NYT Article: On community practice breast pathology errors

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pathstudent

pathstudent

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http://www.nytimes.com/2010/07/20/health/20cancer.html?src=me&ref=homepage

Great article and warning to all women who had their biopsies seen outside of large academic medical centers.

Interesting that they talk about requiring pathologists to be CAP certified breast patholgists. Those CAP certifications will be a good substitute to subspecialty boards and also fair to those who haven't done a fellowship as experience can qualify you. However, if they require a minimum of 250 breast biopsies a year by the applying pathologist that will be hard for many community groups. Think about it, if you are in with 4 people, your group will need over a 1000 a year for the pathologists to be eligible.
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I don't think it is appropriate to get too jaded about the "large academic medical center". For the (almost) 30 years I have been doing this there has always been difficulty in the gray area between ADH and DCIS. That being said, I believe the experienced and capable general pathologist in a non-academic setting can and does accurately diagnose the vast majority of cases of ADH and DCIS. It is the prudent pathologist who recognizes the gray zone and seeks expert consultation. In my personal practice, if I am looking at a breast biopsy and trying to decide if it is or ain't, I ain't gonna sign it out without expert help. We have a Vanderbilt fellowship trained guy in our extended group who I use as well as a number of other associates who see lots more breast pathology than me.
 
pathstudent said:
http://www.nytimes.com/2010/07/20/health/20cancer.html?src=me&ref=homepage

Great article and warning to all women who had their biopsies seen outside of large academic medical centers.

Interesting that they talk about requiring pathologists to be CAP certified breast patholgists. Those CAP certifications will be a good substitute to subspecialty boards and also fair to those who haven't done a fellowship as experience can qualify you. However, if they require a minimum of 250 breast biopsies a year by the applying pathologist that will be hard for many community groups. Think about it, if you are in with 4 people, your group will need over a 1000 a year for the pathologists to be eligible.
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It's a terrible idea. ADH is not challenging to diagnose once your group comes to a consensus on how it's going to be called. It's a subjective diagnosis. If I call ADH on a core biopsy it is because you have a lesion that I believe needs to come out. Just like if I call a suspicious thyroid FNA.

If you can't accurately call flat-out dcis... you fail. ADH v dcis is never as hard as adh v udh. Not that it matters on core (ADH v DCIS that is) ... they should be getting a needle-loc anyways.

General surgical pathologists are more than capable of signing out all but the most uncommon breast diagnoses. It's not that hard. ADH does not qualify as 'uncommon.' What is far more important that what you actually call something, is the relationship you have with your breast surgeons. You have to know how they are going to handle certain situations. The only people this is going to please is 4ssholes on cancer committees and in CAP itself.

Also serious LOL at that article which reads like a giant round of beat the FMG.
 
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The article does a serious disservice to and major rapeage of community practice pathologists. I kind of can't even believe it and I am and uberacademic aupporter. Have you read the comments to the article. All the patients and all the pathologists are saying "have your case reviewed by an academic ". Mary erdington from mda flat states that every biopsy should be reviewed by an academic as if every comm practice pathologist should be assumed to be incompetent and every academic should be assumed to be infalliable. It is major pwnage of community practice pathology. Very harsh.
 
I'd say give it a few years and we'll probably have zero breast specimens being read by general surgical pathologists. Either your group will have a single breast guy handling all cases or breast pathologists will be working at a practice of breast surgical oncologists.

The sad thing is that CAP fully supports this type of dung. We're going to have subspeciality 'certifications' required as part their 'scientifically-validated' protocols in order to sign out breast cases. Your hospital is going to require it because The American College of Surgeons Commission on Cancer will only give your hospital accreditation if you have 'certified' (not board-certified, that is not good enough) pathologists filling out the ridiculous protocols.

Being a general surgical pathologist is going the way of the dodo. Get out now medical students!
 
DrBloodmoney said:
Being a general surgical pathologist is going the way of the dodo. Get out now medical students!
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I completely agree with that. Academic subspecialization is becoming the standard of care. In ten years, community practice will be limited to gallbags, hernia-sacs, and appendicies. Anything more complex will be sent to academic centers and it will be mandated by law.

But on the bright side this will be a great benefit to patients. Yes academics make mistake too, but the quality of care at places like MDA, MSK, BWH is unpteen times superior than every community practice.

Medicine is chainging so rapidly. I think a number of years ago some community practice settings might have even been regarded as superior but those days are ancient history.

Although academics might make less salary, they willl have the last laugh.

So residents, don't blow it. You have the chance now to get on the winning team. Going into private practice is a dead end. No matter how good you are, the fact that you are not associated with academics is a death blow.
 
Another certification...more money and control for the CAP. That is what the CAP is all about.

If I was a community pathologist, I wouldn't donate a penny to the CAP. They are going to take away your specimens or more money out of your pocket in order for you to keep them. They are not working in your best interest.

Just another reason not to go into pathology.

How long until the appendix fellowship/certification????
 
DrBloodmoney said:
The sad thing is that CAP fully supports this type of dung. We're going to have subspeciality 'certifications' required as part their 'scientifically-validated' protocols in order to sign out breast cases. Your hospital is going to require it because The American College of Surgeons Commission on Cancer will only give your hospital accreditation if you have 'certified' (not board-certified, that is not good enough) pathologists filling out the ridiculous protocols.
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The pathologist who missed the diagnosis in this case was not board certified. I think that needs to be emphasized in the discussion.
 
What needs to be emphasized is that this is an anecdote, a tragic anecdote, but an anecdote nevertheless. That same "mistake" could have been, and likely has been made by plenty of academic pathologists, even expert breast pathologists.

It's a more systemic problem, and the article alludes to a couple of issues... 1) DCIS is not only overcalled, but also overtreated in the US. 2) Even experts (at academic centers) don't necessarily agree.

Not mentioned in this article is that breast cancer is screening is imperfect at best... plenty of controversy there not too long ago, and the controversy continues.
 
path24 said:
Another certification...more money and control for the CAP. That is what the CAP is all about.

If I was a community pathologist, I wouldn't donate a penny to the CAP. They are going to take away your specimens or more money out of your pocket in order for you to keep them. They are not working in your best interest.

Just another reason not to go into pathology.

How long until the appendix fellowship/certification????
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Yes this article is an ominous sign to coumminty pathologists. We started subspecializing about ten years ago and bad-mouthed general pathologists since then. First the other physicians (surgical and medical subspecialists) bought into us and even if they went into private practice as gastros and pulmos or ents, they wanted subspecialty pathologists to sign out their case. Now the NYT has exposed you to the public and pathologists like Mary Erdington from MDA and many others are saying send every diagnosis to academia for review.

I tell you this is a landmark article and look it is the #1 emailed article. This article will change everything.

Private practice is kaput.

And I for one believe that 99% of breast biopsies are routine and that the decent PP pathologists know which ones to send out, but this article shows that more prominent people feel that 0% of cases should be assumed to be correct and that 100% should be send out.
 
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I remain rather befuddled that essentially anyone, MD or not, can call themselves a "pathologist."

I don't think requiring someone to see X number of cases of Y per year automatically improves their diagnostic acumen, unless it's part of a training program or they're building on an already solid foundation. In some cases I suspect it would only increase the number of misdiagnoses if they're all being read by a pathologist who doesn't really know what they're looking at.

One of my first "sad" lessons in pathology was that the loudest pathologist generally writes, or rewrites, the standards of diagnosis for a particular set of tumors. That doesn't make them right, or wrong, but it makes them harder to argue with. Similar goes for the battle-of-the-experts in the media.

There are a lot of areas of pathology and medicine in which diagnostic &/or treatment disagreements exist, and there will be (and needs to be) for a very long time to come -- but neither the media nor the public will generally be happy about it. Medicine is "supposed" to give people answers about their health, simple and straightforward and consistent. Disagreement in and of itself is, basically, a fail in that setting. But expectations will remain unachievably high, pressuring for earlier diagnosis, earlier screens and their eventual misuse as something other than a screen, and subsequent arguments about the results.

It is what it is. Welcome to medicine.

Oh, the article.. I don't think it's really an ominous sign to anyone except perhaps a non-pathologist somehow practicing as a pathologist. Diagnostic disagreement and/or medical error is really not news. It's been reported on more or less loudly since pretty much the dawn of recorded history, generally highlighted by someone from a bigger city or institution who knows more than the other guy. But I think finances and logistics means that for the forseeable future there will remain a community/private pathologist market for any of the common biopsy specimens.
 
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pathstudent said:
Yes this article is an ominous sign to coumminty pathologists. We started subspecializing about ten years ago and bad-mouthed general pathologists since then. First the other physicians (surgical and medical subspecialists) bought into us and even if they went into private practice as gastros and pulmos or ents, they wanted subspecialty pathologists to sign out their case. Now the NYT has exposed you to the public and pathologists like Mary Erdington from MDA and many others are saying send every diagnosis to academia for review.

I tell you this is a landmark article and look it is the #1 emailed article. This article will change everything.

Private practice is kaput.

And I for one believe that 99% of breast biopsies are routine and that the decent PP pathologists know which ones to send out, but this article shows that more prominent people feel that 0% of cases should be assumed to be correct and that 100% should be send out.
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Everyone wonders why LADoc00 has left this board, and why the sdn path board sucks compared to the past 5-6+ yrs, well take a good look at who wastes their time posting nonsense and ridiculous propaganda. Even when there were low points on sdn path I occasionally took a peek to see what was going on, but after such bs for so long I cannot continue to keep sdn as a tab in my bookmarks bar (favorites for pc users).This forum was a great resource at one time, it guided me from the tough decision to choose path, great residency interview questions to ask, and was a sounding board for residency issues as well as the great "online unknown conference thread". I met some good friends thru sdn path and will always cherish the positive influence this forum had given me. Unfortunately, I feel that this forum has been spoiled by immature and ill informed voices who do not quit. I feel that this once great resource is now lost. I only hope that those of you out there that have an actual interest in performing the art of medicine with pathology as your speciality find a forum to express your concerns, hopes and expectations in the environment that existed here a few years ago. This is my last post GODSPEED :luck:
 
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KluverB said:
What needs to be emphasized is that this is an anecdote, a tragic anecdote, but an anecdote nevertheless. That same "mistake" could have been, and likely has been made by plenty of academic pathologists, even expert breast pathologists.

It's a more systemic problem, and the article alludes to a couple of issues... 1) DCIS is not only overcalled, but also overtreated in the US. 2) Even experts (at academic centers) don't necessarily agree.

Not mentioned in this article is that breast cancer is screening is imperfect at best... plenty of controversy there not too long ago, and the controversy continues.
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Getting the rest of your points but.. DCIS is overtreated? really? do you think they should just leave it in there? breast cancer is a rather common malignancy..

The NY Times is media. Just like channel 7 news. Attention is what they want. The most dramatic spin will get them their biggest audience. All those academic pathologists probably didn't tell them that community pathologists are incompetent, but they media wants to spin it that way for the big shock and awe.

Obviously the grey area between adh and dcis will not be discussed in the article because as doctors, we should always be able to come up with a definitive answer (public opinion).

i wonder if the public will actually read this article and think that their biopsies should all be sent for consult, or if they will just not buy what the times is selling.. guess time will tell...:cool:
 
Also it is funny how many people are in the dark about pathology. You read the people "saying my oncologist or my surgeon diagnosed me with DCIS? Do people ever see oncologists before they have cancer, certainly not before they are diagnosed with DCIS.

Don't they know that surgeons are just superspecialized pathology techs whose job it is to get tissue for pathologists and that oncologists rarely ever do anything without a signed-out pathology report?

But maybe that is for the best. If there is ever a problem, they can just blame their oncologist. Leave us out of it.
 
Well.. no, most people don't know that their surgeon or oncologist didn't "diagnose" their tissues, at least not on their own. And most people don't know what the "lab" does or how, just that it exists, specimens are plugged in and nice simple consistent unambiguous accurate results come out. At worst, their surgeon/oncologist/other-non-path-MD reviews the "results" and interprets those results into a diagnosis (at least sometimes true). And this mythology persists in part because we as pathologists don't do much to educate people otherwise. But to be honest, I have doubts that the general public would come to understand otherwise unless we start running around or making calls and delivering diagnoses personally -- I think for the average person, whoever tells you your diagnosis diagnosed you. We don't do that for a multitude of reasons, including lack of a pre-existing relationship with the patient, lack of complete clinical information that might alter the diagnosis, lack of time, etc.

One of our regular visiting path attendings from Johns Hopkins told a story about a TV crew doing a documentary on one of their surgeons, and on one of the last days of filming they followed the surgeon to a tumor board meeting. At the end a producer walked up to the path attending and was like, "what the- wait, YOU'RE the guy making the diagnoses?? YOU actually look at the slides? The surgeon just..reads your report??" and once it sunk in they had to scamper around pathology for a while getting more footage.

Unfortunately it happens to be that when things go wrong or a patient (or surgeon, or oncologist, or administrator, or...) is particularly unhappy with the outcome, fingers start getting pointed at the "lab" and the person at the microscope. And as unjust, unrealistic, and unachievable as it may be, as regularly noted by the same aforementioned attending the acceptable error rate for pathologists is...zero.
 
DrBloodmoney said:
The sad thing is that CAP fully supports this type of dung. We're going to have subspeciality 'certifications' required as part their 'scientifically-validated' protocols in order to sign out breast cases. Your hospital is going to require it because The American College of Surgeons Commission on Cancer will only give your hospital accreditation if you have 'certified' (not board-certified, that is not good enough) pathologists filling out the ridiculous protocols.

Being a general surgical pathologist is going the way of the dodo. Get out now medical students!
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Did anyone catch the CAP president's email in response to the article? His organization sets up a bogus "certification" in breast pathology limited to higher volume practices and then laments comments which "undermine our patients’ confidence in the accuracy of their testing and diagnosis."

What an idiot.
 
Pathwrath said:
Did anyone catch the CAP president's email in response to the article? His organization sets up a bogus "certification" in breast pathology limited to higher volume practices and then laments comments which "undermine our patients' confidence in the accuracy of their testing and diagnosis."

What an idiot.
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Yes. This has to be a joke. It is a totally inadequate response (from the supposed leaders of our most-visible professional organization) to the total drive-by shooting done on the profession yesterday.

Here is the joke that arrived in my inbox this morning:

FAIL WHALE said:
July 20, 2010
Dear CAP Member:
You may have seen the article that appeared on the front page of the New York Times today (Tuesday, July 20, 2010), entitled, "Earliest Steps to Find Breast Cancer Are Prone to Error." The article is about several women who received a misdiagnosis of ductal carcinoma in situ (DCIS). We, as pathologists, understand that diagnosing the early stages of breast cancer can be difficult in some cases.
Some of the comments contained in the article reflect negatively on our specialty and can undermine our patients' confidence in the accuracy of their testing and diagnosis.
Today, the CAP sent a letter to the editor of the New York Times addressing pathologists' commitment to continually improve the accuracy of diagnosing DCIS.
If you are asked about the College's position on this issue, please feel free to use the following suggested language:
The College of American Pathologists encourages women who have been diagnosed with breast cancer, including ductal carcinoma in situ (DCIS), to speak with their doctors about the benefits and risks of their treatment options. The CAP encourages women to have their biopsy sample tested by a board-certified pathologist in an accredited laboratory.
The CAP also offers a website developed by pathologists, MyBiopsy.org. On this site, patients can find accurate and credible information about DCIS, along with 40 other cancers and cancer-related conditions.
As physicians, we know how frightening a cancer diagnosis is for a patient. I encourage you to direct your patients to MyBiopsy.org.
As you know, CAP members continue to devote their expertise to develop state-of-the-art proficiency testing programs, accreditation services, comprehensive testing guidelines, and certificate programs on breast pathology and breast predictive factors.
Over the next several days I will send you an email with a link to access responses to frequently asked questions related to this issue.
As your president and on behalf of your professional organization, I understand the sensitivity and complexity of these issues, and I appreciate your dedication to patient care.
Sincerely,
Stephen N. Bauer, MD, FCAP
President, College of American Pathologists
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Disgusted.
Every ***** is pointing fingers at the poor pathologist.
Remember, the therapeutic decision was the surgeon's.
How about we first start with teaching these neanderthals the "very basics of breast pathology including the grey zone of ADH/ DCIS, ALH/LCIS" etc so that they use their few cortical neurons when hacking away at tissue.
These surgeons are very quick to take credit when we diagnose that really esoteric entity, and equally quick at pointing in our direction if a mistake happens.

SURGICAL PATHOLOGISTS ARE THE TRUE GODS OF TODAYS MEDICINE (except ofcourse pathstudent who is a neanderthal and a troglodyte,however we can keep him as a pet)
 
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raider said:
SURGICAL PATHOLOGISTS ARE THE TRUE GODS OF TODAYS MEDICINE (except ofcourse pathstudent who is a neanderthal and a troglodyte,however we can keep him as a pet)[/QUOTE]

Thanks for the laugh of the day...:laugh::laugh::laugh::laugh::laugh::laugh::laugh::laugh::laugh::laugh:
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GlassPusherJack said:
Getting the rest of your points but.. DCIS is overtreated? really? do you think they should just leave it in there? breast cancer is a rather common malignancy...
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We as pathologists, of all people, should know the difference: DCIS is NOT cancer.

Yes, it is a "marker" of increased risk for having or developing invasive carcinoma (= cancer). It may well be the precursor lesion in some, perhaps even in a good proportion of the cases, but is that true for every case? Probably not.

Is a lumpectomy sufficient treatment? Mastectomy? Bilateral prophylactic? Chase that close margin? +/- neoadjuvant therapy? +/- radiation? Women elect or are talked into taking any and all of these choices. There are multiple protocols, studies, etc. Many studies are ongoing to sort some of this out. All of these things from screening protocols, through diagnostic/predictive/prognostic criteria, to treatment modalities are constantly moving targets.

Precisely, because breast neoplasia is so prevalent and our methods for screening, diagnosing, and treating are still rather crude, many women are overtreated to save those who would otherwise succumb to the disease.

So yes, some sort of constant "re-training" will be necessary. But, this is no different than any other hot area of pathology. But it will come down to: how much we will regulate ourselves, how much we will be regulated by others, and who these others will be.

The "good news"... readership of NYT is way down.
 
Much of this garbage noted in the press is behind the push for the designation "DIN 1" for ADH and DCIS grade 1 ( low grade ). Multiple excellent reasons for this terminology conversion are tabulized in the current (2009) AFIP fascicle by Tavassoli and Eusebi on page 71.
 
Some institutions are sending flat epithelial atypia for excision. Hopefully the NYT doesn't get word of that.
 
pathstudent said:
Some institutions are sending flat epithelial atypia for excision. Hopefully the NYT doesn't get word of that.
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These are the reasons I am not fond of breast path. Too nit picking and too many subtleties that can impact the patient. We are pushing early detection so hard but not willing to pay the price, but the majority of patients really don't understand that.


@DrBloodMoney: What response would you have liked to see from CAP? Just curious, not picking a fight or anything.

For that matter, to all of you: what should we do about this now that the article has been written? What response should / can we have?
 
2121115 said:
The pathologist who missed the diagnosis in this case was not board certified. I think that needs to be emphasized in the discussion.
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wasn't he NOT board certified at the time of signing out that case? Likely either a newbie fresh out or a foreign grad in the process of cert'ing. Cut the dude a break. What needs to be emphasized is that the article falls short of appropriately addressing how challenging and controversial ADH vs DCIS can be, and how in path there are several similar situations where diagnostic overlap exists. Everything isn't black or white.
 
SLUsagar said:
wasn't he NOT board certified at the time of signing out that case? Likely either a newbie fresh out or a foreign grad in the process of cert'ing. Cut the dude a break. What needs to be emphasized is that the article falls short of appropriately addressing how challenging and controversial ADH vs DCIS can be, and how in path there are several similar situations where diagnostic overlap exists. Everything isn't black or white.
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I agree. However, I was replying to the discussion about whether we need all these extra CAP breast certifications and to the comment that there is a perception that AP board certification is not enough. The letter from the CAP president emphasized that patients should make sure that their biopsy is read by a board certified pathologist.

But I agree that we should cut the guy some slack here. Especially since he showed it to other members of his practice who agreed with him. I am not board certified yet (although I hope to get word one day soon that I am) so I am in no position to judge.
 
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Yes, the pathologist is getting vilified here, but he made a very understandable error. It is just unfortunate that the NYT picked up on it and skewered him (and all of us) and undermined our credibility.
 
zao275 said:
@DrBloodMoney: What response would you have liked to see from CAP? Just curious, not picking a fight or anything.

For that matter, to all of you: what should we do about this now that the article has been written? What response should / can we have?
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Glad you asked.

It is beyond stupid for a CAP president to complain about an article and its comments undermining patients' confidence in their pathologist while setting up a bogus certification which does precisely that. This certification probably excludes a majority of lower-volume community pathologists, not to mention those who refuse to participate in what is sure to be a growing series of bogus certifications.

Let's not kid ourselves. If CAP really wanted to address pathologist incompetence, it would address the source--poor resident selection and poor residency training in an excess of programs. This garbage is all about recategorizing bread-and-butter pathology into esoterica requiring academic subspecialists to handle properly. It is about making pathology residency even more useless than it already is.

I've said it before--I have no idea why community pathologists belong to this organization.
 
Correct CAP Response:

Increase doctor and layperson knowledge of "who" actually makes the diagnosis and "how" is it actually made by:

1. Pushing for renaming "surgical pathology" as "diagnostic medicine"

2. Pushing for mandatory rotation of all medical students and clinicians dependent on pathologists. During this rotation making medical students and clinicians "take reponsibility for patient diagnosis" by actually being actively involved in formulating diagnosis, not simply "loitering through the pathology department like vagabonds on vacation"

3. Pushing for better resident education by closing all programs that have insufficient number of specimens for the number of residents (far too many programs like that).

4. Pushing for better "reimbursement" of the professional component , so that we are not pushed by "administrator types" to sign-out X number of cases because professional reimbursement is too low.

5. Pushing for "only pathologists can bill what they sign-out".

Just a start, but if you are smart enough you get the idea that a lot needs to improve and starting a new accreditation program in breast pathology without dealing with the real problem is just circumventing real issues.
 
I'll take #2. That was something I whined about all through residency. We actually did have a couple of surgical residents rotate through for a few weeks, but except for maybe..neuro?..it wasn't mandated, and they only really spent time with the neuropathologists. Unfortunately everyone seemed to cite financial issues as the reason regular path rotations aren't mandated really at any level. The fact that med school and residency are primarily for training purposes seems to have escaped notice by those who need warm bodies doing the hospital/department's work. But, even if every med student & resident rotated thru pathology for a month or two, it probably wouldn't change public perception.

As for the non-board-certified (at the time) chap who got finger-pointed in the article, it sounds like he at least made due effort to see that it was reviewed by someone board certified. But if I read the article correctly (and it was written correctly, two things which rarely seem to go together), then he was the -only- "pathologist" for that hospital, was not board certified for years (had to take it a few times), and had no local/on-site board-certified colleague or supervisor. THAT bothers me, which would be the administration's fault, not his. It's possibly why the physically closest board-certified pathologists offered to review cases without cost. Unfortunately the whole thing really blew out of proportion on them. And no, I'm not a fan of uncertified individuals who might have gone through a path residency, or might not have, practicing as pathologists despite the unfortunate reality that they may "have" to for a time between finishing residency and getting even their first board exam results back. But perhaps that's another issue entirely.
 
+1 agreement to comments above (esp. SLUsagar, Pathwrath, raider, KCShaw)
 
zao275 said:
@DrBloodMoney: What response would you have liked to see from CAP? Just curious, not picking a fight or anything.

For that matter, to all of you: what should we do about this now that the article has been written? What response should / can we have?
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1. They were blind-sided by this negative press. PR101 fail:

The article makes it sound as if CAP was contacted during the writing/research stage so they should have known if someone from the NYTimes was about to publish an article on pathology errors. They should have been way out in front of this bad press. If they didn't know about the article, they need better media outreach. What does it say about CAP if an article about failures in the whole point of the profession you represent (ie. accurate diagnosis) is being written by the NYT and you don't even get a phone-call. I don't know what is worse: failure to react or failure to get noticed.

First I would have liked to have read the 'letter to the editor' that CAP wrote. I imagine that it was toothless. They should have posted a copy to the CAP website. I certainly haven't seen it there or in the NYT. A lot of readers of that article probably googled 'College of American Pathologists' and landed on their last-century website. Their response (letter to the editor, an essay by a prominent pathologist, a vote of confidence to the members, a dirty limerick, do something for the love of god) to the article should have been front page. Currently their response (in addition to the single email) is in tiny text on the right-hand side under the 'News' category. It's the 'FAQs on this issue.' Really? Click the link and 'boom' now I'm downloading a .pdf file (that's web-usability 101 failure) that is 100% text. Any reason why that's not in html on your website folks? I don't want to download a pdf to read your 'news.' The 'FAQs' are clearly not intended for the lay-public, it's only intended for CAP members. (And by the way this 'certificate' program sounds as bad as advertised except for that you don't have to actually sign-out 250 breast cases, you just have to touch glass on 250 which is doable for me at least - not that I'm paying to play) So there has been no follow-up with emails and no further outreach to due-paying members.

Their response to getting kicked in the ball-sac in the NYT: send a 250 word email and head out for happy-hour.

2. Brand (recapitulating everything raider wrote):

For all of the 'Pathology in Transformation' or whatever newspeak that CAP is touting, they really dropped the ball on the current situation. They should have turned this into an opportunity to push an aggressive rebranding of the profession in the eyes of our patients and our clinical colleagues. So instead of the impotence of their response they could have:

- written a response to our patients detailing everything that we do to make sure they get high quality care. Standards, accuracy, all tissue diagnosis, etc. Not just directing folks to your crappy mybiopsy.org site... no one cares about that.
- written a response to our clinical colleagues detailing the controversies in proliferative breast lesions, our commitment to high-quality diagnosis, etc etc
- written a response to pathologists that tells me why I should care about anything that CAP does, why I should give them any dues at all because I am struggling to find any reason at all currently.

And put it online so that it's easy to find (eg. press release section of your site).

The public perception of pathologists (if they know anything about us at all) is that we're basement-dwelling lab geeks with a vague air of necrophilia. This article makes all of us look incompetent on top of that. CAP's impotent response (if you can even call it a response) does not to help us forward the profession in the eyes of patients or our clinical colleagues or lawmakers.

Medicine is going to be climbing into the gladiator pit in the next decade to figure out what the future landscape will look like post-health reform. Is CAP really going to be the organization fighting for pathology's piece of the pie? If so, god help us all.

Edit:

Here's the Newsweek article from the same day (Not that anyone reads Newsweek).

Lay Press said:
To reduce the odds that you're misdiagnosed, start by asking about the credentials of the pathologist who first reviewed your results, and whether he or she is a breast specialist. The College of American Pathologists is preparing to certify pathologists who review at least 250 breast biopsy results a year.
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Those 2 sentences spell it out: CAP does not believe board-certified pathologists are good enough to read routine breast cases.

This is the message that the public is getting from CAP by their silence.

DCIS is a routine, common diagnosis that any board-certified pathologist should be able to accurately diagnose in every biopsy, every day. ADH is more controversial, even among experts. Asserting that community pathologists are not good enough to read out routine breast cases is tantamount to suggesting that they are not good enough to read any and all routine cases. That's my reading of that sentence, and I'm sure the reading of any surgeon or clinician or patient.

That is why CAP gets an 'F' on their handling of this disaster.
 
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I have to agree with the above comments on how CAP has handled this situation.
 
It is also hard when pathologists at recognized institutions proclaim in the nations foremost newspaper that all pathologist which they trained are incomptent to practice pathology except for a select few at us news and world report hospitals. I guess they are driving their own agenda and looking out for their own economic well being and justifying their existence and career decisions they made.
 
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Yet another completely rational post by pathstudent.

Agree with the above; CAP has done the specialty a disservice here.
 
malchik said:
Yet another completely rational post by pathstudent.
Click to expand...

Is that sarcasm? I get so much derision, I can't tell the difference.

But I am serious if you look at the comments to the article and some comments in the article, I am correct. The pathologist from MDA said all DCIS and Invasive cancer cases should be reviewed by her. To me that is a bit of a joke as from what I saw in residency, rarely is a breast biopsy ever a diagnostic dilemma. It is not like it is a medical skin biopsy, liver biopsy, lymphoma, medical brain biopsy, medical lung, kidney biopsy or a bone marrow biopsy, where you need to be an intelligent well trained pathologist to give a good answer. Breast biopsies are like prostate biopsies. They are either almost alwasy obviously benign or obviously malignant and you can always do those myoep stains if you cannot decide if it is DCIS with SA versus DCIS with IDC. Those rare times where you cannot decide if it is UDH or ADH, then send it out to true authority in breast (i.e. someone who has written a textbook and not the woman from MDA who I never heard of until the article. I heard of Page, Schnidt, Tavossoli, Rosen, Lester, but not some random junior faculty at MDA).
 
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No sarcasm, just pointing out that some of your recent posts have been uncharacteristically reasonable. Though it does seem clear that you intentionally provoke the derision. Carry on.
 
FYI
Here is an ABP letter to the editor of the NYT that a colleague forwarded me. I have no idea where they got it from because the ABP's circa 1995 geocities-esque webpage is near-unnavagable; it may be a total forgery.

Apparently, ABP is about to prison-shank CAP in a turf war (answer the questions at the end for 2 SAM credits):

Betsy Bennet said:
To the Editor:

The trustees of the American Board of Pathology (ABP) have reviewed the article “Earliest Steps to Find Breast Cancer Are Prone to Error” in Tuesday’s NY Times. This article points out the difficulty of making a diagnosis of ductal carcinoma-in-situ, especially when a pathologist evaluates relatively few breast biopsies per year and when the pathologist is not board-certified. The article also provides comments from several pathologists who are representing the College of American Pathology (CAP) which offers a “voluntary certificate” program for pathologists who sign out breast tissue. The ABP encourages such continuing educational programs offered by the CAP, the United States and Canadian Association of Pathologists, the American Society for Clinical Pathology, and other pathology societies to enhance the ability of all pathologists to sharpen their diagnostic skills. As a member of the American Board of Medical Specialties (ABMS), however, the ABP is the only nationally recognized certifying organization for pathologists in the United States.

All physicians trained in anatomic pathology are taught breast pathology as part of their educational program and those who are certified by the ABP are tested on aspects of breast pathology on their certification examination. Ductal carcinoma-in-situ of the breast occurs in many patterns and may be a very difficult diagnosis even for a recognized expert in breast pathology. As with any type of medical problem in any specialty, the more experience that one has with a particular disease, the more able one becomes at recognizing it in all of its forms. Referring patients or challenging biopsies from patients for a second opinion is a common practice designed for the patient’s welfare if the referring physician has any question or discomfort about the diagnosis. Similarly, patients should not hesitate to ask about the experience and board certification of their physicians, including pathologists, and request a second opinion if one would help them feel more comfortable.

The Maintenance of Certification program sponsored by the ABP as a member of the ABMS will help practicing pathologists to maintain competency in all areas of their practice including new approaches to the diagnosis of ductal carcinoma-in-situ of the breast. This program includes continuing medical education courses, self-assessment courses, participation in activities that assure the quality of one’s practice, and an examination geared toward advancements in the field since the pathologist was last certified. Participation is mandatory for pathologists who completed training in 2006 or later, and the program will also be open to all other pathologists as well.

It will never be possible to eliminate errors or disagreements in diagnosis and management of patients, as much as we would like to be able to do so. The best hope of minimizing these errors and disagreements is to make sure that pathologists and other physicians are keeping up with new developments and practicing quality medicine. This is the aim of all ABMS Maintenance of Certification® programs. The ABP takes this activity very seriously and will be diligent about enforcing provisions of the program and encouraging all of its diplomates to take part.


Betsy D. Bennett, M.D., Ph.D.
Executive Vice President
American Board of Pathology
Click to expand...
 
Interesting... thanks. Be nice to know for sure if this is real, but it certainly looks like it.
 
I thought this was a poor article. The impetus behind it was sound - that DCIS diagnosis is frought with controversy and that pathologists need to be better at it. Unfortunately the article completely misses several things, including what the patient's diagnosis actually was and what the "real diagnosis" was determined to be. There is even terminology about the architecture of the lesion, which is completely unhelpful especially in the context of the rest of the article. The last page of the article was interesting in that the experts said the disagreement was reasonable and it was a difficult distinction. Yet that doesn't matter - it has to be "cancer" or "not cancer" or otherwise the public won't listen. What was the "benign condition"? Was it florid hyperplasia? Or was it ADH that bordered on DCIS?

The board-certification status of the pathologist is emphasized, which is a crucial point mostly to lawyers and hospital administrators but probably has very little bearing on the accuracy of the diagnosis. Subspecialization can help in difficult cases but there have been many studies in other areas of pathology (specifically in GI path and GYN path) about how subspecialists often do no better than generalists when it comes to gray-area lesions.

There was also absolutely nothing in the article about the concept of ADH, the overlap between DCIS and ADH, and how there may be a continuum in many cases. It is typical media whitewashing of important facts which get in the way of a simpler story and confuse the matter for the public. The problem is that the truth is not always simple, which is why doctors exist and why specialists exist, and why textbooks and papers are written.

The breast pathology community also contributes to this nonsense - there is so much fighting and backstabbing. Experts publish articles specifically disagreeing with other experts. Which are right? Does it matter? It certainly does to the patient! Pathology needs to get better at defining "gray area" diagnoses and making it clear that not everything is able to be placed into a specific category. Hemepath is getting better at this. Breast path is terrible with this, especially because once you place the patient into a specific category the treatments radically change.
 
Isn't this similar to radiologists who do fellowships to become subspecialists?
 
KCShaw said:
Interesting... thanks. Be nice to know for sure if this is real, but it certainly looks like it.
Click to expand...

According to someone on the ABP, Dr. Bennett did indeed write a letter to the NYT. I don't know if this is that letter, but I assume that it is, based on the description that I heard.
 
An article in the July 19, 2010, New York Times (“Prone to Error: Earliest Steps to Find Cancer”), has revealed a very real issue but in our opinion has focused on only a small part of the problem.

While it may be true that even well-trained individuals may occasionally make an interpretive error when reading biopsies, the bigger issue is that even for experts there are a variety of borderline or gray-zone lesions that diagnostically are not very reproducible, not only in breast pathology, the focus of this article, but in other areas of diagnostic pathology as well. And these variations are not so much error but rather a biologic reality reflecting the limits of differential diagnosis.

Our understanding of this reality has only recently been clarified. In reality, things are really not as black and white as clinicians or patients may like.

It is not pathologist error or misdiagnosis that is the major problem; it’s really a biological problem that sometimes gets clinically mishandled. Specifically, many clinicians think, as stated in this article, that two breast lesions that are very similar under the microscope are biologically distinct. But the reality is that they are probably not distinct and are only subtly different. Therefore, patients with one of these diagnoses should not be treated in radically different ways as some of the patients featured in the article were.

Furthermore, the article mixes the impression of invasive cancer with something that is not cancer yet, if ever—the concept of precancer or carcinoma in situ. Even in the article, the experts allude to this bigger issue (i.e., ductal carcinoma in situ [DCIS] in California is not the same as in Boston, there are different size criteria, etc.) but focus on the idea that the pathologist is in error, when in fact the interobserver variability is due to the fact that, biologically, these borderline diagnoses, such as atypical ductal hyperplasia (ADH) and some types of DCIS, are much more similar than different and therefore can be extremely hard to separate even for experts.

While subspecialty education and, more importantly, second opinions can help minimize these diagnostic variations, education or certification, or both, will not eliminate it for the subspecialty of breast pathology or any other. Rather, diagnostic medicine should acknowledge the issue and realities of some borderline (subjective) diagnoses and modify their approaches to patient therapy that have diagnoses in these gray zones. Or to put it plainly, the idea that the clinicians so radically treat low-grade DCIS as opposed to ADH is just as much a part of the problem raised by the New York Times article as any perception of pathology error.
 
pathstudent said:
http://www.nytimes.com/2010/07/20/health/20cancer.html?src=me&ref=homepage

Great article and warning to all women who had their biopsies seen outside of large academic medical centers.

Interesting that they talk about requiring pathologists to be CAP certified breast patholgists. Those CAP certifications will be a good substitute to subspecialty boards and also fair to those who haven't done a fellowship as experience can qualify you. However, if they require a minimum of 250 breast biopsies a year by the applying pathologist that will be hard for many community groups. Think about it, if you are in with 4 people, your group will need over a 1000 a year for the pathologists to be eligible.
Click to expand...

I have heard breast pathologists talking about this 'breast certificate' (hehe sounds funny) already two years ago. The NYT article was not a catalyst in any way of this development.

For better or worse, pathology is becoming more and more subspecialized...
 
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