Survive without a hematopathologist?

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Rural community hospital gets 2-3 bone marrows/month and about 5 peripheral bloods. Ability to send things out. It' seems most hematopathologists don't do a lot of general surgpath/cytology. 3 person group. how would you staff it?

a. 3 - general surgical pathologists
b. 2 - general and 1 hemepath

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A. for sure. Unless you've got a pissy heme/onc group that demands you to perform the bx's. Most rural community hospitals don't have much local heme/onc/radiation coverage anyway. We send our onc to the larger regional groups. It's certainly not low-hanging fruit considering the volume. I could easily perform 3-5 bone marrow biopsies a month, but thankfully I am busy enough with a general surg path volume to have zero interest in heme.
 
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Why not 2 general + 1 cyto? Even if you did have good cytotechs, that would be just as useful for non-gyns and even moreso if you did ROSE.

There's only 30 marrows/yr. I covered a small community hospital with exactly that amount and we decided it wasn't worth the revenue, so we sent them all out to a reference lab. As far as the 5 bloods/mo., that doesn't need a hemepath on staff. It should be basic enough for anyone who went to a halfway decent residency program.

Regardless, I don't think the volume is high enough which would necessitate having a particularly subspecialty on site. It really doesn't matter how you staff it as long as all three pathologists are competent and can do the bread & butter as well as cover whenever one person is on vacation.
 
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It depends on how much you like Heme.
Lots of non-fellowship trained punt these.
Other groups read them all.
 
Rural community hospital gets 2-3 bone marrows/month and about 5 peripheral bloods. Ability to send things out. It' seems most hematopathologists don't do a lot of general surgpath/cytology. 3 person group. how would you staff it?

a. 3 - general surgical pathologists
b. 2 - general and 1 hemepath

Why would you not do B if the Hemepath person also signed general surg/cyto?

Here is the problem: There is a list of medical malpractice pitfalls for small groups. They include the usual suspects such as melanoma vs. atypical nevus, breast ADH vs. DCIS, prostate carcinoma vs. atrophy but also includes several heme entities such as Dx of APL specifically, identification of peripheral blasts etc.

Of ALL the pitfalls, the one area where you cannot lean on outside consultation in a timely fashion is heme. You cannot lean on academic consultation for APL, it's too late. You cannot run global outside flow in time for pediatric blasts as that usually buys you a same day ER visit helo ride to a pediatric hospital.

You can call in air support for lots of stuff in rural pathology, but some stuff you have to man up on.
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If you generalists are weak in heme, you will fail.
 
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You don't need a hemepath fellowship to do heme. But you do need sufficient training and volume to stay on top of things. And it helps to have a point person in the group. Hemepath trained folks who are good at general path are invaluable.
 
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You don't need a hemepath fellowship to do heme. But you do need sufficient training and volume to stay on top of things. And it helps to have a point person in the group. Hemepath trained folks who are good at general path are invaluable.

Lets clarify that: You dont need ANY fellowship. None. Zero. A trainee who is highly intelligent, motivated and adaptable will succeed. As long as your training program has adequate exposure to heme in general. Not all do. Same with dermpath. Almost all big academic programs have all subspec areas in depth you can get needed exposure, some small ones do not.
 
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Why not 2 general + 1 cyto? Even if you did have good cytotechs, that would be just as useful for non-gyns and even moreso if you did ROSE.

There's only 30 marrows/yr. I covered a small community hospital with exactly that amount and we decided it wasn't worth the revenue, so we sent them all out to a reference lab. As far as the 5 bloods/mo., that doesn't need a hemepath on staff. It should be basic enough for anyone who went to a halfway decent residency program.

Regardless, I don't think the volume is high enough which would necessitate having a particularly subspecialty on site. It really doesn't matter how you staff it as long as all three pathologists are competent and can do the bread & butter as well as cover whenever one person is on vacation.

No one should be doing cytopath anymore. This isn't the 1990s. Anyone should be able to do ROSE straight out of training.

Hearing anyone recommend cytopath brings out the Thrombus in me.
 
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Lets clarify that: You dont need ANY fellowship. None. Zero. A trainee who is highly intelligent, motivated and adaptable will succeed. As long as your training program has adequate exposure to heme in general. Not all do. Same with dermpath. Almost all big academic programs have all subspec areas in depth you can get needed exposure, some small ones do not.

I can't agree more. Most areas can be done well without an extra year or two in fellowship.
Medicine is getting crazy with all the subspecialties. It is not just pathology.
 
I agree that not every group needs a hematopathologist for routine practice and most acute leukemia patients don't stay long enough to warm a cot at a community hospital. In my experience, acute leukemia patients are all instantly turfed to tertiary care centers because, as it turns out, most community oncologists don't want to deal with the headache of AML or ALL.

All that being said, if non-leukemia heme is a significant part of your practice, you're going to want a heme trained pathologist. A diagnosis of B-cell non-Hodgkin lymphoma or myeloproliferative disorder simply is not enough these days as we're increasingly being asked to put an exact name to the pathology. All of us in community practice have to remember that our heme competition is not the group next door but a national reference laboratory that will put an exact name to that pathology (whether its right or wrong is another matter entirely).
 
No one should be doing cytopath anymore. This isn't the 1990s. Anyone should be able to do ROSE straight out of training.

Hearing anyone recommend cytopath brings out the Thrombus in me.

Conceptually, you are probably right. It’s certainly not rocket science, if you have adequate experience. ROSE certainly does not require a cytopathology fellowship, a fact which should be obvious since non-MD cytotechs do lots of them.

I agree with the general sentiment that we are getting too specialized, but practically, lots of pathologists aren’t comfortable with cytology. Some jobs (such as the one I have now) explicitly require board-certified cytopathologists, and some facilities won’t allow anyone but board-certified cytopathologists to sign out cytology. Pretty much any board-certified fellowship—even neuropathology—opens doors that would otherwise remain closed. Thus, I still think cytology is a better fellowship option for most pathologists than the typical non-board-eligible surgical pathology fellowship.
 
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Conceptually, you are probably right. It’s certainly not rocket science, if you have adequate experience. ROSE certainly does not require a cytopathology fellowship, a fact which should be obvious since non-MD cytotechs do lots of them.

I agree with the general sentiment that we are getting too specialized, but practically, lots of pathologists aren’t comfortable with cytology. Some jobs (such as the one I have now) explicitly require board-certified cytopathologists, and some facilities won’t allow anyone but board-certified cytopathologists to sign out cytology. Pretty much any board-certified fellowship—even neuropathology—opens doors that would otherwise remain closed. Thus, I still think cytology is a better fellowship option for most pathologists than the typical non-board-eligible surgical pathology fellowship.

Hell, "experts" aren't real comfy with cytopathology either, based on the vague diagnoses I get when I request their help.

You get out in the real world and the typical day in cytopath is:
spending hours in endo looking at lymphocytes from 10L, 10R, 4L etc,
going down to ultrasound to look for 6 groups of follicle cells,
back to the office to sign out some fluids and paps,
heading down to CT to find a core laying on a telfa pad, which you stain up and look at only to find the radiologist could care less what you are seeing. He has put 6 more cores into formalin and called it a day.

A fellowship in cytopath is a waste of time.
 
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Hell, "experts" aren't real comfy with cytopathology either, based on the vague diagnoses I get when I request their help.

You get out in the real world and the typical day in cytopath is:
spending hours in endo looking at lymphocytes from 10L, 10R, 4L etc,
going down to ultrasound to look for 6 groups of follicle cells,
back to the office to sign out some fluids and paps,
heading down to CT to find a core laying on a telfa pad, which you stain up and look at only to find the radiologist could care less what you are seeing. He has put 6 more cores into formalin and called it a day.

A fellowship in cytopath is a waste of time.

I agree that it would be a waste of resources to have a physician spend all day triaging tissue. Why would you run your practice that way? In my facility, all of the inefficient things you mentioned are done by cytotechs or pathology technicians unless they call for our help. My RVU production on cytology is comparable to my colleagues on surgical pathology services.

I remember when I was choosing my fellowship, Jared Schwartz (former CAP president) spoke at my institution and told us that cytopathology fellowship was a waste of time. That worried me, but my personal experience has been that I have secured two different desirable, well-compensated private practice jobs I would not have been considered for without cytopathology boards, and it has juiced my career earnings considerably. The fellowship year was certainly not a waste of time, in my case.

No argument from me that cytology is 95% making **** up, hedging, and reading tea leaves. A competent general pathologist could certainly do it. Lucky for me, though, many of them won’t.
 
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Hearing anyone recommend cytopath brings out the Thrombus in me.

I never recommended doing a cytopath fellowship. I meant hiring a cytopath + 2 generalists if the volume justifies it, and/or the other 2 people are not confident in it as opposed to their heme competence. Particularly in a place with high volume cyto and low volume heme.

A fellowship in cytopath is a waste of time.

The thing I'll say that a cytopath fellowship does have going for it in term of post-fellowship marketability is: 1. Colleagues who are not confident in it and want a go-to-guy/safety net 2. Colleagues who are confident in it, but want somebody they can dump pap smears on.
 
Hell, "experts" aren't real comfy with cytopathology either, based on the vague diagnoses I get when I request their help.

Sometimes in cytology a "vague" diagnosis is the best diagnosis. Knowing when to pull the trigger or not is part of dealing with a cytology specimen, so I'm not sure why this implies your expert is not "comfy" with cytology.
 
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Hell, "experts" aren't real comfy with cytopathology either, based on the vague diagnoses I get when I request their help.

You get out in the real world and the typical day in cytopath is:
spending hours in endo looking at lymphocytes from 10L, 10R, 4L etc,
going down to ultrasound to look for 6 groups of follicle cells,
back to the office to sign out some fluids and paps,
heading down to CT to find a core laying on a telfa pad, which you stain up and look at only to find the radiologist could care less what you are seeing. He has put 6 more cores into formalin and called it a day.

A fellowship in cytopath is a waste of time.

Webb, make sure you emphasize DRY Telfa pad or, better yet, dry gauze.:boom:
 
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Interesting comments... I feel cytopath is currently the most marketable fellowship for securing a job both in academia and private practice post training.

Less and less non cyto boarded APs are signing cyto nowadays esp non-gyns. Even with the big cuts to ROSE reimbursements a lot of groups are still being asked by hospitals for MDs to cover roses and staffing accordingly (ie hospital employing the path group are making them whole for the time needed to do the roses).
 
Interesting comments... I feel cytopath is currently the most marketable fellowship for securing a job both in academia and private practice post training.

Less and less non cyto boarded APs are signing cyto nowadays esp non-gyns. Even with the big cuts to ROSE reimbursements a lot of groups are still being asked by hospitals for MDs to cover roses and staffing accordingly (ie hospital employing the path group are making them whole for the time needed to do the roses).

Im not sure Im following the logic...
1.) Gyn was a huge % of the billable CPT work for a cytopath, and its being replaced by 1st line molecular Dx
2.) FNA is becoming obsolete as onc's want tissue cores for molecular studies

yet cytopath is the most marketable, why?

What are cytopaths doing exactly in New England where they are more marketable than derm/heme/GI/GU? The "marketability" has to be lap dances because there is nothing I can think of in the CMS CPT roster that makes sense.
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Im not sure Im following the logic...
1.) Gyn was a huge % of the billable CPT work for a cytopath, and its being replaced by 1st line molecular Dx
2.) FNA is becoming obsolete as onc's want tissue cores for molecular studies

yet cytopath is the most marketable, why?

What are cytopaths doing exactly in New England where they are more marketable than derm/heme/GI/GU? The "marketability" has to be lap dances because there is nothing I can think of in the CMS CPT roster that makes sense.
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I seriously doubt it’s the most marketable, but there are still plenty of jobs out there that require or at least favor cytopath boards.

I think both the factors you mentioned are real and will eventually cut the demand, but it’s still kind of early. It varies by region, but in a lot of places Pap volumes haven’t (yet) fallen to the degree one might expect based on longer recommended screening intervals. HPV-first screening has had essentially no uptake in my part of the world. It doesn’t really have anything to do with cytology boards, but regarding #2: it’s an indiosyncracy of my institution, but here the cytopathologists handle lots of the core biopsies, and where I trained the cytology service handled 100% of image-guided core biopsies.
 
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Unless I was "doing it wrong" ...ummmm.....rapid onsite eval aka ROSE is like the worst compensated activity aside from actual medical autopsies. And to make the rose turd even more ripe, the liability on these is sky high. Rich fertile manure pile for low pay with high malpractice risk...if hospitals are asking you to do something which completely sucks like rose, you dont have the proper relationship with that hospital.

Makes me think of a movie scene I love, maybe the guy from New England can relate...

That's a tough one, but I'll take a shot. Say I'm workin' at the N.S.A. and somebody puts a code on my desk, somethin' no one else can break. Maybe I take a shot at it, maybe I break it. And I'm real happy with myself, 'cause I did my job well. But maybe that code was the location of some rebel army in North Africa or the Middle East. And once they have that location, they bomb the village where the rebels are hidin'. Fifteen hundred people that I never met, I never had no problem with, get killed. Now the politicians are sayin', 'Oh, send in the Marines to secure the area,' 'cause they don't give a ****. It won't be their kid over there gettin' shot. Just like it wasn't them when their number got called 'cause they were out pullin' a tour in the National Guard. It'll be some kid from Southie over there takin' shrapnel in the ass. He comes back to find that the plant he used to work at got exported to the country he just got back from. And the guy who put the shrapnel in his ass got his old job, 'cause he'll work for fifteen cents a day and no bathroom breaks.

Meanwhile he realizes the only reason he was over there in the first place was so that we could install a government that would sell us oil at a good price. And of course the oil companies used the little skirmish over there to scare up domestic oil prices. A cute little ancillary benefit for them but it ain't helpin' my buddy at two-fifty a gallon. They're takin' their sweet time bringin' the oil back, of course, maybe they even took the liberty of hirin' an alcoholic skipper who likes to drink martinis and ****in' play slalom with the icebergs. It ain't too long 'til he hits one, spills the oil and kills all the sea life in the North Atlantic. So now my buddy's out of work. He can't afford to drive, so he's walkin' to the ****in' job interviews, which sucks because the shrapnel in his ass is givin' him chronic hemorroids. And meanwhile he's starvin' 'cause every time he tries to get a bite to eat, the only blue plate special they're servin' is North Atlantic scrod with Quaker State.

So what did I think? I'm holdin' out for somethin' better.
 
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My boy’s wicked smaht.

Agree, ROSE reimbursement and risk/reward is terrible and no pathologist should agree to do it unless you have no choice.


Unless I was "doing it wrong" ...ummmm.....rapid onsite eval aka ROSE is like the worst compensated activity aside from actual medical autopsies. And to make the rose turd even more ripe, the liability on these is sky high. Rich fertile manure pile for low pay with high malpractice risk...if hospitals are asking you to do something which completely sucks like rose, you dont have the proper relationship with that hospital.

Makes me think of a movie scene I love, maybe the guy from New England can relate...

That's a tough one, but I'll take a shot. Say I'm workin' at the N.S.A. and somebody puts a code on my desk, somethin' no one else can break. Maybe I take a shot at it, maybe I break it. And I'm real happy with myself, 'cause I did my job well. But maybe that code was the location of some rebel army in North Africa or the Middle East. And once they have that location, they bomb the village where the rebels are hidin'. Fifteen hundred people that I never met, I never had no problem with, get killed. Now the politicians are sayin', 'Oh, send in the Marines to secure the area,' 'cause they don't give a ****. It won't be their kid over there gettin' shot. Just like it wasn't them when their number got called 'cause they were out pullin' a tour in the National Guard. It'll be some kid from Southie over there takin' shrapnel in the ass. He comes back to find that the plant he used to work at got exported to the country he just got back from. And the guy who put the shrapnel in his ass got his old job, 'cause he'll work for fifteen cents a day and no bathroom breaks.

Meanwhile he realizes the only reason he was over there in the first place was so that we could install a government that would sell us oil at a good price. And of course the oil companies used the little skirmish over there to scare up domestic oil prices. A cute little ancillary benefit for them but it ain't helpin' my buddy at two-fifty a gallon. They're takin' their sweet time bringin' the oil back, of course, maybe they even took the liberty of hirin' an alcoholic skipper who likes to drink martinis and ****in' play slalom with the icebergs. It ain't too long 'til he hits one, spills the oil and kills all the sea life in the North Atlantic. So now my buddy's out of work. He can't afford to drive, so he's walkin' to the ****in' job interviews, which sucks because the shrapnel in his ass is givin' him chronic hemorroids. And meanwhile he's starvin' 'cause every time he tries to get a bite to eat, the only blue plate special they're servin' is North Atlantic scrod with Quaker State.

So what did I think? I'm holdin' out for somethin' better.
 
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Unless I was "doing it wrong" ...ummmm.....rapid onsite eval aka ROSE is like the worst compensated activity aside from actual medical autopsies. And to make the rose turd even more ripe, the liability on these is sky high. Rich fertile manure pile for low pay with high malpractice risk...if hospitals are asking you to do something which completely sucks like rose, you dont have the proper relationship with that hospital.

Makes me think of a movie scene I love, maybe the guy from New England can relate...

That's a tough one, but I'll take a shot. Say I'm workin' at the N.S.A. and somebody puts a code on my desk, somethin' no one else can break. Maybe I take a shot at it, maybe I break it. And I'm real happy with myself, 'cause I did my job well. But maybe that code was the location of some rebel army in North Africa or the Middle East. And once they have that location, they bomb the village where the rebels are hidin'. Fifteen hundred people that I never met, I never had no problem with, get killed. Now the politicians are sayin', 'Oh, send in the Marines to secure the area,' 'cause they don't give a ****. It won't be their kid over there gettin' shot. Just like it wasn't them when their number got called 'cause they were out pullin' a tour in the National Guard. It'll be some kid from Southie over there takin' shrapnel in the ass. He comes back to find that the plant he used to work at got exported to the country he just got back from. And the guy who put the shrapnel in his ass got his old job, 'cause he'll work for fifteen cents a day and no bathroom breaks.

Meanwhile he realizes the only reason he was over there in the first place was so that we could install a government that would sell us oil at a good price. And of course the oil companies used the little skirmish over there to scare up domestic oil prices. A cute little ancillary benefit for them but it ain't helpin' my buddy at two-fifty a gallon. They're takin' their sweet time bringin' the oil back, of course, maybe they even took the liberty of hirin' an alcoholic skipper who likes to drink martinis and ****in' play slalom with the icebergs. It ain't too long 'til he hits one, spills the oil and kills all the sea life in the North Atlantic. So now my buddy's out of work. He can't afford to drive, so he's walkin' to the ****in' job interviews, which sucks because the shrapnel in his ass is givin' him chronic hemorroids. And meanwhile he's starvin' 'cause every time he tries to get a bite to eat, the only blue plate special they're servin' is North Atlantic scrod with Quaker State.

So what did I think? I'm holdin' out for somethin' better.

ha ha -- In order to maximize re-imbursement for ROSEs, I've sent my associate to negotiate.....REEE- Tainer !

Just calling it the way I see it, but I would recommend cyto over a non-boarded SP organ system based sub-speciality that you should have mastered from AP training anyhow or could easily become a go to person just by signing a lot of said sub-speciality , covering the TB, etc post training.
I dont think there is tremendous liability with ROSEs. I have never seen nor heard of a litiginous case from a poorly done ROSE, and have seen plenty of cases miscalled and mis-triaged at ROSE.
 
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Rule #1 on ROSE: If it looks funny to you, call it atypical and ask for more.

Problem solved.
 
I wish there would be a survey about whether people coming out of training were actually comfortable doing things outside of their fellowship training - we have definitely interviewed quite a few who are - but most do have things that they say they are not comfortable doing (sometimes it's cyto, sometimes it's something in CP, heme might be most common to mention though). But some of our most recent hires have been pretty flexible.

Why is ROSE a high lawsuit area? Seems kind of odd, either there are cells there or not. They don't typically go and do anything immediate that would cause harm, more that they just stop and the worst case scenario is they have to go back and get another sample.
 
I am not aware that it’s a high lawsuit area, but, in my opinion, it’s risky in a way comparable to frozen sections: high and sometimes unreasonable clinician expectations, evaluation of limited material, and an opportunity to be embarrassingly wrong once the final slides are examined. Of course, you are right, the difference between ROSE and frozen section is that with ROSE the worst case scenario is typically that they have to repeat the procedure. Whereas with frozens there’s is no real limit to how badly you can screw up.
 
I wish there would be a survey about whether people coming out of training were actually comfortable doing things outside of their fellowship training - we have definitely interviewed quite a few who are - but most do have things that they say they are not comfortable doing (sometimes it's cyto, sometimes it's something in CP, heme might be most common to mention though). But some of our most recent hires have been pretty flexible.

Why is ROSE a high lawsuit area? Seems kind of odd, either there are cells there or not. They don't typically go and do anything immediate that would cause harm, more that they just stop and the worst case scenario is they have to go back and get another sample.

From my experience, most traineesarent comfortable signing out general Path straight out of residency. I'm not meaning general surg Path. I'm talking about doing it all....hemepath, Cytopathology, dermpath, managing a clinical lab on top of all that.

The volume of material you have to know is incredible. You do t have sign out responsibilities in residency. It's not until you push the sign out button after a few years you start to feel somewhat comfortable.

I know many residents who would be hesitant to sign out a tray of derm or hemepath. Hell I know many attendings with 10 plus years of experience who couldn't even do the same!!!!!

Pathology is a broad field. As one dermatopathologist once told me, you are the jack of all trades master of none. I do agree with that after having finished residency and fellowship.

Sure if you do a year of hemepath fellowship, Cytopathology fellowship or dermpath, you feel more comfortable signing out just based on obvious reasons.

If you don't feel comfortable, and you screw up, you are in serious trouble. I've seen attendings with 30 years of experience, one of the better pathologists I've seen misdiagnose a biopsy!!!!!

Surgical Path in itself is a broad field. Most groups you can consult other pathologists who are more experienced in that area as we all know.

Crap I prob know tons of residents who wouldn't know the first thing to managing a lab lol. These are board certified cp folks too. Throw them into a busy lab, see what happens. Most likely they will get killed just due to the lack of experience and would have to rely on experienced lab managers.

Pathology as a field is broad and as we all know you have to be 100% correct 100% of the time (as one of my attendings once said). If you screw up, you can seriously kill a patient and your reputation will be ruined for years.

If you are a resident who is highly confident in signing out general Path, then kudos to you. In my experience of seeing residents and other fellows I'd tgat most are not able or confident to sign out general Path straight out of residency. With a fellowship, most would be confident I would say.

The volume of pathology is just too much for one to work independently. Sure if you are lucky to work with colleagues who are willing to look over your cases then that's nice.

Just make sure you don t miss cancer (because you weren't confident or didn't feel comfortable at signing out in a particular area)or you are screwed.

Like I said, if I were to hand a trays of heme or cyto to some graduating residents to sign out I would think that a fair number of them would not feel comfortable at signing them out. Don't forget frozen sections too. Don't make a mistake or you are screwed.

You just got to know when to ask for help. If you sign out a case without asking for help when you should have (but you didn't think you needed help), you are in trouble. Patient comes back with metastatic diseases because you missed cancer or you misdiagnosed a cancer...I've seen this happen to experienced pathologists!!!

Patient comes back with metastatic disease because you missed cancer or you misdiagnose a cancer....it happens even in experienced pathologists.

To all the residents....as one my attendings once said....make sure you look at as many cases you possibly can. A few trays per day at signout just ain't going to cut it.
 
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I wish there would be a survey about whether people coming out of training were actually comfortable doing things outside of their fellowship training - we have definitely interviewed quite a few who are - but most do have things that they say they are not comfortable doing (sometimes it's cyto, sometimes it's something in CP, heme might be most common to mention though). But some of our most recent hires have been pretty flexible.

Why is ROSE a high lawsuit area? Seems kind of odd, either there are cells there or not. They don't typically go and do anything immediate that would cause harm, more that they just stop and the worst case scenario is they have to go back and get another sample.

Yes. Until you do ROSE in some crazy situation where patients are taken directly to lumpectomy or mastectomy even based on the findings. Producing a permanent surgical effect of an absurd clinical situation you have been forced into. And before someone cries B.S., I have literally been in clinical setting where this was happening. I was even expected to schedule the patients for surgery after I read the bedside breast FNA...yes insanity.

ROSE is an utter waste of pathology manpower. Pathology man hours are no less valuable than Radiology's. We cant be expected to sit next some bumbling radiologist and assess whether they got diagnostic tissue, if they cant get diagnostic tissue they need either 1.) better training or 2.) flipping new occupation. End of story.
 
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We use ROSE for EUS cases, mostly. Mediastinal nodes and pancreatic masses - basically to tell whether there is diagnostic tissue there, and whether to get more material for flow, genetic studies, etc. I have not encountered a situation of ROSE impression leading directly to a therapeutic procedure, with the possible exception of pancreatic mass FNAs leading to slight alterations in the remainder of the procedure. They have tried to call us for thyroids but typically we just send the cytotech, who tells them it's adequate for diagnosis or not adequate for diagnosis.
 
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