End of Micro Descriptions

[LADoc00]

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Im finding myself describing the microscopic features of cases less and less. Im predicting in a few years that micro descriptions will be obsolete replaced with a combination of synoptic reporting formats and embedded images.

I can no longer see the value in mentioning the "blue myxoid-appearing stroma" of a fibroadenoma or the "marked nuclear pleomorphism with prominent inclusion-like nucleoli" of a metastatic melanoma. And I dont think clinicians care.

Someone asked on another thread how vastly more volume is being done by fewer and fewer pathologists and this is how. PAs are grossing, gallbladders are being bottom lined with canned texts and new breast cancers are being signed out as "Infiltrating ductal carcinoma, favor grade 2, no evidence of an in situ component or angiolymphatic invasion" with no description(for a core biopsy specimen).

I cannot see how people are really justifying spending the time to describe Owl's eye nuclear features, ropey collagenous stroma etc...

 

[djmd]

Im finding myself describing the microscopic features of cases less and less. Im predicting in a few years that micro descriptions will be obsolete replaced with a combination of synoptic reporting formats and embedded images.

I can no longer see the value in mentioning the "blue myxoid-appearing stroma" of a fibroadenoma or the "marked nuclear pleomorphism with prominent inclusion-like nucleoli" of a metastatic melanoma. And I dont think clinicians care.

Someone asked on another thread how vastly more volume is being done by fewer and fewer pathologists and this is how. PAs are grossing, gallbladders are being bottom lined with canned texts and new breast cancers are being signed out as "Infiltrating ductal carcinoma, favor grade 2, no evidence of an in situ component or angiolymphatic invasion" with no description(for a core biopsy specimen).

I cannot see how people are really justifying spending the time to describe Owl's eye nuclear features, ropey collagenous stroma etc...

It is hard to see how one can spend much time on descriptions without resorting to canned text, or generalization, and still do the work in a timely fashion...

 

[yaah]

We don't have microscopic descriptions here at all, the exception maybe being some heme cases where it is in a comment. THere are templates for a lot of things though, mainly large resections but also for some biopsies.

I think templates are going to become more and more important, even for biopsies, because so many clinicians want to know specific things about the case (was there extranodal extension? How much necrosis? What was the mitotic rate? Did it stain for marker x? How much inflammatory response was present?). It will basically be a de-facto microscopic description!

 

[mrp]

We don't do micros, unless it's a difficult case or there's some other particular reason to. And then, they're usually pretty brief. We do a lot of synoptics, tho.

At our local Children's hospital, however, they LOVE microscopic descriptions. All trainees that rotate out there have to do full micros on every case, including all of the normal biopsies and things like appy's, epidermal inclusion cysts, etc. It drove me crazy.

 

[CameronFrye]

Here, we usually don't include micros (well, the bm cores still get them).

However, I do notice that a lot of outside private practice material contains a microscopic description on every case.

 

[DrBloodmoney]

Yup no micros here either. They're pointless unless you are a consulting pathologist writing for other pathologists. If your audience is clinicians then just tell them what they need to know.

 

[Brian Pavlovitz]

I think our program tends to overuse microscopic descriptions, and I'm not sure why. As a University program, I understand the "academic" aspect, but it's just that: academic. I'm a big fan of just calling it what it is, and moving on.

 

[Neddy]

Im finding myself describing the microscopic features of cases less and less. Im predicting in a few years that micro descriptions will be obsolete replaced with a combination of synoptic reporting formats and embedded images.

I can no longer see the value in mentioning the "blue myxoid-appearing stroma" of a fibroadenoma or the "marked nuclear pleomorphism with prominent inclusion-like nucleoli" of a metastatic melanoma. And I dont think clinicians care.

Someone asked on another thread how vastly more volume is being done by fewer and fewer pathologists and this is how. PAs are grossing, gallbladders are being bottom lined with canned texts and new breast cancers are being signed out as "Infiltrating ductal carcinoma, favor grade 2, no evidence of an in situ component or angiolymphatic invasion" with no description(for a core biopsy specimen).

I cannot see how people are really justifying spending the time to describe Owl's eye nuclear features, ropey collagenous stroma etc...

Huh, I didn't realize that pathologists ever did that outside of heme and the occasional case that needs to be signed out without a definitive diagnosis.

 

[RyMcQ]

My 2 cents:

I still dictate microscopic descriptions for the following reasons:

1. Doing the dictation actually helps me to consider everything that I need to think about. I am verbally making the case for what is going on the diagnostic line. That said, my dictations have very little fat. They are almost terse. Our secretaries have enough to do already.

2. I think "Microscopic examination performed" makes pathologists look totally lazy. Even if most clinicians don't read the micro, they can see that I put some thought into the diagnosis. And some clinicians actually read the micro on every report and call me on typos and the like. Like it or not, we have a lot to gain by focusing on customer service, PR, etc.

3. The patient might like to see that we put some thought into our report. They pay a lot of money for it.

I do think synoptics and canned comments are valuable for standarizing reports, making them more readable, and prompting pathologists to look for important things. The synoptics in my reports are in addition to the micro description.

 

[yaah]

.

3. The patient might like to see that we put some thought into our report. They pay a lot of money for it.

I and my attending had an exchange of faxes (since that was the way the patient wanted to communicate) with a fairly upset patient who was unhappy that his tumor was not "examined more carefully." He had a prior excision of a sarcoma which was extensively worked up with immunostains and a description was given in a comment as it was a strange case. Then he had a recurrence and we signed it out as "recurrent high grade leiomyosarcoma" and gave the size and said margins were negative. That's all that was necessary. But he wanted to know the mitotic count, the appearance, etc, because he was under the impression that unless we put that in we weren't actually doing a reasonable examination. No matter how detailed we described the fact that it was the same tumor and prognostic features weren't going to change and that immunostains weren't necessary because it was the same tumor, he still complained and suggested he was going to request a second opinion. I suppose all of this could have been avoided if we just made a comment and said what the tumor cells look like, what the mitotic rate was, that it was identical to the prior tumor, etc, but it wouldn't have added anything to the diagnosis or the treatment.

Appearances matter!

 

[pathstudent]

We don't have microscopic descriptions here at all, the exception maybe being some heme cases where it is in a comment. THere are templates for a lot of things though, mainly large resections but also for some biopsies.

I think templates are going to become more and more important, even for biopsies, because so many clinicians want to know specific things about the case (was there extranodal extension? How much necrosis? What was the mitotic rate? Did it stain for marker x? How much inflammatory response was present?). It will basically be a de-facto microscopic description!

templates are very non-academic. That is disappointing to hear.

I put a microscopic exam on every single case I do as it helps me better understand diagnostic criteria and my own thinking.

 

[yaah]

templates are very non-academic. That is disappointing to hear.

I don't think so. Every place I've been has used them. They are actually very academic because there are many things that highly specialized clinicians want to know, and the template is the way to convey them. In addition, templates are useful for research purposes.

I have no idea where you came up with that statement. There are many different kinds of templates, however, so perhaps you're thinking of something else.

Our templates here give things like tumor size, grade, stage, # lymph nodes, marginal status, etc, with many things specific to organ type (like % necrosis in sarcomas, % different components in testicular tumors, etc).

 

[dermpathdoc]

I don't think so. Every place I've been has used them. They are actually very academic because there are many things that highly specialized clinicians want to know, and the template is the way to convey them. In addition, templates are useful for research purposes.

I have no idea where you came up with that statement. There are many different kinds of templates, however, so perhaps you're thinking of something else.

Our templates here give things like tumor size, grade, stage, # lymph nodes, marginal status, etc, with many things specific to organ type (like % necrosis in sarcomas, % different components in testicular tumors, etc).

Even if I use do the microscopic description( and listen to the Dermatologists yell if I DONT!), templates help to make sure I don't forget anything anything important. We use a computerized format where a number will bring up a canned message or a template. I use that to tailor my micro description.

 

[LADoc00]

I think solidly photographed digital images of the microscopy are almost always more well received by clinicians and patients than text.

 

[DrBloodmoney]

templates are very non-academic. That is disappointing to hear.

Regardless of your opinion of CAP, their cancer protocols for synoptic reporting is what clinicians will be requesting in the future (if they don't already - ours certainly do).

 

[Osteopathology]

Very few microdescriptions here...seems Dermpath and some of the Gyn sign outs still use it.

Osteo

 

[PathJet]

sometimes a good micro is needed

cytology for example we tend to say only a few things in the final but i think it helps in atypical or suspicious cases for the next pathologist /clinician to read the report to understand the what is going on in the patient

what should be banned forever though is a question mark in a pathology report

this really really bugs me--i would be so mad if some one read my biopsy and the result had some crazy punctuation in the final DX

?lesion ?representative --no kidding --we arent that busy we cant add on a few more words

 

[mlw03]

i'm just a student still, but some of the comments i've heard from attending pathologists about micro descriptions is the same as what pathjet said. specifically, i've heard some of them say that when they give a description of a tumor it's not for the clinician (who really may not need to care about morphologic characteristics to treat the patient well), but it's for the pathologist who might be looking at a liver biopsy in 3 years and trying to determine if it's a recurrence of the patient's prior colorectal cancer. from the clinical side it's a pain reading old notes and not knowing what the person was thinking, so i would suspect a similar thing would occur in pathology.

also, like some have said, i think templates are good if it makes the pathologist include all the data. for example, at moffitt cancer center, all melanoma diagnoses follow a template that includes things like depth of invasion, neurovascular invasion, necrosis, mitotic rate, etc. i don't think uniformity in reporting is a bad thing, in fact, i think it's good for yielding the same diagnosis anywhere in the world. for all the crap i give psychiatrists, they at least are very strict about using the DSM-IV criteria for every diagnosis they list.

 

[PathJet]

I agree... mlw

i have also hear people complain about uniformity in reporting becuase canned texts or templates "takes their creativity away"

1. how creative should we be in a patient's chart--i am not in pathology to be creative i want to takecare of patients-one of our most important duties is to communicate to patients and doctors what the findings are in the biopsy/surgical spec/molecular report/consutls etc

2. what?

3. the english language is robust -you can be succint and sound intelligent why do we need to make each person hunt in the report for tumor size and LVI just list these things out and then describe in language the aspects of the specimen which may portend an alternative biological behavior or are unclear etc

 

[ygdrasil]

I'm not sure about photos standing in for micro description:
1) They take up more room/memory/ink than micro descriptions.
2) Getting the right image might take more time than dictating a micro description.
3) Some (a lot? most?) clinicians won't really know what they're looking at.