Radiology/Pathology Merger

[Enkidu]

I recently came across some articles talking about a merger of pathology and radiology into a great specialty called "diagnostic medicine". My impression was that this was entirely impractical and would never happen... Of course, what would I know? Have any of you heard about this kind of theoretical merger and/or have an opinion about its feasibility?

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[2121115]

Given what I know about pathologists and radiologists...

It would not be so much a merger but more like radiology taking over what we do and giving us the boot.


However, I don't see it happening. If anything radiology will push the in vivo imaging and decrease the number of biopsies by a few here and there.

 

[pathstudent]

Yeah like in five years we will work along side TSA agents at the airport and look for dysplasia in the bowels, cervixes, pancreases and GI tracts of the unknowing public as they get screened.

 

[pathstudent]

Given what I know about pathologists and radiologists...

It would not be so much a merger but more like radiology taking over what we do and giving us the boot.


However, I don't see it happening. If anything radiology will push the in vivo imaging and decrease the number of biopsies by a few here and there.

Or it could generate a few more biopsies.

 

[2121115]

Or it could generate a few more biopsies.

It definitely could. I agree.

 

[Substance]

If it does happen, it will consist of radiology reading their own biopsies through IR. The paps and surgical resections and all the other crap will stay with path.

 

[Enkidu]

Well, I was thinking that somehow the training for the two would also be combined... I'm not sure how that would work out time-wise, but it seemed that the idea was that radiology and pathology were converging with molecular imaging techniques and that they should become a single specialty called "Diagnostic Medicine".

 

[Substance]

Well, I was thinking that somehow the training for the two would also be combined... I'm not sure how that would work out time-wise, but it seemed that the idea was that radiology and pathology were converging with molecular imaging techniques and that they should become a single specialty called "Diagnostic Medicine".

The molecular imaging techniques will be a cash-cow for the rads, and rest assured they will not let path within ten miles of it.

Nobody in path will argue with that because most pathologists do not know enough english.

Since immunophenotype will be delineated through imaging, paths will basically stick to things that are entirely based on micro and gross, like cytology and staging. Sounds like a potentially boring future for path.

 

[green mantis]

My co-residents & I often bantered about a similar idea when we rotated at the VA. At our VA, pathology & radiology were under the auspices of the diagnostic & molecular medicine group. The residents from both specialties attended many of the same conferences.

My idea wasn't to merge the 2 fields into one residency but to offer a combined residency, like Med-Peds. It would be call Rad-Path. You could be fully trained in both areas in 6-7 years & be eligible for fellowships in both. Just think of the possibilities! I would've done this residency if it existed since I also like radiology.


----- Antony

 

[pathstudent]

The molecular imaging techniques will be a cash-cow for the rads, and rest assured they will not let path within ten miles of it.

Nobody in path will argue with that because most pathologists do not know enough english.

Since immunophenotype will be delineated through imaging, paths will basically stick to things that are entirely based on micro and gross, like cytology and staging. Sounds like a potentially boring future for path.

If they can immunophenotype and classify tumors, then I imagine they can stage them too.


But don't forget about autopsies, we will always have those.

 

[levels x3]

Nope...The military has been working on virtual autopsies using high-dose CT scans. We'll lose those too.

 

[Parts Unknown]

My idea wasn't to merge the 2 fields into one residency but to offer a combined residency, like Med-Peds. It would be call Rad-Path. You could be fully trained in both areas in 6-7 years & be eligible for fellowships in both. Just think of the possibilities!

The only possibility that comes to my mind is this:

"To do two things a once is to do neither."
- Publilius Syrus, 1st century B.C.

 

[Oluwadi]

The only possibility that comes to my mind is this:

"To do two things a once is to do neither."
- Publilius Syrus, 1st century B.C.

Does this quote apply to the AP-CP paradigm? Afterall, there are areas of overlap between AP and CP, just as there are between Pathology and Radiology, as well as between Medicine and Pediatrics.

Your quote seems to suggest we all do either AP or CP (which in the spirit of full disclosure, is my preference).

 

[Oluwadi]

My idea wasn't to merge the 2 fields into one residency but to offer a combined residency, like Med-Peds. It would be call Rad-Path.


----- Antony

Why not Path-Rad?!

 

[Parts Unknown]

Does this quote apply to the AP-CP paradigm?

Certainly. I have no doubt that AP-only and CP-only residents get more bang for the buck. I would venture that for most private practice pathologists the main benefit of CP training/certification is that it prevents us from having to cede the clinical lab to PhDs.

Afterall, there are areas of overlap between AP and CP, just as there are between Pathology and Radiology, as well as between Medicine and Pediatrics.

I don't see any realistic way to compare Med-Peds with a Rad-Path construct. Family practice physicians already routinely see a full age range of patients in outpatient practice. However, it is very difficult to become and remain a competent pathologist, just like it is very difficult to become and remain a competent radiologist. Hell, it's hard enough to remain current in general AP and hematopathology!

Combine the training and the end product isn't going to be some hybrid superdiagnostician. I would be either a pathologist with an unusually high knowledge of radiology, a radiologist with an unusually high knowledge of pathology, or someone who isn't fully capable of doing either. Not a great outcome for an extended residency plus fellowship.

 

[Oluwadi]

Certainly. I have no doubt that AP-only and CP-only residents get more bang for the buck. I would venture that for most private practice pathologists the main benefit of CP training/certification is that it prevents us from having to cede the clinical lab to PhDs.

I don't see any realistic way to compare Med-Peds with a Rad-Path construct. Family practice physicians already routinely see a full age range of patients in outpatient practice. However, it is very difficult to become and remain a competent pathologist, just like it is very difficult to become and remain a competent radiologist. Hell, it's hard enough to remain current in general AP and hematopathology!

Combine the training and the end product isn't going to be some hybrid superdiagnostician. I would be either a pathologist with an unusually high knowledge of radiology, a radiologist with an unusually high knowledge of pathology, or someone who isn't fully capable of doing either. Not a great outcome for an extended residency plus fellowship.

Agreed!

 

[gbwillner]

Why not Path-Rad?!

You've got to admit "Rad Path" sounds better.

 

[green mantis]

Combine the training and the end product isn't going to be some hybrid superdiagnostician. I would be either a pathologist with an unusually high knowledge of radiology, a radiologist with an unusually high knowledge of pathology, or someone who isn't fully capable of doing either. Not a great outcome for an extended residency plus fellowship.

I wouldn't expect the end product to be a super diagnostician, just like I wouldn't expect the end product of Med-Peds to be a super clinician. The resident will probably choose either pathology or radiology somewhere down the road. None of the Med-Peds people I know see both adults & kids. The ones that have done a fellowship usually take one path or the other, so to speak.


----- Antony

 

[Oluwadi]

You've got to admit "Rad Path" sounds better.

I suppose so......

 

[Parts Unknown]

I wouldn't expect the end product to be a super diagnostician,

You just sounded rather ebullient when you said "Just think of the possibilities!"

The resident will probably choose either pathology or radiology somewhere down the road.

So, you are positing a 6-7 year long combined training program so that trainees can eventually make a choice they should have made in medical school. You will have to forgive my skepticism.

 

[Oluwadi]

Ok, here is a two-part compromise:
1. Each specialty could permit trainees from the other specialty to take elective postings in their specialty.
2. Each specialty could also recognize electives taken in the other specialty as valid postings that will count towards meeting the requirements for board certification.

 

[Enkidu]

I think it would make sense if either radiology or pathology could do a common subset of fellowships (like molecular imaging) and to just have the departments combine for economy of scale. This would allow some of those big radiology bucks to hit the lab.

 

[2121115]

This would allow some of those big radiology bucks to hit the lab.

One reason of many that it won't happen.

 

[pathstudent]

One reason of many that it won't happen.

Let's face it. Pathologists are 2015s syphillisologists.

Osler once said, "know syphiiis and you shall know all of medicine". Goes to show you what he knew.

 

[lipomas]

Yeah good luck with this merger. I don't think I can think of any specialties which have merged in the recorded history of medicine, although there may be some. What happens instead is things keep branching off. And now we have specialties that would have been unthinkable 50 years ago. PM&R? Med-Peds? No way Osler could have comprehended that. Radiology and pathology are not going to merge in the near future. Pathology is no closer to disappearing than any other field is. I would think radiology is the closest to disappearing anyway - with the advent of digital images every doc can look up their own films and interpret them on their own. But have radiologists gone away? No, they are proliferating! And wouldn't you think that computer-assisted diagnosis would be much more of a threat in radiology that in pathology? Pathology images are thousands of times more complex and detailed than radiology images, yet the sky-is-falling crowd on these forums would have you believe that pathology is more threatened.

Look - technology is changing medicine. We all have to be prepared. But being prepared does not mean entrenching yourself and fighting off all comers. It means being familiar with things, up on technological advances, and being among the first to integrate important tasks.

If pathology is replaced by full body high-capability imaging systems then why the hell would radiologists need to exist either? I swear, people on these forums are a little thick sometimes. It's like you try to have your paranoia just the way you want it.

I tell you what though - when doctors are replaced by robots and computers the first that are going to be up against the wall are the luddites and the paranoid.

 

[pathstudent]

Yeah good luck with this merger. I don't think I can think of any specialties which have merged in the recorded history of medicine, although there may be some. What happens instead is things keep branching off. And now we have specialties that would have been unthinkable 50 years ago. PM&R? Med-Peds? No way Osler could have comprehended that. Radiology and pathology are not going to merge in the near future. Pathology is no closer to disappearing than any other field is. I would think radiology is the closest to disappearing anyway - with the advent of digital images every doc can look up their own films and interpret them on their own. But have radiologists gone away? No, they are proliferating! And wouldn't you think that computer-assisted diagnosis would be much more of a threat in radiology that in pathology? Pathology images are thousands of times more complex and detailed than radiology images, yet the sky-is-falling crowd on these forums would have you believe that pathology is more threatened.

Look - technology is changing medicine. We all have to be prepared. But being prepared does not mean entrenching yourself and fighting off all comers. It means being familiar with things, up on technological advances, and being among the first to integrate important tasks.

If pathology is replaced by full body high-capability imaging systems then why the hell would radiologists need to exist either? I swear, people on these forums are a little thick sometimes. It's like you try to have your paranoia just the way you want it.

I tell you what though - when doctors are replaced by robots and computers the first that are going to be up against the wall are the luddites and the paranoid.

I remember reading about a computer program that was being developed by Yale Interntists that would take your history and other information and try to give you a diagnosis. The Yale people claimed it would be used widespread in the future. Shows you what they know.

 

[pathstudent]

Yeah good luck with this merger. I don't think I can think of any specialties which have merged in the recorded history of medicine, although there may be some. What happens instead is things keep branching off. And now we have specialties that would have been unthinkable 50 years ago. PM&R? Med-Peds? No way Osler could have comprehended that. Radiology and pathology are not going to merge in the near future. Pathology is no closer to disappearing than any other field is. I would think radiology is the closest to disappearing anyway - with the advent of digital images every doc can look up their own films and interpret them on their own. But have radiologists gone away? No, they are proliferating! And wouldn't you think that computer-assisted diagnosis would be much more of a threat in radiology that in pathology? Pathology images are thousands of times more complex and detailed than radiology images, yet the sky-is-falling crowd on these forums would have you believe that pathology is more threatened.

Look - technology is changing medicine. We all have to be prepared. But being prepared does not mean entrenching yourself and fighting off all comers. It means being familiar with things, up on technological advances, and being among the first to integrate important tasks.

If pathology is replaced by full body high-capability imaging systems then why the hell would radiologists need to exist either? I swear, people on these forums are a little thick sometimes. It's like you try to have your paranoia just the way you want it.

I tell you what though - when doctors are replaced by robots and computers the first that are going to be up against the wall are the luddites and the paranoid.

Seriously. How the hell is a radiologist going to be able to tell the difference between a sessile serrated adenoma and a hyperplastic polyp, or an atypical leiomyosarcoma vs a low grade leiomyosarcaoma?

What we need to do in pathology is too further convolute neoplastic classification and come out with a bunch of studies that claim it is meaningful.

Seriously I just read a paper in the AJSP about e-cadherin positive Invasive Lobular Carcinomas and another paper about e-cadherin negative ductal carcinomas. How the hell is a radiologist going to figure that out. Seriously by creating a bunch of BS diagnoses, we can save ourselves.

 

[Entgegen]

Seriously by creating a bunch of BS diagnoses, we can save ourselves.

This actually made me lol.

 

[KCShaw]

I remember reading about a computer program that was being developed by Yale Interntists that would take your history and other information and try to give you a diagnosis. The Yale people claimed it would be used widespread in the future. Shows you what they know.

I believe it is now call the Inter-Websnet. I hear it's just a fad, though. Who in their right mind would give up waiting rooms, gowns that won't close, fighting with insurance companies, and physical examination from a stranger in a dingy white coat, to just do it themselves and ask the Inter-Websnet for answers?

 

[pathstudent]

It is not hard to imagine radiology greatly altering surgery and pathology. Radiology has done more to alter the face of medicine the last 40 years than any other field. Angiograms, PET-scans, MRI, Image Guided biopsies... There are very smart people developing the technology. it should be embraced because ultimately it is better for patients and that is what medicine is about. It is not about making sure pathologists maintain their lifestyle. If a few cancers can be diagnosed and treated without ever making an H&E slide, so be it. Pathology is changing too, and there will still be a huge roll for pathologists for the foreseeable future, and clearly things like Hemepath and Dermpath won't be affected by any of this.

 

[wild0ne]

What we need to do in pathology is too further convolute neoplastic classification and come out with a bunch of studies that claim it is meaningful.

Pretty funny post.

 

[2121115]

What we need to do in pathology is too further convolute neoplastic classification and come out with a bunch of studies that claim it is meaningful.

Sincerely, hematopathology.

 

[zao275]

Yeah like in five years we will work along side TSA agents at the airport and look for dysplasia in the bowels, cervixes, pancreases and GI tracts of the unknowing public as they get screened.

Brilliant idea, pathstudent!

 

[Cruzinman]

Radiologists work in the dark. Pathologists see the light.

 

[Enkidu]

So I recently ran into a guy in my medical school who was applying in radiology. Apparently he had done some research on a nuclear medicine test that could detect renal cell carcinoma. I guess it used radioactive antibodies or something. He seemed to think that this would be a big problem for pathology in the future. It seems like a lot of the people on this forum think that too.

But how could it? That nuclear study is worse than a biopsy in nearly every way. It's an invasive test that requires injecting radioactive antibodies to react in a patient's kidneys. I'm sure it's incredibly expensive, compared to a glass slide, and all it gives you is a yes or no to RCC. If the patient is negative after his super scan, he just has to get a biopsy anyway. And in any case, there will necessarily be more misdiagnoses by a system that relies entirely on immunophenotype to diagnose a cancer.

Now, in a patient with pathologically confirmed RCC, this study might be amazing for staging and determining response to treatment, and maybe for lesions that can't be biopsied it would be better than nothing, but in the vast majority of cases I can't imagine that it would replace tissue diagnosis.

 

[mlw03]

If I were a diagnostic pathologist, this wouldn't worry me. Surgeons don't want to operate without a definitive diagnosis. Nephrectomy without tissue diagnosis --> no tumor --> huge lawsuit. Like you said, sounds like such a test could have some value in detecting recurrence.

So I recently ran into a guy in my medical school who was applying in radiology. Apparently he had done some research on a nuclear medicine test that could detect renal cell carcinoma. I guess it used radioactive antibodies or something. He seemed to think that this would be a big problem for pathology in the future. It seems like a lot of the people on this forum think that too.

But how could it? That nuclear study is worse than a biopsy in nearly every way. It is still an invasive test, since it involves injecting radioactive antibodies into a persons body that are meant to react in their kidneys. I'm sure it's incredibly expensive, compared to a glass slide, and all it gives you is a yes or no to RCC. If the patient is negative after his super scan, he just has to get a biopsy anyway. And in any case, there will necessarily be more misdiagnoses by a system that relies entirely on immunophenotype to diagnose a cancer.

Now, in a patient with pathologically confirmed RCC, this study might be amazing for staging and determining response to treatment, and maybe for lesions that can't be biopsied it would be better than nothing, but in the vast majority of cases I can't imagine that it would replace tissue diagnosis.

 

[WEBB PINKERTON]

So I recently ran into a guy in my medical school who was applying in radiology. Apparently he had done some research on a nuclear medicine test that could detect renal cell carcinoma. I guess it used radioactive antibodies or something. He seemed to think that this would be a big problem for pathology in the future. It seems like a lot of the people on this forum think that too.

But how could it? That nuclear study is worse than a biopsy in nearly every way. It's an invasive test that requires injecting radioactive antibodies to react in a patient's kidneys. I'm sure it's incredibly expensive, compared to a glass slide, and all it gives you is a yes or no to RCC. If the patient is negative after his super scan, he just has to get a biopsy anyway. And in any case, there will necessarily be more misdiagnoses by a system that relies entirely on immunophenotype to diagnose a cancer.

Now, in a patient with pathologically confirmed RCC, this study might be amazing for staging and determining response to treatment, and maybe for lesions that can't be biopsied it would be better than nothing, but in the vast majority of cases I can't imagine that it would replace tissue diagnosis.

Nuclear medicine is known as Unclear medicine where i work. Causes more biopsies than it prevents, which makes me very thankful. I am curious to see what General Electric has in the works. They own Clarient now and I could see them coming up with some invivo diagnostics to replace biopsies.

 

[caffeinegirl]

If I were a diagnostic pathologist, this wouldn't worry me. Surgeons don't want to operate without a definitive diagnosis. Nephrectomy without tissue diagnosis --> no tumor --> huge lawsuit. Like you said, sounds like such a test could have some value in detecting recurrence.

At our institution, the urologists routinely perform nephrectomies without a tissue diagnosis. The imaging is diagnostic for renal cell carcinoma (ie. exophytic mass without fat usually seen on CT) and the patient undergoes radical or partial nephrectomy (the latter usually with intraop pathology gross or frozen to detect margins). Biopsies of renal malignancies, at least in our institution, are not routinely performed...and weren't performed routinely where I trained either.

 

[Enkidu]

At our institution, the urologists routinely perform nephrectomies without a tissue diagnosis. The imaging is diagnostic for renal cell carcinoma (ie. exophytic mass without fat usually seen on CT) and the patient undergoes radical or partial nephrectomy (the latter usually with intraop pathology gross or frozen to detect margins). Biopsies of renal malignancies, at least in our institution, are not routinely performed...and weren't performed routinely where I trained either.

How often does this result in a misdiagnosis uncovered after the resection? Also, in these cases is treatment or prognosis altered by any histological or immunophenotype findings in rcc?

 

[caffeinegirl]

How often does this result in a misdiagnosis uncovered after the resection? Also, in these cases is treatment or prognosis altered by any histological or immunophenotype findings in rcc?

Rarely does this result in a misdiagnosis (ie. benign lesion upon resection). The benign resected cases sometimes are oncocytomas or very rarely encapsulated hemorrhage. There are different subtypes of renal cell carcinoma (clear cell, papillary, translocation associated etc) which have different prognoses. With the advent of the Da Vinci, laparoscopic partial nephrectomies are commonly performed for lesions up to approximately 5-8 cm (depending on location), which have less morbidity (per our urologists).

 

[mlw03]

You say "rarely" is there a benign lesion upon resection. What do you think the outcomes are in these cases, and why do the urologists risk even the small chance of this happening? This is obviously getting a bit off-topic, but I just don't understand why send someone for major surgery when a biopsy or FNA could provide a definitive diagnosis.

 

[caffeinegirl]

I'm not sure about the risk benefit analysis for biopsy or FNA of renal lesions. I was just relating the experience that I have in two institutions (both academic and private). As far as I know based on anecdotal evidence, interventional radiology doesn't like to biopsy renal tumors due to the high risk of bleeding.

 

[TMZ2007]

Agree, we *rarely* get pre-op, diagnostic kidney biopsies for tumor/mass at our program. Radiology makes a prelim dx of RCC/TCC/whatever and the kidney just comes out. Very rarely (twice a year?), we get a intraop renal frozen for diagnosis, at which point if benign, the nephrectomy stops. We get ureter margins for frozen just about every case, even if the tumor is >5cm away.

None of this makes much sense to me. Is there something preventing routine diagnostic renal mass biopsy (eg, risk of bleeding)?

 

[caffeinegirl]

A quick search yielded a study from Mayo Clinic (Anatomic Path dept), which likely is the reason that masses aren't biopsied as routine care, given that the nondiagnostic rate is similar for 18G core biopsies and CT imaging (20% and 31%) with low specificity.

Dechet CB, Zincke H, Sebo TJ, et al. Prospective analysis of computerized tomography and needle biopsy with permanent sectioning to determine the
nature of solid renal masses in adults. J Urol 2003; 169:71–74

Also found one paper advocating FNA's prior to RFA for small lesions, in which benign FNA diagnosis was seen in less than 5% of lesions that where diagnosed as RCC by CT or MRI features, with an approx 12% nondiagnostic rate. They conclude that .."as a routine component of the workup and treatment of the small renal mass with typical imaging features of malignancy, the added utility of the biopsy has not been established."

AJR Am J Roentgenol. 2007 Jun;188(6):1500-5.
CT-guided biopsy for the diagnosis of renal tumors before treatment with percutaneous ablation.
Heilbrun ME, Zagoria RJ, Garvin AJ, Hall MC, Krehbiel K, Southwick A, Clark PE.

 

[Enkidu]

Agree, we *rarely* get pre-op, diagnostic kidney biopsies for tumor/mass at our program. Radiology makes a prelim dx of RCC/TCC/whatever and the kidney just comes out. Very rarely (twice a year?), we get a intraop renal frozen for diagnosis, at which point if benign, the nephrectomy stops. We get ureter margins for frozen just about every case, even if the tumor is >5cm away.

None of this makes much sense to me. Is there something preventing routine diagnostic renal mass biopsy (eg, risk of bleeding)?

This is a pretty interesting discussion to me. So it seems like a new nuclear test that was "specific" for renal cell carcinoma wouldn't affect pathology at all. It would only be at the expense of a CT study. But this situation is apparently due to poor accuracy of needle biopsies, so a better histochemical marker could very well replace this CT study.

 

[Tiki]

Rarely does this result in a misdiagnosis (ie. benign lesion upon resection). The benign resected cases sometimes are oncocytomas or very rarely encapsulated hemorrhage. There are different subtypes of renal cell carcinoma (clear cell, papillary, translocation associated etc) which have different prognoses. With the advent of the Da Vinci, laparoscopic partial nephrectomies are commonly performed for lesions up to approximately 5-8 cm (depending on location), which have less morbidity (per our urologists).

Same here, we don't get a biopsy unless they plan to ablate the tumor and then they'll biopsy it before hand. Otherwise we just get the nephrectomy specimen.

 

[scienceguy19]

if we merged with radiology, would pathologists be their equals?

would we be the doctor's doctor?

or would we be the doctor's b****?

Same here, we don't get a biopsy unless they plan to ablate the tumor and then they'll biopsy it before hand. Otherwise we just get the nephrectomy specimen.

 

[lipomas]

Wait - so you're worried about pathology's future on a niche clinical test which would avert a biopsy or resection in about 5% of the cases that currently are biopsied, and provide no additional information in the 95% of cases that are? Are you high?

If you want to worry about something, worry about reimbursement. Or worry about large reference labs somehow managing to make a profit despite providing many services for free and providing kickbacks to clinicians.

Pathology isn't going anywhere for awhile. Yes, there is a digital future which is going to change things. But I think any changes will be seen in radiology before they are seen in pathology. Digital imaging in radiology hasn't hurt them at all, has it. Nobody is going to merge until many years in the future when every doctor either becomes a glorified technician or signs off on what the robot tells them. At that point, since every other worker in this country other than politicians will have been replaced also, then the systems will be in place to make sure we don't suffer any more.

However, reimbursement is likely to continue to gradually decrease more and more.