Dermatologists and General Pathologists

[levels x3]

Been quite some time since I've posted, but I'm curious what others might have experienced here. I am a partner in a private pathology group that has an exclusive contract with a hospital system. We are responsible for everything that happens in our system. Within the past 2 years, this hospital system has hired 2 dermatologists; fully employed by the hospital. We are a 4 1/2 pathologist group and none of us are a boarded dermatopathologist. I am the youngest partner, 5 years working, but most of my partners have been working for >20 years. Prior to the hiring of these dermatologists, we saw a decent amount of derm from our plastic and general surgeons, as well as a smattering from our primary care offices. Now, we see a lot more. Two of us (me included) have more than the usual amount of dermpath training, and feel quite comfortable in this area. To our knowledge, we have never had a significant miss...i.e., we have never missed a melanoma. Nonetheless, our dermatologists do not trust us at all when it comes to melanocytic lesions. They distrust us "a priori", because we are not boarded dermatopathologists. This has created an enormous problem for us, the dermatologists, and the hospital. As a result, we are being forced to send out much of what we call dysplastic nevi for second opinion. Specifically, anything we call "moderate" and above. Our dermpath consultant agrees with us in essentially every case, but this does not change the opinion of our dermatologists for reasons beyond me and the scope of this post. The send outs create an enormous burden for our administrative assistants, as well as us. It's also an infuriating imposition to have so many cases subject to outside review. Our dermatologists would like to be able to directly send pigmented lesions to a dermpath lab of their choosing.

Editorial comment: Personally, I have come to question this part of practice of dermatology. The incidence of melanoma has increased dramatically over the past decades, but death rates have remained constant. Are we really doing anyone a service in how we interpret nevi? This seems similar to the preoccupation with "premalignant" lesions elsewhere, such as low-grade DCIS...end editorial comment...

More practically, I am curious if anyone else has been in a similar situation. Is anyone else in a system with employed dermatologists, but no dermpath? How do you handle this? How has it affected you?

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[dr.weiner]

Looks like you'll need to hire at least a .5 dermpath person. Agree that dermatologists won't send specimens to non-dermpath boarded pathologists in this medicolegal era. They would prefer to send to dermatology trained dermpaths if they could, so general pathologists are not very high on their list. And it's hard to prove competence without the certification, however unfair that is.

 

[Thrombus]

Pathology leadership and academia has SOLD US DOWN THE RIVER!

You can't get dermpath certified unless you go to a fellowship and work for them. Most cant even get into this private little fellowship club anyway unless you have your nose stuck up someone's arse.

Complete BULLSHT. All pathologists should all be able to get dermpath certified or they should get rid of the damn certification.

 

[Torsed]

I've had similar experiences. Its a good ole boy system and never neglect the kickbacks that dermatopathologists are often times giving dermatologists. We had one dermatopath buy a dermatologists EMR. My beef is when dermatologists have their PA shave off melanocytic lesions! I could blabber on for hours about that, but will refrain.

I don't mind sending things out for second opinion honestly. I wouldn't go to any of the local dermatologists where I am with the exception of one.

And am I wrong, but didn't Dr. Ackerman miss a melanoma?
Not sure why they (derm residents) are being taught they are free from liability, no matter who reads the case they will burn with everyone else I assure you.

 

[WEBB PINKERTON]

Derm is a lost cause. Most of us have had similar experiences. We lost every derm account we had years ago for the same reason. Your accession numbers sure go in the s**tter when you lose all that volume.

 

[coroner]

This is a similar situation to the practice I joined in one of the hospitals we cover. None of us are trained in DP and the only skin bxs. we get are from surgeons, PCPs, and ENT. The derms here do not send anything to us (not just non-melanocytic lesions) unless the pt. is a hospital employee and they're under the system's insurance plan. Even if the dermatologists at your institution are employed by the hospital and not private, they apparently have some clause in their contract that allows them to send their specimens to whomever they want. From the hospital admin perspective, even if they lose the TC, just based on numbers they are still coming out ahead by providing a new service that wasn't there before. As someone suggested, you may want to hire a DP down the road if it's not practical to do so now i.e. when someone else retires/leaves your group. I can guarantee you'll get a ton of applicants.

It seems your concern is more academic and laboratory-workflow oriented which I respect vs griping about losing a few extra bucks. But, ultimately, the derms will call the shots because [the perception is] they are the glam specialty bringing in the extra dough and the lab is the nerds with microscopes who ends up getting pushed to the sidelines…

Editorial question: Are you suggesting things are being overcalled that are not prognostically significant if pt's with such diagnoses are still having the same outcome e.g. dysplastic nevus, DCIS, etc? Or are you questioning how they called e.g. dysplastic nevus without cytologic atypia, low-grade DCIS in relation to M&M?

 

[doctalaughs]

Been quite some time since I've posted, but I'm curious what others might have experienced here. I am a partner in a private pathology group that has an exclusive contract with a hospital system. We are responsible for everything that happens in our system. Within the past 2 years, this hospital system has hired 2 dermatologists; fully employed by the hospital. We are a 4 1/2 pathologist group and none of us are a boarded dermatopathologist. I am the youngest partner, 5 years working, but most of my partners have been working for >20 years. Prior to the hiring of these dermatologists, we saw a decent amount of derm from our plastic and general surgeons, as well as a smattering from our primary care offices. Now, we see a lot more. Two of us (me included) have more than the usual amount of dermpath training, and feel quite comfortable in this area. To our knowledge, we have never had a significant miss...i.e., we have never missed a melanoma. Nonetheless, our dermatologists do not trust us at all when it comes to melanocytic lesions. They distrust us "a priori", because we are not boarded dermatopathologists. This has created an enormous problem for us, the dermatologists, and the hospital. As a result, we are being forced to send out much of what we call dysplastic nevi for second opinion. Specifically, anything we call "moderate" and above. Our dermpath consultant agrees with us in essentially every case, but this does not change the opinion of our dermatologists for reasons beyond me and the scope of this post. The send outs create an enormous burden for our administrative assistants, as well as us. It's also an infuriating imposition to have so many cases subject to outside review. Our dermatologists would like to be able to directly send pigmented lesions to a dermpath lab of their choosing.

Editorial comment: Personally, I have come to question this part of practice of dermatology. The incidence of melanoma has increased dramatically over the past decades, but death rates have remained constant. Are we really doing anyone a service in how we interpret nevi? This seems similar to the preoccupation with "premalignant" lesions elsewhere, such as low-grade DCIS...end editorial comment...

More practically, I am curious if anyone else has been in a similar situation. Is anyone else in a system with employed dermatologists, but no dermpath? How do you handle this? How has it affected you?

If you want a perspective from the derm standpoint - as we train we usually rotate only with dermatopathologists (both derm and path trained) and they are usually the ones ingraining the difficulty and nuance in both melanocytic lesions as well as certain inflammatory conditions and cutaneous lymphoma. In addition, most derm residents rotate though VAs where dermpath may not be available and may have had bad experiences with genpath there (Im guessing there are more talented pathologists elsewhere). There is of course the liability piece you mentioned whether real or perceived.

In regards to shaving melanocytic lesions this is not too uncommon even for dermatologists. The key is how you actually do the shave. While excising to adipose every lesion would be ideal, its neither practical nor possible for every mildly suspicious mole. Punch would be ok except larger lesions suffer from sampling errors (and inability for you to see true architecture across the lesion). So deep shave with intent to remove the entire lesion is common. You may transect a few melanomas in your career but you will miss fewer. The problem comes if someone is doing a superficial partial shave of a melanocytic lesion, which is a problem.

By the way I do agree we are sampling too many dysplastic nevi and treating them too aggressively. I try not to sample unless I actually think it could be melanoma, but many dermatologists seem to take off every mild atn, which probably isnt doing the patient any good. There are probably non clinically important melanomas too but until you find a way to distinguish these as indolent we will treat aggresively.

 

[Autopsy101]

We have a similar situation with the dermatologists who send specimens to our group. We have one dermpath. When the dermpath is on vacation, they absolutely refuse to have their cases signed out by anyone else - unless they have a blistering/desquamating disorder with DIF...then and only then any pathologist with eyes will do.

 

[WEBB PINKERTON]

Hopefully one of those "shine a light on the lesion and get a diagnosis" devices will put an end to everyone's misery. There seem to be many in development for derm.

 

[doctalaughs]

Hopefully one of those "shine a light on the lesion and get a diagnosis" devices will put an end to everyone's misery. There seem to be many in development for derm.

I have about the same confidence that these devices will work as I do that computers will make routine path diagnoses by scanning the slides.

Also although dysplastic nevi I think are sometimes overtreated by derm, some of the blame does rest with dermatopathologists as well with constant comments that "complete excision is recommended." It seems almost standard now that moderate and above is excised although there is pretty good evidence we aren't doing much good. But since there is some subjectivity grading these, moderate has almost become a code word that the pathologist is worried enough about it. I've had these discussions about the comments and the grading; some pathologists have literally told me: if you stop removing moderates I will start calling them severe, because I want those out.

 

[Nilf]

I have about the same confidence that these devices will work as I do that computers will make routine path diagnoses by scanning the slides.

Also although dysplastic nevi I think are sometimes overtreated by derm, some of the blame does rest with dermatopathologists as well with constant comments that "complete excision is recommended." It seems almost standard now that moderate and above is excised although there is pretty good evidence we aren't doing much good. But since there is some subjectivity grading these, moderate has almost become a code word that the pathologist is worried enough about it. I've had these discussions about the comments and the grading; some pathologists have literally told me: if you stop removing moderates I will start calling them severe, because I want those out.

Le sigh...

There is no such thing as 'dysplastic nevus'. There are only nevi or melanomas. And there is no objective, reproducible grading system. 'Mild, moderate, severe', all of these grades are made up.

HOWEVER, in real life there are some funky nevi which are so bad-looking that I make clinicians remove them. Basically I still think it's a nevus, but I'm gonna sleep better if it's out. Oftentimes I am not sure just because of inadequate biopsy.

 

[doctalaughs]

Le sigh...

There is no such thing as 'dysplastic nevus'. There are only nevi or melanomas. And there is no objective, reproducible grading system. 'Mild, moderate, severe', all of these grades are made up.

HOWEVER, in real life there are some funky nevi which are so bad-looking that I make clinicians remove them. Basically I still think it's a nevus, but I'm gonna sleep better if it's out. Oftentimes I am not sure just because of inadequate biopsy.

Sure its fine if you are in that school (I am fine with that). Unfortunately it seems about 75 percent of dermatopathologists are now in the other school, depending on what part of the country you are in.

 

[dr.weiner]

Le sigh...

There is no such thing as 'dysplastic nevus'. There are only nevi or melanomas. And there is no objective, reproducible grading system. 'Mild, moderate, severe', all of these grades are made up.

HOWEVER, in real life there are some funky nevi which are so bad-looking that I make clinicians remove them. Basically I still think it's a nevus, but I'm gonna sleep better if it's out. Oftentimes I am not sure just because of inadequate biopsy.

Do you write "Funky nevus, very bad looking" in your report? Seems made up to me. Otherwise, severe atypia is much more accepted terminology, regardless of whether dysplastic nevi truly exist or not.

 

[icpshootyz]

The real problem is if you give people a 3-tier grading system, they tend to fall in the middle most of the time. I would say 80% of the dysN's I diagnose I call mild, around 18-19% moderate, and 1-2% severe. For me severe means I'm close but not quite there for melanoma. But then other people review my cases and overcall them, so who knows. Even the textbook writers can't agree on these things, might as well just call it whatever you want. I, however, don't give recommendations on my reports. It's your patient - take it off if you want, don't take it off if you don't want. Only recommendations I give is when a legitimate malignancy is at a margin and needs more therapy. And for weird Spitz nevi or the like I'll put a comment about how "some authors recommend complete excision for nevi of this type", to cover my own rear. But moderately dysplastic nevi? I'll leave that up to the dermatologist for their patient.

 

[cmz]

For the most part, three-tiered systems have always sucked.

 

[AZpath]

It is BS
General pathologists can do a great job on derm. It is time stand on your group's record.
You need to put the diagnostic correlation from your send outs on public dysplay infront on the most visible hospital comittee probably medical excutive.

You have the training, experience and the evidence. You don't require proctoring. If we take the attitude that a dermpath is necessary for skin then we should be sending out general surgeons and FP cases.

Besides any outside lab should be full active staff and be able present the same data as you can. Is the hospital medical community at large ready to ignor credentialing standards?

The liability issue is bull too. I don't pay extra malpractice to read skin

 

[jp123ok]

It is BS
General pathologists can do a great job on derm.

I disagree. Most general pathologists are not adequately trained to diagnose inflammatory derm or pigmented lesions. It takes a dermpath fellowship or other specialist training to be comfortable with these types of lesions.

 

[Thrombus]

I disagree. Most general pathologists are not adequately trained to diagnose inflammatory derm or pigmented lesions. It takes a dermpath fellowship or other specialist training to be comfortable with these types of lesions.

Speak for yourself.

 

[Nilf]

Sure its fine if you are in that school (I am fine with that). Unfortunately it seems about 75 percent of dermatopathologists are now in the other school, depending on what part of the country you are in.

Start sending to those minority dermpaths then. You will get straightforward diagnosis, you will know what to do and your liability will be minimal.
Broad categories of melanocytic lesions should be:
1. Benign
2. Can't tell for sure but out just to be safe.
3. Malignant.

Anything else is smoke and mirrors.