consults and pathology

[pathstudent]

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out of curiosity, why is pathology unique in that community practice types seek consults from academics.

I have never ever heard of an MRI or CT scan being sent to academics for consult. Nor have I ever heard of general surgeon sending their patient to the university for consult. But pathologists send out cases to the university all the time for consults.

 

[yaah]

It happens all the time in clinical specialties - physicians send their patients to experts, particularly when they get diagnosed with something uncommon or with difficult management issues. Sometimes this is patient-driven, sometimes it's physician driven. Their radiology goes with them when this happens, and their pathology. I don't know whether radiologic studies get sent around for consult, but I suspect it does happen on occasion, although it may be more informal.

 

[2121115]

Radiology diagnoses are inherently less specific than pathology diagnoses so there is less need for specialists. You can just be descriptive in radiology because all their reports are basically only descriptive anyway.

 

[pbp4]

This is not unique to path - every specialty sends consults- in path it is just easier- why do you think academic centers have so many ICU beds- they are filled with "consults" aka dumps from clinicians in the community (I know they are set up to handle them- but they are consults in a way).

Also, many path consult cases do have outside radiology that gets reviewed. Some institutions have joint conferences with outside material (path and radiology).

 

[pathstudent]

Believe me I know that patients get transported to academia when they need a higher level of care. Or that when patients want experts seeing them they go to academia, of course their prior medical records and lab results and pathology is brought with them so that they can better understand the patient and avoid repeating things that don't need to be repeated.

What I am talking about is sending the slides out to figure out what it is. I have never seen an MRI or CT or X-ray sent out for interpretation. That is what I am talking about.

 

[rockit]

Believe I know that patients get transported to academia when they need a higher level of care. Or that when patients want experts seeing them they go to academia, of course their prior medical records and lab results and pathology is brought with them so that they can better understand the patient and avoid repeating things that don't need to be repeated.

What I am talking about is sending the slides out to figure out what it is. I have never seen an MRI or CT or X-ray sent out for interpretation. That is what I am talking about.

Liability.

Tissue diagnosis is the most influential work in all of medicine. Ultimately it benefits no one to stick your neck out on a diagnosis.

 

[pathstudent]

Liability.

Tissue diagnosis is the most influential work in all of medicine. Ultimately it benefits no one to stick your neck out on a diagnosis.

So does this imply that academic pathologists are superior or at least are regarded as superior by the general public and medical establishment?

 

[KluverB]

So does this imply that academic pathologists are superior or at least are regarded as superior by the general public and medical establishment?

Doubt it's that. Plenty of ppl in private practice know what they're doing. Academic centers usually have dozens of pathologists on staff, some of whom are considered "experts" in one area or another. So, it's easier to send a case to one place for all your consulting needs. Also, they're much more likely set up to take in consults and deal with the minutiae of billing, or more likely collection issues involved; mostly because they're not really trying to make money. I doubt anyone in private practice would want to deal with that BS, unless it was guaranteed to make them money... like perhaps Bostwick labs, or similar set ups.

 

[pathstudent]

Doubt it's that. Plenty of ppl in private practice know what they're doing. Academic centers usually have dozens of pathologists on staff, some of whom are considered "experts" in one area or another. So, it's easier to send a case to one place for all your consulting needs. Also, they're much more likely set up to take in consults and deal with the minutiae of billing, or more likely collection issues involved; mostly because they're not really trying to make money. I doubt anyone in private practice would want to deal with that BS, unless it was guaranteed to make them money... like perhaps Bostwick labs, or similar set ups.

I have seen hundreds of cases come to academia straight from generalist community practice types, but I have never seen a case sent out from my academic center anywhere for consult. Sure maybe the patient took their slides elsewhere for a second opinion but we NEVER send our cases anywhere for help. Why would that be?

 

[mcfaddens]

I have seen hundreds of cases come to academia straight from generalist community practice types, but I have never seen a case sent out from my academic center anywhere for consult. Sure maybe the patient took their slides elsewhere for a second opinion but we NEVER send our cases anywhere for help. Why would that be?

It does happen, you as a resident are just not aware of it. You really have to follow the paper trail on some cases, Ive seen multiple consults on certain cases go from coast to coast many with the same diagnosis repeated over and over. You probably see the consults come in but don't see them go out, that job usually ends up with the department secretaries.

 

[lipomas]

I don't know where pathstudent trained, but where I trained there was an occasional case sent out as a consult. Often it was a borderline case or possibly a recently described lesion that someone had written about. It was less common, but it did happen.

Pathology just lends itself to formal written consults at other institutions more than other specialties. For other specialties you would have to package up the patient and send them off - but even then it still happens. What is more common is that the oncologist calls an expert at the academic center and asks them management related questions - more informal. But they also will recommend to the patient that they seek an opinion at an expert center for certain rare diseases or whatever.

Radiology stuff doesn't get sent out as formal consults for three reasons. 1) EVerything is kind of vague anyway; and 2) the clinicians all think they are experts in it; 3) The patient just gets a new scan at a different place anyway when they seek a second opinion.

 

[Cloaca]

We send out cases on occasion, sometimes you need to send something to Rosen or whoever. So, as a previous poster said, you are probably just not aware that people in your department are requesting consults.

But what you are really forgetting is not every pathologist works within a big pathology community of many pathologists. It's easy in academia to show 3, 4, or 10 other pathologists a difficult case at the daily QC conference. But if you work in the community in a small hospital, you don't have all those people around you. Furthermore, you are less likely to have "experts" in a particular subspecialty to show a case to. For example, if you are part of a small group, you may have a GI guy, a breast person, and a cytology person. But what if you have a complicated head and neck case or a renal biopsy? You could probably make a good start at it but unless you've had a lot of training and experience in those areas, you may not feel confident being the last and final word on the case. So it's not that you are inadequate but that you are not as experienced in that one area.

Radiologists just need to provide a DIFFERENTIAL. Not a definitive tissue diagnosis. This is a whole other level of knowledge and experience that is required of a pathologist.

Furthermore, surgeons send out "consults" all the time. You think general surgeon "X" in small town "Y" does all their own Whipples or kidney transplants? Obviously not. That doesn't mean they are a crappy surgeon, just not experienced in that area.

 

[KluverB]

But what you are really forgetting is not every pathologist works within a big pathology community of many pathologists. It's easy in academia to show 3, 4, or 10 other pathologists a difficult case at the daily QC conference. But if you work in the community in a small hospital, you don't have all those people around you. Furthermore, you are less likely to have "experts" in a particular subspecialty to show a case to. ...

+1

Also +1 on mcfaddens comment, "shopping around for a diagnosis". Some of that is patient driven, some may be clinician driven; consult material makes the rounds from coast-to-coast via a few choice places in between.

Do academic centers send out consults to private practice pathologists? I dunno for sure. I see plenty of consult material from recent grads who've gone both into private practice as well as smaller academic centers who'll send consults back to their old stomping grounds. If some of the attendings to whom these consults are directed leave for private practice, would they still send the cases to them? Personally, I think I would. If you get used to something, I think you tend to stick with it.

 

[sohsie]

Just as a counterexample, Lester Thompson is a private practice physician (SoCal Kaiser Permanente) and gets consults from academic centers (Ive seen academic attendings send stuff to him), so it can happen that way.

As an aside, he does very good customer service. I sent him a case and he made to sure to give me a phone call, send his report by fax the same day, and this month I got personalized holiday cards from him with a little Starbucks $5 card to boot.

 

[pathstudent]

Just as a counterexample, Lester Thompson is a private practice physician (SoCal Kaiser Permanente) and gets consults from academic centers (Ive seen academic attendings send stuff to him), so it can happen that way.

As an aside, he does very good customer service. I sent him a case and he made to sure to give me a phone call, send his report by fax the same day, and this month I got personalized holiday cards from him with a little Starbucks $5 card to boot.

hmmm....i am suspicious. I have a head and neck pathology book written by a Lester Thompson. I seriously doubt a community practice pathologist would get picked to write a textbook or have consults sent to him from other experts in head and neck. I am guessing he did some serious time in academics for people to know who he is. I call BS on your counter example.

 

[sohsie]

hmmm....i am suspicious. I have a head and neck pathology book written by a Lester Thompson. I seriously doubt a community practice pathologist would get picked to write a textbook or have consults sent to him from other experts in head and neck. I am guessing he did some serious time in academics for people to know who he is. I call BS on your counter example.

You are a complete idiot. You could have spent 2 seconds looking him up on google to know who he is, but you didn't bother.

Lester Thompson spent most of his career at the AFIP, but has spent the last few years at Kaiser. He has never worked for a university or other academic center. He has written the WHO fascicles on head and neck and endocrine tumors among his numerous other publications, as well as the Foundations books on those topics (probably the one that you own.)

Your original post states: "out of curiosity, why is pathology unique in that community practice types seek consults from academics.

I have never ever heard of an MRI or CT scan being sent to academics for consult. Nor have I ever heard of general surgeon sending their patient to the university for consult. But pathologists send out cases to the university all the time for consults. "

Lester Thompson never worked for a university a day as an attending, but he receives consults in a private practice setting all of the time. Hence, it is a counter-example. Game over again for you.

I call BS on you even graduating college.

 

[yaah]

Dude - Lester Thompson was at the AFIP for several years. A position which likely allowed him to cultivate many relationships with potential clients who would send consults. He also has continued teaching and writing book chapters. This is not that unusual although it can be hard to maintain a busy consult practice in private practice. Dr Unni from Mayo is now in private practice also. There are other counter examples.

 

[pathstudent]

Dude - Lester Thompson was at the AFIP for several years. A position which likely allowed him to cultivate many relationships with potential clients who would send consults. He also has continued teaching and writing book chapters. This is not that unusual although it can be hard to maintain a busy consult practice in private practice. Dr Unni from Mayo is now in private practice also. There are other counter examples.

Of course. Being at the AFIP or NIH is equivalent to being in academics. I knew that counter example was BS.

 

[sohsie]

Of course. Being at the AFIP or NIH is equivalent to being in academics. I knew that counter example was BS.

Whatever jerk. You couldnt even be bothered to look him up on google, and now you magically expanded your definition of a university to include non-universities as well as defining a university consult to include sending a case to someone who has been in private practice for the last 6 years. Everyone knows you are full of BS.

Its no surprise that you are one of the main "the job market sucks" posters. After all, no group in their right mind would want to hire you. Its too bad that you taint the other posters in that group, many of which are actually intelligent and accomplished.

 

[pathstudent]

Whatever jerk. You couldnt even be bothered to look him up on google, and now you magically expanded your definition of a university to include non-universities as well as defining a university consult to include sending a case to someone who has been in private practive for the last 6 years. Everyone knows you are full of BS.

Its no surprise that you are one of the main "the job market sucks" posters. After all, no group in their right mind would want to hire you. Its too bad that you taint the other posters in that group, many of which are actually intelligent and accomplished.

I have never ever said the job market sucked, never ever ever ever ever. In fact I have pointed out all the great job offers on pathologyoutlines. I think the job market is great for people from good programs. I do think the field is "falling apart" a bit as MBAs and alpha-type MDs have figured out how they can make money of pathology services.

The only thing I have said is I don't agree with being a pollyanna and saying don't worry about salaries and job markets and just "do what you love". I am a pragmatist at heart and think people should know all their options and the implications of their decisions. Life is complicated. I would do something I absolutely hated for 10 years if it would pay me 100,000,000 versus doing something I that i loved, like academic pathology for all my life. Even if I hated it would only be 8 hours a day. Do you think immigrant laborers love picking the fields. No they do it because it provides. If they only did what the loved, their family would not eat.

oh yes, and people that work at the AFIP or NIH, like Jaffe, are like alpha academics. It surprises that you don't understand that.

 

[cozmopak]

I have never ever said the job market sucked, never ever ever ever ever. In fact I have pointed out all the great job offers on pathologyoutlines. I think the job market is great for people from good programs. I do think the field is "falling apart" a bit as MBAs and alpha-type MDs have figured out how they can make money of pathology services.

The only thing I have said is I don't agree with being a pollyanna and saying don't worry about salaries and job markets and just "do what you love". I am a pragmatist at heart and think people should know all their options and the implications of their decisions. Life is complicated. I would do something I absolutely hated for 10 years if it would pay me 100,000,000 versus doing something I that i loved, like academic pathology for all my life. Even if I hated it would only be 8 hours a day. Do you think immigrant laborers love picking the fields. No they do it because it provides. If they only did what the loved, their family would not eat.

oh yes, and people that work at the AFIP or NIH, like Jaffe, are like alpha academics. It surprises that you don't understand that.

Dude, who are you? And where are you an academic pathologist?

 

[KeratinPearls]

Dude, who are you? And where are you an academic pathologist?

Dude is a resident and is believed to be next Rosai and Sternberg combined.

 

[sohsie]

I have never ever said the job market sucked, never ever ever ever ever. In fact I have pointed out all the great job offers on pathologyoutlines. I think the job market is great for people from good programs. I do think the field is "falling apart" a bit as MBAs and alpha-type MDs have figured out how they can make money of pathology services.

The only thing I have said is I don't agree with being a pollyanna and saying don't worry about salaries and job markets and just "do what you love". I am a pragmatist at heart and think people should know all their options and the implications of their decisions. Life is complicated. I would do something I absolutely hated for 10 years if it would pay me 100,000,000 versus doing something I that i loved, like academic pathology for all my life. Even if I hated it would only be 8 hours a day. Do you think immigrant laborers love picking the fields. No they do it because it provides. If they only did what the loved, their family would not eat.

oh yes, and people that work at the AFIP or NIH, like Jaffe, are like alpha academics. It surprises that you don't understand that.

Lester Thompson has worked in private practive for the last six years. Im not at all surprised that you dont understand that that means he is not at an academician anymore.

People send consults to known experts in the field, no matter where they are, not just to the university for the sake of sending it to the university, which was your original point.

 

[lipomas]

People send consults to known experts in the field, no matter where they are, not just to the university for the sake of sending it to the university, which was your original point.

While I agree with that, many patients will request that their slides be sent to "the local university" even if they have no idea if the pathologists there are any good or have any more expertise than the person who read out the slide. They just assume that they are going to get a better diagnosis there. Sometimes that's true, sometimes that isn't. Of course, many patients think that their surgeon is the one making the diagnosis. And I remember talking with a researcher who did a lot of work on prostate cancer but hadn't seen a biopsy since residency training (he did research full time). Pathologists and patients would send him consults. Made me laugh, but made me realize the importance of the "name" and the lack of importance (sometimes) to many people of simply being good at what you do.

 

[SLUsagar]

Lester Thompson has worked in private practive for the last six years. Im not at all surprised that you dont understand that that means he is not at an academician anymore.

People send consults to known experts in the field, no matter where they are, not just to the university for the sake of sending it to the university, which was your original point.

completely concur. Andrew Renshaw is another (semi) bigname pathologist who made his fame in academia before bolting to a ($$) private practice gig in Florida. Still writes and receives consults.

 

[Gaz]

I am somewhat loathe to bring this thread back to the top of the list because I feel my fingers are going to be nipped by the troll, but I did want to point out that from my experience working in a radiology department in a community 200 bed hospital, I saw many imaging studies, mostly CT and MRI, go out for an overread at an academic center. This especially occured with pediatric patients or studies we didn't perform very often, but would also occur when a radiologist wanted another opinion from the academic center.

 

[schrute]

I'm going to throw my freaking pager at the computer if pathstudent keeps posting his asinine questions so he can set up his "academics are better" rebuttals.

Seriously, dude's laid down I don't know how many posts on the superiority of "academics"...it's getting old. As is your grammar.

PPs send cases to big institutions because that's where the experts in various fields reside (whether it's pathology, surgery, dermatology, etc...). I'm at IU--we've got buku GU pathologists that are authors of AFIP, WHO, and various surp path chapters. They get kidney consults.

If you have panc CA, do you want to go to John Doe, MD, who does one every few weeks, or do you want to go to the group that does several a day?
Same thing applies to pathology.

Rads does send out cases, but as numerous people have already posted, the "diagnoses" are descriptive...suggestive...NOT definitive.

 

[alois]

At least as of a few years ago, radiologists did not have an allowable billing code for consultation -- unlike pathologists, who have three different levels of billing for review of consultation material (88321, 88323 and 88325: review of slides; review of slides with preparation of additional material; and review of slides along with other medical records including imaging).

 

[BrainPathology]

1/3 to 1/2 of our brain tumor boards consist of consults from radiology studies for the neuroradiologists to review.

Most if not all of the patients reviewed in pituitary tumor board are referred to the endocrinology service from community hospitals.

 

[BrainPathology]

Also from observing private practice pathologists who taught me, 95% of the time you don't send something out for a consultation because you don't know the answer. Most of the time you send it because it's unusual and the surgeon or patient asks for a second opinion and the consultant just confirms your impression (unless it's one of a handful of people who will disagree with ANYTHING you send them for ego reasons). Less often it's a case that seems borderline and for saftey's sake you send it to whoever is considered the expert. In pathology the "experts" are people who write the most about something even if they never diagnose slides. If a borderline tumor then behaves in an unexpected way you have the backup of someone who wouldn't be challenged in court (because with some experts in pathology the tumor essentially IS whatever they say it is).

 

[alois]

1/3 to 1/2 of our brain tumor boards consist of consults from radiology studies for the neuroradiologists to review.

Most if not all of the patients reviewed in pituitary tumor board are referred to the endocrinology service from community hospitals.

But the radiologists don't get paid for reviewing the outside studies, while the pathologists do get paid for reading consults. Without the financial draw, few radiologists are eager to review outside studies.

 

[BrainPathology]

But the radiologists don't get paid for reviewing the outside studies, while the pathologists do get paid for reading consults. Without the financial draw, few radiologists are eager to review outside studies.

I know.. even though that post was right after yours it wasn't meant as a rebuttal to it. It was simply another voice saying that I do see consults for radiology and other professions. If they got paid for them I'm sure they would increase 10 to 1 million fold.