Common cases that pathologists in practice miss

[yaah]

Have spent the last couple of months bouncing around consults. It's interesting to see the common consults.

For instance, a lot of pulmonary consults are on cases where the outside pathologist missed DAD (ARDS). DAD gets called UIP a lot, or BOOP, or organizing pneumonia. Hypersensitivity pneumonia also gets called UIP or NSIP.

Ischemic colitis (or should I say "Acute mucosal necrosis" because it's not a colitis, as I have drilled into me daily) gets called colitis with dysplasia. And normal, slightly inflamed gastric cardia also gets called dysplasia. And normal anal transition zone can get called dysplasia.

Metastatic SCC to the neck gets called branchial cleft cyst.

I find all of these very interesting.

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[Mindy]

Lacerations get called abrasions get called contusions.



Mindy

 

[yaah]

Lacerations get called abrasions get called contusions.

Heh, we just had a lecture about that the other day. Apparently one of the major problems is that clinicians (ER docs, surgeons) call incised wounds lacerations or some other variation. And it makes things difficult for the ME.

I just find it interesting to spend time on consults and see what kinds of things people in the real world have trouble with and send in for another view.

Most frequent GI consults:

1) Barretts dysplasia
2) Is this PBC or something else?
3) Is this some kind of hepatitis? (basically, this is a liver biopsy, I don't see many of them, please advise)
4) Is this HCC or adenoma or cirrhotic nodule? (it's often FNH!)
5) What kind of colitis is this?
6) Is this cancer? (polyp or duodenal adenoma)

Most frequent pulmonary consults
1) Is there anything on this transbronch?
2) How do I classify this interstitial process?
3) What kind of lung CA is this, if it is CA?
4) Is this capillaritis?

GU
1) Is this prostate CA?
2) Is this prostate CA?
3) Is this atrophy or prostate CA?
4) How do I grade this prostate CA?
5) Is this bladder bx invasive?

Soft tissue consults consist of "name that lump" or "is this lump benign or malignant."

 

[KeratinPearls]

Heh, we just had a lecture about that the other day. Apparently one of the major problems is that clinicians (ER docs, surgeons) call incised wounds lacerations or some other variation. And it makes things difficult for the ME.

I just find it interesting to spend time on consults and see what kinds of things people in the real world have trouble with and send in for another view.

Most frequent GI consults:

1) Barretts dysplasia
2) Is this PBC or something else?
3) Is this some kind of hepatitis? (basically, this is a liver biopsy, I don't see many of them, please advise)
4) Is this HCC or adenoma or cirrhotic nodule? (it's often FNH!)
5) What kind of colitis is this?
6) Is this cancer? (polyp or duodenal adenoma)

Most frequent pulmonary consults
1) Is there anything on this transbronch?
2) How do I classify this interstitial process?
3) What kind of lung CA is this, if it is CA?
4) Is this capillaritis?

GU
1) Is this prostate CA?
2) Is this prostate CA?
3) Is this atrophy or prostate CA?
4) How do I grade this prostate CA?
5) Is this bladder bx invasive?

Soft tissue consults consist of "name that lump" or "is this lump benign or malignant."

Today, 04:01 AM Mad propz

 

[LADoc00]

Have spent the last couple of months bouncing around consults. It's interesting to see the common consults.

For instance, a lot of pulmonary consults are on cases where the outside pathologist missed DAD (ARDS). DAD gets called UIP a lot, or BOOP, or organizing pneumonia. Hypersensitivity pneumonia also gets called UIP or NSIP.

Ischemic colitis (or should I say "Acute mucosal necrosis" because it's not a colitis, as I have drilled into me daily) gets called colitis with dysplasia. And normal, slightly inflamed gastric cardia also gets called dysplasia. And normal anal transition zone can get called dysplasia.

Metastatic SCC to the neck gets called branchial cleft cyst.

I find all of these very interesting.

I guess my question is how do you know your consultants are right??

Answer: You dont. People pick and choose criteria they see to validate their own hypothesis.

I think the medical lung is most controversial area of surgical path and personally I tend not to put much weight into what people call stuff unless its Tom Colby at Mayo.

 

[mcfaddens]

I guess my question is how do you know your consultants are right??

Answer: You dont. People pick and choose criteria they see to validate their own hypothesis.

I think the medical lung is most controversial area of surgical path and personally I tend not to put much weight into what people call stuff unless its Tom Colby at Mayo.

When they are wrong, you are still liable (legaly) because you chose them as the expert consult, so you can still get nailed right?

 

[LADoc00]

When they are wrong, you are still liable (legaly) because you chose them as the expert consult, so you can still get nailed right?

it depends. If your attorney is good he will argue you followed the standard of care in seeking consultation from an "expert". The plantiff will argue your expert sucks and got it wrong but that doesnt neccessarily prove malpractice on your part.

 

[yaah]

I guess my question is how do you know your consultants are right??

Answer: You dont. People pick and choose criteria they see to validate their own hypothesis.

I think the medical lung is most controversial area of surgical path and personally I tend not to put much weight into what people call stuff unless its Tom Colby at Mayo.

Indeed. Lots of consults are simply on stuff that reasonable people will differ, particularly dysplasia. Others are simply things that require experience to be familiar with, and once you see a lot of them you are better at making the distinctions.

But yes, you don't really know if your consultants are right. Some consults are sent to certain individuals when a certain diagnosis is desired, and others if a different diagnosis is desired (like the "is this papillary thyroid CA" consult).

It's another fascinating thing about consults.

 

[Matte Kudesai]

it depends. If your attorney is good he will argue you followed the standard of care in seeking consultation from an "expert". The plantiff will argue your expert sucks and got it wrong but that doesnt neccessarily prove malpractice on your part.

This must be a biyatch in dermpath....

Aren't there a variety of cadre's formed around a handful to a dozen "experts"?

Aren't some of these experts and their trainees at odds with other experts and their disciples?

Who will end up having the trumping expertise in a heated medicolegal case? The one with the most publications and textbook authorships? But there are so many textbooks and so many papers with differing views.
... so many sensitive ego's and so much variability in DX and outcome?

This probably happens in GU as well (heard of a couple of catfights at USCAP) . GI people seem to get along the best.

People... why can't we all just get along?

What do you think of Travis for Lung?

 

[djmd]

This probably happens in GU as well (heard of a couple of catfights at USCAP) . GI people seem to get along the best.

That is because GI knows they can't agree... Esophagus dysplasia anyone?

 

[Matte Kudesai]

That is because GI knows they can't agree... Esophagus dysplasia anyone?

True true...

 

[yaah]

That is because GI knows they can't agree... Esophagus dysplasia anyone?

There are also a couple of large personalities in the GI world who make it their business to spread collegiality and cooperation. Without these individuals, GI would become just like GU and Breast - there are some big name GI pathologists who are just as irritating and self-superior as those in other fields, it's just that GI minimizes them. I saw a great catfight in GU at 2007 USCAP, and another one started but fizzled this year. And I saw one simmering at the breast session that I had to walk out on because it was too uncomfortable and annoying to listen to. Someone else told me that a GYN session had a similar issue. I guess competition does things to certain people, makes them into the kind of person everybody hates.

But yes, the dysplasia issue is a fascinating one. Part of the reason to do a GI fellowship is to become a go-to person on dysplasia cases. But experts don't agree on dysplasia any more than community pathologists agree. Basically you do the GI fellowship and your biased and unscientifically based opinion carries more weight, even though it isn't any better. You can say that you've seen more cases, but even that doesn't make your opinion any better.