could become a miniature pathologist restricted to just the colon and be able to bill for it with out any hassle?

Do you think the pathology college could grant a special restricted certificate of proficiency after x amount of correct reads?

I don't know the equipment/procedures involved to make them into a slide, so could the equipment/chemicals be purchased for an office based practice, or would a hospital pathology department be open to having the GI doc stroll in to fix the slides?

My response:

This is malpractice, in my opinion. No one should be interpreting GI biopsies without training in pathology (and not just a couple of months looking at them). Whether you have an affinity for a microscope is irrelevant. Making a diagnosis of many cases is easy, yes (adenoma, adenoma) but pathology diagnoses are not quantitated simply (i.e., one adenoma does not look like all others, "normal" is not uniform, etc). You may have seen reference on our forums to things like "pod labs" which is what this refers to and what so many are upset about (not just pathologists). Usually it means GI or GU groups are hiring a pathologist to read their slides, but they keep part of the technical (slide preparation and things like that) component. It's akin to double billing and it's horrible practice.

The "hassle" you are referring to is a complex procedure which is not at all as simple as you are making it out to be. A pathology slide doesn't take 30 minutes to make. Tissue has to fix awhile, then process for several hours, then be preparing for sectioning, then cut onto a slide, then stained, and all this time you have to ensure that the proper specimen was received and kept in continuity. Certain specimens can be rushed to make it faster (like 6-7 hours or less) but in general histologic quality is poorer.

Pathology organizations are NEVER going to grant licenses to interpret slides to other specialties who did what amounts to a correspondence course in the specialty. As I said, that's malpractice. It happens in derm because of a long tradition of dermatologists getting a significant amount of pathology training during their residency, and clinical impression being such an important part of the diagnosis.

I doubt you are going to find any significant support (outside of fringe individuals) for your idea. It's akin to saying why not let GI pathologists do colonoscopies themselves, if they get a little bit of training, it isn't that hard.

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I would also add, is turnaround time so vitally important in GI biopsies anyway? In my impression, clinicians take the biopsies and unless they are trying to rule out cancer or some acute inflammatory process that would require immediate treatment, whether you sign the case out in 1 day or 5 days doesn't make a whole lot of difference.

Any other thoughts? I also wonder, there are dermatologists who are NOT dermpath boarded who sign out their own biopsies at their offices. How do they get away with this in terms of billing, logistically? How do they get approved for this? Or am I missing something?

 

[deschutes]

While this PM is a blip on the radar, I do think it speaks to the dearth of clinical training in laboratory medicine/pathology in the making of a doctor. All specialties utilize the services of hospital laboratories (note plural), yet there is no formal training in medical school or clinical medicine-type residencies regarding what a hospital or outpatient laboratory can or cannot do for doctors, whether generalist or specialist. Pathologists on the other hand have exposure to most if not all specialties in their medical training.

One might say that it is the fault of pathologists for not being more pro-active about consulting with clinicians, but pathologists are easily outnumbered by clinicians. And yet it is pathologists who have the big picture in terms of resource management.

I've mentioned off-service residents formally rotating (i.e. not an elective) through the path department at my med school. I think there is great value in this practice. And it could not have happened without the agreement of the respective clinical services.

I think as long as clinicians continue to misunderstand the breadth and depth of what goes on in the different hospital laboratories and the nature of the pathology and laboratory medicine services, we will continue to see these queries.

 

[mcfaddens]

Hey I have driven an endoscope before in med school, why don’t I open up a clinic and do it all in one. Its more feasible for me as a pathologist than an internist type, one stop shopping no inpatients that I have to round on ect. Plus its easier to go this was many Fam docs, gen surgeons, internists do endoscopy. The scopes are not that expensive either. You know a radiologist friend of mine asked why we didn’t take our own biopsies and turn and read them.

 

[mlw03]

i don't have that much to add other than to say that the person who sent you the PM just doesn't seem to understand what's involved in making a diagnosis - i'm an MS3 who's definately going into path and even i only have a superficial understanding of the process. the idea s/he proposes is interesting, but i don't think one can study pathology in a box, and therefore dangerous to the point of malpractice as yaah suggests. that is, to be able to read colon biopsies requires much more than just recognizing normal, hyperplastic polyps, adenomas, and then adenoCA. it requires an understanding of all sorts of gastrointestinal pathologies and the histopathologic appearances. these same arguments could be made for most any specialty (urology, ENT, breast surgeon, etc).

i will be interested in the comments about why dermatology practice is different in that the practice model suggested in the PM to yaah appears to work, both in terms of providing good patient care and in terms of it being a solid business plan.

 

[sequela]

i have often wondered why pathologists don't do the biopsy themselves...it make more sense: you can see the pathology "in situ"...that's your gross for christ sakes (in the case of gi and derm, esp derm)

you can train a monkey to take a biopsy but your can't teach path in a weekend workshop.....i don't think it's even necessary to have a medical degree to take a biopsy, at least for skin.

i personally deplore doing procedures so i'm not necessarily keen on the idea but it is an idea...i know that there would have to be a clinical md on site in case of injury or adverse events but that could easily be arranged.

as far as derm and dermpath, it will be interesting to see if that relationship will stick as the years go by and there are more and more derm fellowships that are far more appealing. as it stands, derms are not breaking down dermpath doors...not when they could be doing mohs or cosmetics w laser.

 

[DarksideAllstar]

i have often wondered why pathologists don't do the biopsy themselves...it make more sense: you can see the pathology "in situ"...that's your gross for christ sakes (in the case of gi and derm, esp derm)

you can train a monkey to take a biopsy but your can't teach path in a weekend workshop.....i don't think it's even necessary to have a medical degree to take a biopsy, at least for skin.

i personally deplore doing procedures so i'm not necessarily keen on the idea but it is an idea...i know that there would have to be a clinical md on site in case of injury or adverse events but that could easily be arranged.

as far as derm and dermpath, it will be interesting to see if that relationship will stick as the years go by and there are more and more derm fellowships that are far more appealing. as it stands, derms are not breaking down dermpath doors...not when they could be doing mohs or cosmetics w laser.

I think the idea of doing our own biopsies is interesting, but I also feel like certain types of lesions will be and should still be done by clinicians. For instance, lesions on the face should be off limits and done only by derm or plastics (which they currently are). Interventional radiology does a lot of the biopsies (FNAs and cores) and there is no way in hell that a pathologist would ever be able to competently handle these types of procedures. While the idea is interesting, I think we would be severely limited in what we could do and the simple fact that NO ONE would ever give up the biopsies in their practice (read: money maker).

 

[yaah]

Well, we see occasional transfer cases from private derm offices where the dermatologist reads their own slides. There are (infrequently, but frequent enough) major errors. Usually they do not seriously affect patient care, because the misdiagnosis was made on a small biopsy, and the larger excision reveals it. But there is a big practice out there. Again, I am not sure how dermatologists get this free pass, but it may be due to dermatology regulations and not pathology regulations. Does anyone know?

Part of the problem is that, especially with the diminution of pathology education in med school, med students and clinicians seem to be thinking more than making a diagnosis is easy, because of "classic" images that they see. We had a lymphoma conference here that I presented at, and one case was a tough differential between HL and DLBCL on a small needle biopsy. There were a couple of very atypical, Reed-Sternberg like cells, but they didn't have the right staining pattern. We showed the image on the screen and clinicians in the room immediately decided it was probably Hodgkin, one actually said it was right out of med school lecture.

Lots of people think they are amateur pathologists, and often times they are pretty good (we have a heme-onc here who is really good at bone marrows, and an orthopedic oncologist who is decent at recognizing most lesions on biopsy).

The truth is, most fields of medicine have easy procedures or diagnostic problems that make up a lot of their practice. With a few months of intensive training, you can train almost any doctor to do most things. But that doesn't mean you SHOULD.

 

[LADoc00]

This issue is one of liability. Clinicians surgeons etc want the liability to be shared. Why do I hire an attorney? To hedge my liability. Why dont many dermies read their own slides? Liability.

Liability increases EXPONENTIALLY when you have only 1 guy or girl who does the biopsy and self reads. One case can effectively terminate your career.

Pathology groups are part medical expertise, part liability shield. The latter is a very important.

I think in the future endoscopy will likely be performed by technicians/specialist nurses employed by hospitals who run patients through them at high volumes.

 

[triguy]

One important point that I don't believe has been addressed is: what is good for the patients?

Let's say you have the scenario where a GI doc takes and then reads his/her own biopsies. What is stopping that person from taking 50 biopsies of the colon and putting them in a separate bottle. That is 50 x 88305! There is a certain checks and balances by having the clinician and pathologist act independently.

That is one of the reasons that I am totally against POD labs. I feel that if the pathologist is an employee of the clinical group, then you lose the watchdog function of the respective specialties. I know this is an extreme example, but when your job is dependent on protecting your boss, ethical dilemmas may come up that are never addressed.

And what is the argument that an outpatient procedure needs a faster turn-around time? What happens is that the pathology report gets faxed to the clinician, they initial it, and file it away until they see the patient TWO WEEKS from now! There are a few cases where a rush is appropriate, but it is not as often as you would think. I think the current culture from administrators is influencing pathology such that turn-around time becomes a measure of "quality assurrance." Not true, gettting the right diagnosis is "quality;" turn-around time is marketing. Enough of my rant for now...

 

[ygdrasil]

Regarding pathologists collecting their own biopsies, in a previous thread ( http://forums.studentdoctor.net/showthread.php?t=378624 ) LADoc said "I think it is VERY inefficient to have pathologists do marrows or needles." His point (and I'm paraphrasing) being that, the time it takes to explain the procedure, consent the patient, prep 'em... etc, would be better spent just signing out cases.

A moolah procedure like a colonoscopy would likely be cost-effective, but I doubt that other simple surgeries would be worth it. I was with my surgery attending yesterday, and we spent 45 minutes digging out two superficial lipomas AND I stuck him with a bloody scalpel (which was deeply satisfying). After all that, the idea of "pathologists doing the biopsy themselves" definitely seemed more trouble than it's worth.

 

[yaah]

Definitely, doing biopsies is much too time consuming. Don't forget the time to get consent, to sedate or anesthetize, or to "establish a relationship with the patient" 🙄

When we go on FNAs, it can take 45 minutes sometimes. Go down to the clinic (2-3 minute walk), meet patient (1-2 minutes), prepare consent forms and have them signed (4 minutes), prepare slides and other equipment for actual biopsy (4-5 minutes), perform a pass, etc etc. It keeps going. Then you have to stain the slides, look at them, call the attending down, keep doing more passes maybe. Meanwhile upstairs they have signed out 20 fluids.