Hematology + Hematopathology?

[drfunktacular]

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Does anyone know of Hematologists who have done a heme-path fellowship? It seems natural for a hematologist to receive further training in this. I can imagine at least 2 scenarios in which this would be useful:

1) A hematologist could potentially look at their own peripheral smears/bone marrows while the patient is still in the office and begin treatment planning without having to wait for the pathologist to get around to it. I would imagine if properly trained the hematologist could also bill for their own bone marrow sign-out and just send to a reference lab if they are unsure. I guess the downside to this would be that a single hematologist might not be able to get enough resources to do special stains/immunostaining that would be required for some diagnoses.

2) In a research/academic setting it seems like it would be useful for a hematologist who researches e.g. lymphomas to be able to handle/interpret their own research specimens.

 

[stefanlukic]

Where I am from all hematologists do their own pathology for marrow and peripheral blood and sometimes lymph nodes.
They do all the stainings (even immuno) and they do the flowcytometry.

 

[yaah]

1) A hematologist could potentially look at their own peripheral smears/bone marrows while the patient is still in the office and begin treatment planning without having to wait for the pathologist to get around to it. I would imagine if properly trained the hematologist could also bill for their own bone marrow sign-out and just send to a reference lab if they are unsure. I guess the downside to this would be that a single hematologist might not be able to get enough resources to do special stains/immunostaining that would be required for some diagnoses.

2) In a research/academic setting it seems like it would be useful for a hematologist who researches e.g. lymphomas to be able to handle/interpret their own research specimens.

In regards to point #1, many hematologists (most?) already do this, although often it is a preliminary interpretation and they seek out a hematopathologist's final review and official interpretation, sometimes taking it directly to them if it is a difficult case. Hematopathologists almost always have more experience which helps in the subtleties. However, I don't believe you can bill for a bone marrow signout/interpretation unless you are board certified in pathology or hematopathology (or both). I may be wrong on this though. Many hematologists do differential counts on their own bone marrow aspirations, however. This is common.

The rate limiting step in many cases is not "waiting for the pathologist to get around to it," it's waiting for the specimen to get processed and stained, etc. In the case of a bone marrow core biopsy this takes many hours, although the aspirate is available quicker which is why many hematologists look at them, even if they don't bill for them.

Hematopathology requires extensive training and experience, knowing clinical information is important also. Classic cases are actually rare.

You do not need to do any sort of fellowship to interpret things for research projects, because there is no patient care involved.

With enough training, anybody can do almost anything. The question comes down to why, and how much time you have in the day. Hematologists have busy enough days without taking all the time to properly evaluate a bone marrow biopsy. Hematopathologists, obviously it's the opposite.

 

[Reddpoint]

However, I don't believe you can bill for a bone marrow signout/interpretation unless you are board certified in pathology or hematopathology (or both). I may be wrong on this though.

Board certification does not really have much to do with whether a doctor can bill for anything. It is more about whether a hospital will hire you or allow you to perform certain functions in the hospital. A hematologist probably does not want to be officially reading the path because if they screw up a diagnosis and it ends up in court the lawyers will say it was a lack of expertise.

My question is why would you want to officially read your own path?

 

[yaah]

Yeah, that sounds more like it. I think that's what I was meaning to say. I did think there were some insurance regulations though, but maybe not.

I'm not sure why you would want to completely read your own path either (speaking as a pathologist) - it takes quite a bit of time to thoroughly go through a bone marrow aspirate and biopsy and issue a report, it is not a trivial task. It is more than just issuing a diagnosis. And lymph node pathology is very difficult except in classic cases.

 

[drfunktacular]

Thanks for the input, experts. I guess I was just wondering because I spoke with a hematologist who trained in the UK, where it sounds like the hematologists have more intensive training/practice in hematopathology, and I wondered if it would be possible/worthwhile to have a similar practice model in the US. You've made some pretty convincing cases that it isn't, though.

 

[jdh71]

Thanks for the input, experts. I guess I was just wondering because I spoke with a hematologist who trained in the UK, where it sounds like the hematologists have more intensive training/practice in hematopathology, and I wondered if it would be possible/worthwhile to have a similar practice model in the US. You've made some pretty convincing cases that it isn't, though.

I THOROUGHLY enjoyed the the time I spent with the hemepath guys, wonderful teachers all, while doing my heme/onc rotation (and it had nothing to do with the smokin' hawt path resident) - I had forgotten how enjoyable I found the microscope (checking your own peripheral smears when evaluating a platelets of 3 on a middle of the night consult - schisto's clinching the dx; or looking at the blood in a patient with a WBCs of 147,000, seeing the blasts - it's ****ing cool). The truth is, in practice a hematologist/oncologist lacks the practical time to do this. Admitting, consults, chemo infusions, clinic . . . you are seriously busier than a one legged man in an ass kicking contest.

Let the experts do what they do - not only because they will do it better, but because you won't have time for that crap.

 

[texashemonc]

In private practice heme/onc, I see about 40 % hematology cases on a daily basis in the office. I've got a good phlebotomist in office who helps me with making smears right away so I do glance at every new patient's smear when I see them for first time for relevant problems (anemia, thrombocytopenia, leukocytosis). However, I think that majority of doctors do not have microscope nor do not bother to look at slides, which is unfortunate. I don't see how many docs don't even have automated cbc machine in office - they send pts across the street to hospital for labs.

For bone marrows, I just do not have the time to look at aspirates. I often send them out to hemepath labs (such as Quest ) with turnaround time quite good as they are shipped overnight across country with flow cytometry and biopsy results back usually next afternoon. I don't deal with interpretation of aspirates as the pathologists will bill for this anyway.