What AP critical results do you call on?

[ygdrasil]

We've taken on a lot of outreach work, and in getting to know some of our new clients many have requested more FYI calls on significant biopsy results. Examples include a presumed POC with no chorionic villi, a mass that was clinically thought to be lymphoma that turned out to be abscess (specific example that had a bad outcome due to delayed treatment) and an endometrial curettage that has carcinoma.

A lot of these clinicians are serving multiple health systems and have to navigate a myriad of EMRs, so I get the anxiety about missing a critical result. We have a policy for this, but it's intentionally vague. Does anyone have a reasonable list of diagnoses that should be called on?

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[octopusprime]

We call on all new malignancies, excluding BCCs and SCCs, in house and outreach, in addition to POCs without villi...and rare infectious entities (TB, blasto, cocci, etc).

 

[deleted314957]

We call on all new malignancies, excluding BCCs and SCCs, in house and outreach, in addition to POCs without villi...and rare infectious entities (TB, blasto, cocci, etc).

I would also add “ unexpected “ things like adipose in EMC, etc.

 

[cmz]

I call on anything unexpected, even the ascites fluids I get for cytology that have a significant amount of acute inflammation. I have a huge roladex (kidding) with every single clinician we deal with and call their personal cellphone to discuss results. They appreciate that service.

 

[musom]

AJCP published an article in 2004 that helped define some criteria. It's simple titled "Critical Values in Anatomic Pathology" and is accessible via pubmed.

Personally, POC with NO villi, carcinoma within any GI biopsy specimen, prostate CA in a TURP, obvious fat on a EMC/EB....

 

[ygdrasil]

Wow, that's way more than what we do. What do you do when you can't get ahold of the clinician of concern?

 

[musom]

This is the 21st century....you shoot them a text with a photo of the TVA with intramucosal adenocarcinoma and give them a quick descriptor.

 

[octopusprime]

I would also add “ unexpected “ things like adipose in EMC, etc.

yeah anything unexpected...CNS tissue in a sinus specimen, etc... whether it's malignancy or a procedural peculiarity.

Wow, that's way more than what we do. What do you do when you can't get ahold of the clinician of concern?

leave message with office/nurse, and document in report we attempted to get ahold of them but could not be reached, etc. if it's a malignancy and can't get ahold of them i usually leave a message and ask to call me back. if they don't by the time i'm ready to leave for the day, i either sign out a prelim without calling them, and call them back the next day, or put a note in the report RE making an attempt to call.

 

[octopusprime]

This is the 21st century....you shoot them a text with a photo of the TVA with intramucosal adenocarcinoma and give them a quick descriptor.

would only recommend doing that with secure messaging app unless you're not using pt info/descriptors...too much liability. IF you even have their contact info...hard for outreach.

 

[cmz]

Wow, that's way more than what we do. What do you do when you can't get ahold of the clinician of concern?

I ask for a nurse and add their name to my comment that I spoke with such and such RN, etc. I will often add an addendum to show that I made the effort to phone back at a later date if I didn't get ahold of the clinician the first time (or second).

 

[Euchromatin]

We call on all new malignancies, excluding BCCs and SCCs, in house and outreach, in addition to POCs without villi...and rare infectious entities (TB, blasto, cocci, etc).

I personally feel that calling every single new malignancy (even if you exclude skins) is excessive. I don't see the point in calling core biopsies of breast, lung, liver, lymph nodes, etc. that are performed on highly suspicious nodules/lesions - the clinical suspicion is really high already, they won't have enough info to have a useful discussion with the patient until ancillary studies are done (ER/PR/HER2 for breast; molecular/FISH results for lung primaries; immunos to determine primary site of liver/bone mets, etc.) and, for a significant number of cases, the radiologist who did the biopsy (which is the "referring physician" contact listed) won't be the one following/treating the patient anyway. Thankfully, we do not do this in our group, as the amount of time it would take would be prohibitive, and, as it is not current practice, none of our clinicians expect it. In fact, I am certain it would annoy the majority of the surgeons if we started calling them on a near-daily basis with routine positive cases. The exceptions I can think of in which we would usually call would be acute leukemia, superior vena cava syndrome or otherwise critically ill inpatients in which the treating team wants to start chemo and/or radiation stat and just needs to know if there is adequate tissue in the biopsy or if it is small cell vs. adeno or something like that - but those cases are usually already rush/rapid and are often marked with a request for a phone call with preliminary findings anyway.

We maintain a list of results to call that I think is otherwise fairly extensive, but we also try not to make it too binding by adding wording like "suggested" and "discretion." Similar to what others have posted we generally call on findings that could warrant urgent intervention and/or are entirely unexpected:
positive temporal artery biopsies (so steroids can be initiated ASAP if patient isn't already being treated)
acid fast bacilli, invasive fungi, unexpected endocarditis
uterine contents/POC without villi
fat in EMC/bx, colon bx
clinically significant discrepancy between frozen and final diagnosis
unexpected malignancy (I, personally, don't think finding a bit of low Gleason prostate ca in a TURP is really all that "unexpected" since it is known to occur in a certain percentage of cases, I tend do this more for specimens with almost zero expectation of neoplasm, like if one found carcinoma in a hernia sac, hemorrhoid, hip replacement for osteoarthritis, etc.)

When we do call, we document that we spoke with the referring physician and/or note what attempts we made to contact them. I cannot fathom anyone in my current group even remotely considering text messaging info or pics about a case - the group overall is extremely risk averse and liability conscious.

 

[jupiterianvibe]

I personally feel that calling every single new malignancy (even if you exclude skins) is excessive. I don't see the point in calling core biopsies of breast, lung, liver, lymph nodes, etc. that are performed on highly suspicious nodules/lesions - the clinical suspicion is really high already, they won't have enough info to have a useful discussion with the patient until ancillary studies are done (ER/PR/HER2 for breast; molecular/FISH results for lung primaries; immunos to determine primary site of liver/bone mets, etc.) and, for a significant number of cases, the radiologist who did the biopsy (which is the "referring physician" contact listed) won't be the one following/treating the patient anyway. Thankfully, we do not do this in our group, as the amount of time it would take would be prohibitive, and, as it is not current practice, none of our clinicians expect it. In fact, I am certain it would annoy the majority of the surgeons if we started calling them on a near-daily basis with routine positive cases. The exceptions I can think of in which we would usually call would be acute leukemia, superior vena cava syndrome or otherwise critically ill inpatients in which the treating team wants to start chemo and/or radiation stat and just needs to know if there is adequate tissue in the biopsy or if it is small cell vs. adeno or something like that - but those cases are usually already rush/rapid and are often marked with a request for a phone call with preliminary findings anyway.

We maintain a list of results to call that I think is otherwise fairly extensive, but we also try not to make it too binding by adding wording like "suggested" and "discretion." Similar to what others have posted we generally call on findings that could warrant urgent intervention and/or are entirely unexpected:
positive temporal artery biopsies (so steroids can be initiated ASAP if patient isn't already being treated)
acid fast bacilli, invasive fungi, unexpected endocarditis
uterine contents/POC without villi
fat in EMC/bx, colon bx
clinically significant discrepancy between frozen and final diagnosis
unexpected malignancy (I, personally, don't think finding a bit of low Gleason prostate ca in a TURP is really all that "unexpected" since it is known to occur in a certain percentage of cases, I tend do this more for specimens with almost zero expectation of neoplasm, like if one found carcinoma in a hernia sac, hemorrhoid, hip replacement for osteoarthritis, etc.)

When we do call, we document that we spoke with the referring physician and/or note what attempts we made to contact them. I cannot fathom anyone in my current group even remotely considering text messaging info or pics about a case - the group overall is extremely risk averse and liability conscious.

I agree with everything you said here.

A peeve of mine: calling these critical RESULTS. Are we machines? They're not results, they're diagnoses.

 

[cmz]

I personally feel that calling every single new malignancy (even if you exclude skins) is excessive. I don't see the point in calling core biopsies of breast, lung, liver, lymph nodes, etc. that are performed on highly suspicious nodules/lesions - the clinical suspicion is really high already, they won't have enough info to have a useful discussion with the patient until ancillary studies are done (ER/PR/HER2 for breast; molecular/FISH results for lung primaries; immunos to determine primary site of liver/bone mets, etc.) and, for a significant number of cases, the radiologist who did the biopsy (which is the "referring physician" contact listed) won't be the one following/treating the patient anyway. Thankfully, we do not do this in our group, as the amount of time it would take would be prohibitive, and, as it is not current practice, none of our clinicians expect it. In fact, I am certain it would annoy the majority of the surgeons if we started calling them on a near-daily basis with routine positive cases. The exceptions I can think of in which we would usually call would be acute leukemia, superior vena cava syndrome or otherwise critically ill inpatients in which the treating team wants to start chemo and/or radiation stat and just needs to know if there is adequate tissue in the biopsy or if it is small cell vs. adeno or something like that - but those cases are usually already rush/rapid and are often marked with a request for a phone call with preliminary findings anyway.

I disagree. All it takes is one busy doctor to say that they never received notification that their patient has cancer. You're assuming that patients never get lost to follow-up and clinicians are constantly checking and making sure they get all of their results. In a perfect world, yes. In reality, you need to cover your butt. If your lab is CAP-accredited, I believe that it is a requirement to provide documentation that you relayed information on all new cancer diagnoses, etc.

On a side note, I have to ask the purpose of having a useful discussion regarding ancillary breast biomarkers on a breast cancer case or molecular/FISH results on a lung cancer case. In my mind, it's enough to let the oncologist or primary doctor know that the patient has cancer (with a specific diagnosis that has been fully worked up with IHC if necessary). The ancillary studies don't change the fact the patient has a certain cancer. Those studies are to provide more info about prognostication and for therapeutics. If something like a heme case comes up and I render a diagnosis of "diffuse large B-cell lymphoma with high grade features"... I will let the oncologist know ASAP so they can begin treatment. Then, once I get my FISH studies back, I can call again to relay any pertinent info that may change my original diagnosis. So in that regard, I may call a clinician at least twice on the same cancer case. Is this overkill? I think that more often than not, most clinicians would be more pissed off if they didn't hear from their pathologist regarding a new malignancy. You have to establish a relationship with your clients/clinicians. Mine are more than OK with me calling them personally to relay this type of information.

Step through the paraffin curtain and talk to your doctor colleagues and let them know you exist. I also almost never contract the radiologist who does some of our core biopsies and FNAs since they aren't technically the referring physician. The radiologist who provides the service of performing the biopsy has to receive an order comes from someone else. I call THAT person. We do have one client who is a radiologist who kind of also acts as the primary, but to me, this is not a very common scenario.

 

[AZpath]

I disagree. All it takes is one busy doctor to say that they never received notification that their patient has cancer. You're assuming that patients never get lost to follow-up and clinicians are constantly checking and making sure they get all of their results. In a perfect world, yes. In reality, you need to cover your butt. If your lab is CAP-accredited, I believe that it is a requirement to provide documentation that you relayed information on all new cancer diagnoses, etc.

On a side note, I have to ask the purpose of having a useful discussion regarding ancillary breast biomarkers on a breast cancer case or molecular/FISH results on a lung cancer case. In my mind, it's enough to let the oncologist or primary doctor know that the patient has cancer (with a specific diagnosis that has been fully worked up with IHC if necessary). The ancillary studies don't change the fact the patient has a certain cancer. Those studies are to provide more info about prognostication and for therapeutics. If something like a heme case comes up and I render a diagnosis of "diffuse large B-cell lymphoma with high grade features"... I will let the oncologist know ASAP so they can begin treatment. Then, once I get my FISH studies back, I can call again to relay any pertinent info that may change my original diagnosis. So in that regard, I may call a clinician at least twice on the same cancer case. Is this overkill? I think that more often than not, most clinicians would be more pissed off if they didn't hear from their pathologist regarding a new malignancy. You have to establish a relationship with your clients/clinicians. Mine are more than OK with me calling them personally to relay this type of information.

Step through the paraffin curtain and talk to your doctor colleagues and let them know you exist. I also almost never contract the radiologist who does some of our core biopsies and FNAs since they aren't technically the referring physician. The radiologist who provides the service of performing the biopsy has to receive an order comes from someone else. I call THAT person. We do have one client who is a radiologist who kind of also acts as the primary, but to me, this is not a very common scenario.

There is difference between critical calls in AP and great customer service. Critical calls themselves are mostly intended to require immediate action by the clinician. I don't include most malignancy follow ups in this category .
Nevertheless, you can provide a better service and secure a higher place in your medical community if you communicate better.
In my case, I like to call anything unexpected ( tumor in hernia sac or small polyp etc) and urgent findings. I don't relay every diagnosis.

 

[cmz]

There is difference between critical calls in AP and great customer service. Critical calls themselves are mostly intended to require immediate action by the clinician. I don't include most malignancy follow ups in this category .
Nevertheless, you can provide a better service and secure a higher place in your medical community if you communicate better.
In my case, I like to call anything unexpected ( tumor in hernia sac or small polyp etc) and urgent findings. I don't relay every diagnosis.

I wouldn't consider most malignancy follow-ups in the "critical value" category either. However, if you don't call on a new breast cancer case (core biopsy)... that is kind of ridiculous...

 

[Euchromatin]

I disagree. All it takes is one busy doctor to say that they never received notification that their patient has cancer. You're assuming that patients never get lost to follow-up and clinicians are constantly checking and making sure they get all of their results. In a perfect world, yes. In reality, you need to cover your butt. If your lab is CAP-accredited, I believe that it is a requirement to provide documentation that you relayed information on all new cancer diagnoses, etc.

I think we will have to agree to disagree about calling all new malignancy diagnoses and accept that there are significant differences in practice patterns and expectations of clinicians. The varied opinions on this topic here in our forum appear to be similar to what has been found in published surveys and literature on the topic. The most extensive review I could find is this consensus statement by CAP and ADASP (Consensus statement on effective communication of urgent diagnoses and significant, unexpected diagnoses in surgical pathology and cytopathology fr... - PubMed - NCBI).

Interestingly, one of the large CAP surveys (Significant and unexpected, and critical diagnoses in surgical pathology: a College of American Pathologists' survey of 1130 laboratories. - PubMed - NCBI) showed that 48% of departments included "malignancy" in their critical diagnosis policy/list and 36% included "all malignancies." So it would appear that you are actually in the minority based on that data. There has also been a push to try and separate "urgent/critical" results from "significant, unexpected" diagnoses, which further complicates the discussion.

I looked it up and, as far as I can tell, the only item in the AP CAP checklist relating to conveyance of diagnoses is this one:

ANP.12175 Significant/Unexpected Findings Phase II
There is a policy regarding the communication and recording of significant and unexpected surgical pathology findings.
NOTE: Certain surgical pathology diagnoses may be considered significant and unexpected. Such diagnoses may include: malignancy in an uncommon location or specimen type (e.g. hernia sac, intervertebral disk material, tonsil, etc.), or change of a frozen section diagnosis after review of permanent sections. There should be a reasonable effort to ensure that such diagnoses are received by the clinician, by means of telephone, pager or other system of notification. There must be records of the date of communication of these diagnoses. The pathology department may designate certain surgical pathology diagnoses for prompt communication to the clinician. Such diagnoses may include, for example, neoplasms causing paralysis, or fat in an endometrial curettage. Diagnoses to be defined as “significant and unexpected,” and those for prompt communication should be determined by the pathology department, in cooperation with local clinical medical staff. Records of communication of these diagnoses may be included in the pathology report, or in other laboratory records.

I would not interpret that this checklist item requires direct communication for "all new cancer diagnoses." I completely agree with you that documentation of communications with clinicians is essential.

I also agree that ensuring that the referring/ordering provider does actually get the results of any testing they have ordered is important and it would be optimal for patient care to prevent anyone from falling through the cracks. However, one has to balance the reduced risk to patients with efficient use of limited resources. At some point, it becomes infeasible for pathologists to personally confirm that the ordering provider has received and understood the results of every case.

In my practice, it would not be practical to call on all new malignancies. For reference, January is the month in which the surgical case load per pathologist is lowest in our group (because the fewest vacation days are taken). I did a quick lookup of my cases from last week. There were 22 new malignancy diagnoses - about 4-5 per day. When I try to reach the relevant physician (and, no, I don't ever try to call the radiologist), I get their office receptionist, who inevitably tells me they are rouding/with a patient, in the OR or off that day and I have to leave a detailed message including the patient's name, DOB, etc. They usually do (eventually) call me back, although we can end up in a horrible game of phone tag if they happen to call while I am doing a frozen, at a meeting or otherwise not in my office. I would say on average it takes me about 10-15 minutes total to speak to a clinician on a straightforward case and document it - that would be an additional 40-75 minutes per day during the slowest month of the year. Not a feasible or efficient use of pathologist resources in my opinion.

On a side note, I have to ask the purpose of having a useful discussion regarding ancillary breast biomarkers on a breast cancer case or molecular/FISH results on a lung cancer case. In my mind, it's enough to let the oncologist or primary doctor know that the patient has cancer (with a specific diagnosis that has been fully worked up with IHC if necessary). The ancillary studies don't change the fact the patient has a certain cancer. Those studies are to provide more info about prognostication and for therapeutics. If something like a heme case comes up and I render a diagnosis of "diffuse large B-cell lymphoma with high grade features"... I will let the oncologist know ASAP so they can begin treatment. Then, once I get my FISH studies back, I can call again to relay any pertinent info that may change my original diagnosis. So in that regard, I may call a clinician at least twice on the same cancer case. Is this overkill?

Yes, it is useful at some level to know the patient "officially" has "cancer." The sometimes arduous process of setting up appointments with oncology, surgery, radiation, etc., can then be started. However, at least in our neck of the woods, I don't believe that a call to a clinician at 9:00 am to tell them that a biopsy is positive vs. them getting the final report at 4:00-5:00 pm that day (or the next morning) would result in patients getting specialty appointments significantly earlier. I already mentioned that very ill inpatients/new leukemias/lymphomas who actually would be in a position to get urgent/same day treatment are an exception and, in select cases in which the physician does want a phone call, they just write that on the requisition and we call them.

I think that more often than not, most clinicians would be more pissed off if they didn't hear from their pathologist regarding a new malignancy. You have to establish a relationship with your clients/clinicians. Mine are more than OK with me calling them personally to relay this type of information.

Step through the paraffin curtain and talk to your doctor colleagues and let them know you exist.

If you have the time to call your docs and they are used to getting that many calls, great. Local practice here is not to call on every single new malignancy, but that does not imply that I don't have an established relationship with the physicians here - they definitely know I exist. I think it is a bit harsh and unwarranted to jump to the conclusion that I am not an effective communicator or not providing "great customer service" because there is some local/regional variation in practice patterns in regards to one particular gray area in critical/unexpected diagnosis reporting.

 

[Euchromatin]

However, if you don't call on a new breast cancer case (core biopsy)... that is kind of ridiculous...

This would actually be the most pointless specimen to call about where I practice. At the two largest hospitals we cover, we have a weekly conference with the breast surgeons, radiology and oncology in which we correlate the radiology and pathology findings of EVERY SINGLE breast core biopsy and all the patients with relevant pathology are appropriately referred.

 

[coroner]

Different places I've gone and even different doctors at the same institution, had varying expectations of what they did and did not want to be notified about. The bottom line is know your audience i.e. medical staff (and practice bylaws).

I ask for a nurse and add their name to my comment that I spoke with such and such RN, etc.

This is an important point. I once contacted a clinician's office before to report critical/important results. Couldn't get a hold of him, so I told his nurse/PA the patient's results. He called back a week later in a fury, when he finally got around to reading the path report and was upset because the results were never passed onto him immediately. He asked who I spoke with and all I could say was, "some lady" which makes up pretty much his entire office staff. So now, I put that person's name whom I spoke with in the comment of my report if I can't get a hold of the clinician. It adds a layer of accountability.

 

[cmz]

This would actually be the most pointless specimen to call about where I practice. At the two largest hospitals we cover, we have a weekly conference with the breast surgeons, radiology and oncology in which we correlate the radiology and pathology findings of EVERY SINGLE breast core biopsy and all the patients with relevant pathology are appropriately referred.

I see your point and I apologize with my off-putting comment. To echo what coroner stated above, "know your audience." Again, my apologies.

 

[jupiterianvibe]

Different places I've gone and even different doctors at the same institution, had varying expectations of what they did and did not want to be notified about. The bottom line is know your audience i.e. medical staff (and practice bylaws).



This is an important point. I once contacted a clinician's office before to report critical/important results. Couldn't get a hold of him, so I told his nurse/PA the patient's results. He called back a week later in a fury, when he finally got around to reading the path report and was upset because the results were never passed onto him immediately. He asked who I spoke with and all I could say was, "some lady" which is pretty much his entire office staff. So now, I put that person's name whom I spoke with in the comment of my report if I can't get a hold of the clinician. It adds a layer of accountability.

Your referring doctor is a jerk. If he is upset maybe he should check the path consultation reports in a timely manner.

With that in mind, I never communicate my consultation to anyone who isn't an MD or DO. I learned that rule in residency, and so far it has proven to be excellent advice. If a diagnosis is crucial enough to make a phone call on, it's for the ears of the requesting physician. Not their staff.

 

[jupiterianvibe]

I wouldn't consider most malignancy follow-ups in the "critical value" category either. However, if you don't call on a new breast cancer case (core biopsy)... that is kind of ridiculous...

Why did you say this?

In my practice, we only call on unexpected cancers. If someone's getting a breast core then the possibility that cancer comes back is quite high. Calling here would be redundant, as the biopsy is specifically done for diagnosing cancer or ruling it out. Same goes with polyps etc. They can be cancer, its not out of the ordinary, and the referring doctor should know this already and expect this potential diagnosis.

Cancer in a hernia sac (saw it once), or an "epidermal inclusion cyst" (saw it a dozen times), or a hemorrhoid (common), or a breast reduction specimen (that too, a few times) yada yada yada gets a call, if only to ensure that the patient isn't lost to follow up.

 

[coroner]

Your referring doctor is a jerk. If he is upset maybe he should check the path consultation reports in a timely manner.

Agree 100%. He is known to have a high-and-mighty attitude. But, "Mr. Pathologist, meet Mr. Surgeon"...such is our world

 

[octopusprime]

In my practice, it would not be practical to call on all new malignancies. For reference, January is the month in which the surgical case load per pathologist is lowest in our group (because the fewest vacation days are taken). I did a quick lookup of my cases from last week. There were 22 new malignancy diagnoses - about 4-5 per day.
...
If you have the time to call your docs and they are used to getting that many calls, great. Local practice here is not to call on every single new malignancy, but that does not imply that I don't have an established relationship with the physicians here - they definitely know I exist. I think it is a bit harsh and unwarranted to jump to the conclusion that I am not an effective communicator or not providing "great customer service" because there is some local/regional variation in practice patterns in regards to one particular gray area in critical/unexpected diagnosis reporting.

I think it depends on the culture and infrastructure. I routinely dx >5 new CAs in a day, but a combination of established points of contact (care coordinators for surgical oncology, breast, gyn, etc) and secure messaging apps make notifications easier. It's never easy calling outreach, and I routinely find myself Googling Joe & Jane Smith, MD, in some rural clinic about the melanoma, colon CA, etc. new cancer dx...and they appreciate the discussion with a specialist as most PCPs in the rural trenches do.

If you can get away not calling, great, but the culture of pathology is--IMO--trending more in the direction of prompt discussion, molecular testing done yesterday, and going above & beyond. Maybe that's just my perception, but I also don't think it's an inconvenience to notify our breast, gyn onc, surg onc, and heme onc docs the same day... As a patient, I would appreciate the expeditious treatment of my case.
Would you be prompted to call if the patient was a VIP? If it was your mom/loved one?

 

[DrfluffyMD]

Something I don’t see mentioned here are evidence of procedural complications. For example, lung tissue in a liver bx and such. The proceduralist will def appreciate to know about this sooner than later and this is the only time I got an urgent path call.

 

[deleted314957]

Most of us think that falls squarely into the category of “unexpected”

 

[AZpath]

Something I don’t see mentioned here are evidence of procedural complications. For example, lung tissue in a liver bx and such. The proceduralist will def appreciate to know about this sooner than later and this is the only time I got an urgent path call.

Everybody should call on these types of findings. This the core idea behind all critical calls.
A result that really needs immediate action or the patient may suffer harm.

 

[AZpath]

The next tier of action has to be tailored to the medical community as most point out.
Nobody wants anyone to drop the ball.

Sometimes you can over do it too.
A urologist or uro group might have a problem with all CC for a routine adeno ca.

 

[Euchromatin]

As a patient, I would appreciate the expeditious treatment of my case.
Would you be prompted to call if the patient was a VIP? If it was your mom/loved one?

The only patients I can think of that might qualify as "VIP" that I was aware of were specimens from other local physicians or their family members. In such cases, our group's culture is generally more concerned that everything is absolutely correct - every t crossed and i dotted - vs. providing a speedier but perhaps less accurate result (I think I heard someone once ask "Do you want a fast diagnosis/diagnosis right now or the right diagnosis?"). Generally speaking, if the oncologist/surgeon/whoever knows they have a particularly anxious patient (or needs results ASAP for treatment or really for any reason), they will request a phone call on the requisition or just call us themselves. Although it isn't the reality in some places and could open an entirely different can of worms discussing pros and cons of our current healthcare system in the U.S., I don't think VIP patients necessarily deserve better/special/more expedited care than "average Joe" patients.

As a matter of fact, my mother was diagnosed with a carcinoma a couple years ago (thankfully relatively low grade, successfully treated with only surgical resection to date) and lives in a different state. I specifically did NOT hound the local pathology group who received her specimen or her treating physician for a quick answer - a couple of days does not make much difference and I didn't want to do anything to rush or change their usual procedures and increase the likelihood of any kind of error. The treating team knew she had a physician/pathologist as a family member and I felt that was more than enough to keep them on their toes, but hopefully not make them too nervous. I did later have her primary diagnostic specimen reviewed by our group (I had a trusted colleague look at it), just to double check, but it was a straightforward case.

 

[Autopsy101]

I specifically did NOT hound the local pathology group who received her specimen or her treating physician for a quick answer - a couple of days does not make much difference and I didn't want to do anything to rush or change their usual procedures and increase the likelihood of any kind of error.

This X1000 - Thank you for being so reasonable. It makes me very angry to be asked to rush a specimen for non-therapeutic reasons. The patient is anxious, they really want to know, they are related to so and so who can go complain to administration. Very few situations in pathology are actually legitimate stat/rush results needed. When we deviate from protocols, that is when serious mistakes are likely to happen. Quality, accurate results are needed much more often than fast. I wish more oncologists and surgeons realized this. No attorney gives a darn if that breast cancer was signed out with 24 hour turn around time if its really a metastatic melanoma, and you missed it because you didn't want to order any stains to "hold up the case".

 

[deleted314957]

In the Navy we called this the "admiral's wife syndrome" and the outcome
was often less than desirable.

 

[octopusprime]

The only patients I can think of that might qualify as "VIP" that I was aware of were specimens from other local physicians or their family members. In such cases, our group's culture is generally more concerned that everything is absolutely correct - every t crossed and i dotted - vs. providing a speedier but perhaps less accurate result (I think I heard someone once ask "Do you want a fast diagnosis/diagnosis right now or the right diagnosis?"). Generally speaking, if the oncologist/surgeon/whoever knows they have a particularly anxious patient (or needs results ASAP for treatment or really for any reason), they will request a phone call on the requisition or just call us themselves. Although it isn't the reality in some places and could open an entirely different can of worms discussing pros and cons of our current healthcare system in the U.S., I don't think VIP patients necessarily deserve better/special/more expedited care than "average Joe" patients.

As a matter of fact, my mother was diagnosed with a carcinoma a couple years ago (thankfully relatively low grade, successfully treated with only surgical resection to date) and lives in a different state. I specifically did NOT hound the local pathology group who received her specimen or her treating physician for a quick answer - a couple of days does not make much difference and I didn't want to do anything to rush or change their usual procedures and increase the likelihood of any kind of error. The treating team knew she had a physician/pathologist as a family member and I felt that was more than enough to keep them on their toes, but hopefully not make them too nervous. I did later have her primary diagnostic specimen reviewed by our group (I had a trusted colleague look at it), just to double check, but it was a straightforward case.

I guess what I'm trying to say is that signing out cases expeditiously is not a bad thing, and I've had infinitely more positive feedback from prompt & frequent communication than negative feedback (in fact the only 'negative' feedback I've gotten is from NOT calling to discuss a case or because I've been sitting on a prelim diagnosis for 3 days)...
I will shoot for same day TAT in cases for which that is possible (eg. malignant FNA cases, particularly on a Friday). A day or two "not mattering" is not the point--getting the right diagnosis is, and if you get the right diagnosis sooner, that is almost invariably going to be appreciated more than taking an extra day or two because "it doesn't matter in the grand scheme of things."
I have my share of several day cases, but I fail to see how better TAT and more frequent commo with clinicians is a bad thing.

And if I'm asked to rush a specimen for non-therapeutic reasons (eg. the patient is 'anxious'), if the situation allows, I have no problem accomodating [it's not like it happens that often]. If i see an obvious PTC Friday AM and receive the slides by the afternoon the same day, why not sign it out? That's not recklessly rushing things or not taking it seriously, that's being efficient and making the diagnosis when it's staring you in the face. I'm not advocating shirking your duties because you valued TAT more than ordering HMB45 on a melanoma SLN, that's just ridiculous.

Yes, clinicians' expectations often exceed our capabilities or are unreasonable...but I've seen too many cases of poor TAT and lack of communication. Most medicolegal cases have a significant component of "lack of communication"...and across the board, the complaint most patients in our system have [aside from healthcare cost obviously] is "lack of communication"...we don't interact with patients at all but a documented, prompt and recurring dialogue with providers is never going to look bad in a court of law.

 

[LADoc00]

Call on? I dont call on crap. Calling implies someone is going to IMMEDIATELY do something or should do something. If I called all malignant diagnoses I would be on phone 12 hours a day running people down.

You call on one thing and one thing only: You find a biopsy with signs of Zombie Virus and the infected limb needs to be immediately amputated, that's it. Literally.

 

[LADoc00]

AJCP published an article in 2004 that helped define some criteria. It's simple titled "Critical Values in Anatomic Pathology" and is accessible via pubmed.

Personally, POC with NO villi, carcinoma within any GI biopsy specimen, prostate CA in a TURP, obvious fat on a EMC/EB....

hahahahahhaha are you serious? I have to look that article up and then track down the idiots who authored that to specifically mock them to their faces.

 

[pathstudent]

I personally feel that calling every single new malignancy (even if you exclude skins) is excessive. I don't see the point in calling core biopsies of breast, lung, liver, lymph nodes, etc. that are performed on highly suspicious nodules/lesions - the clinical suspicion is really high already, they won't have enough info to have a useful discussion with the patient until ancillary studies are done (ER/PR/HER2 for breast; molecular/FISH results for lung primaries; immunos to determine primary site of liver/bone mets, etc.) and, for a significant number of cases, the radiologist who did the biopsy (which is the "referring physician" contact listed) won't be the one following/treating the patient anyway. Thankfully, we do not do this in our group, as the amount of time it would take would be prohibitive, and, as it is not current practice, none of our clinicians expect it. In fact, I am certain it would annoy the majority of the surgeons if we started calling them on a near-daily basis with routine positive cases. The exceptions I can think of in which we would usually call would be acute leukemia, superior vena cava syndrome or otherwise critically ill inpatients in which the treating team wants to start chemo and/or radiation stat and just needs to know if there is adequate tissue in the biopsy or if it is small cell vs. adeno or something like that - but those cases are usually already rush/rapid and are often marked with a request for a phone call with preliminary findings anyway.

We maintain a list of results to call that I think is otherwise fairly extensive, but we also try not to make it too binding by adding wording like "suggested" and "discretion." Similar to what others have posted we generally call on findings that could warrant urgent intervention and/or are entirely unexpected:
positive temporal artery biopsies (so steroids can be initiated ASAP if patient isn't already being treated)
acid fast bacilli, invasive fungi, unexpected endocarditis
uterine contents/POC without villi
fat in EMC/bx, colon bx
clinically significant discrepancy between frozen and final diagnosis
unexpected malignancy (I, personally, don't think finding a bit of low Gleason prostate ca in a TURP is really all that "unexpected" since it is known to occur in a certain percentage of cases, I tend do this more for specimens with almost zero expectation of neoplasm, like if one found carcinoma in a hernia sac, hemorrhoid, hip replacement for osteoarthritis, etc.)

When we do call, we document that we spoke with the referring physician and/or note what attempts we made to contact them. I cannot fathom anyone in my current group even remotely considering text messaging info or pics about a case - the group overall is extremely risk averse and liability conscious.

That a real lazy douche opinion.

 

[pathstudent]

Call on? I dont call on crap. Calling implies someone is going to IMMEDIATELY do something or should do something. If I called all malignant diagnoses I would be on phone 12 hours a day running people down.

You call on one thing and one thing only: You find a biopsy with signs of Zombie Virus and the infected limb needs to be immediately amputated, that's it. Literally.

That's a pathology douche opinion. What if you saw a peripheral smear loaded with Auer rods. What if the clinical is cyst and it ends up being synovial sarcoma? You aren't going to call and let them know. That's a seriously douche pathology opinion.

 

[pathslides]

That's a pathology douche opinion. What if you saw a peripheral smear loaded with Auer rods. What if the clinical is cyst and it ends up being synovial sarcoma? You aren't going to call and let them know. That's a seriously douche pathology opinion.

I'll give you the leukemia, that makes sense to call.
What is the immediate action for synovial sarcoma? Or other biopsies that say to rule out malignancy? Just because it is malignant doesn't mean it's critical and calling on all malignancies would be a huge time waster in my practice.

 

[Euchromatin]

That a real lazy douche opinion.

What a very thoroughly explained and well-reasoned argument. Thank you so much for your valuable contribution to the discussion. I am also glad that you avoided resorting to personal attacks. /sarcasm

 

[cmz]

I guess I am biased here... I call on quite a few things because a) If "we" don't call, the blame game starts with the clinicians dragging my name through the mud because I did not communicate a diagnosis; and b) doctors where I practice expect the phone call (except the GI docs who have usually already sent the huge colon mass for surgery after performing the biopsy, same day). Where I work, some doctors need to be told what to do and have their hand held on quite a few things. Am I going to tell them to piss off? Not if I want to keep receiving their volume of cases.

I would love to go through my day just reading cases and signing out. We just got an angry phone call the other day from a clinician who said that we didn't phone them about a new cancer diagnosis. I had to point out that not only did I have a conversation with them, but I also documented it in the report. I suppose the argument could still be made that I never really called and I just documented it as if I really did. Maybe this is just a regional thing in Texas... I certainly would not have guessed it...

 

[LADoc00]

That's a pathology douche opinion. What if you saw a peripheral smear loaded with Auer rods. What if the clinical is cyst and it ends up being synovial sarcoma? You aren't going to call and let them know. That's a seriously douche pathology opinion.

As I said, if you someone was going to do something...like immediately, then I would call. Yes if I see AML, yah I call of course. But Im not calling the endoscopic because the big mass HE KNEW ALREADY was obviously malignant is adenoCA.

If you want to waste your time on the phone, have at it. But that means you are either:
1.) In your office burning years of your life you couldve spent at your kids' ballgames calling people
2.) not making much money but still leaving at 5 and working until you are dead

If deciding NEITHER option is appealing and going a third way of sanity, then Im a douche. An epic douche. I will go to a CAP conference and wear a **** that says Im an Epic Douche so you see me live.
There are a TON of problems with calling diagnoses period. What if you catch a clinician at the wrong time and he swaps which patient had which result, what if you swap the results? Do you have them READ BACK? Because if you are calling "Panic AP Values" and dont have an actual process which I predict you dont, then you are introducing far more chaos than you will ever solve by calling to begin with.

This is what I despise the most, anti-intellectual vitriol that can be summarized as "if you dont do it my way or see it my way, then you are X: either lazy, greedy, evil or bigoted".

That is modern academics, modern societal cancer. Brain rot. Beta male. Break free of that crap. Have agency in your life.

Just curious tho pathSTUDENT, where are you where a code is called and crash team is deployed for a new diagnosis of SYNOVIAL SARCOMA?? Is that Canadian? British? New England? Curious because I want to make sure I let the head of Ortho here in on what is state of the art medicine in Idiot Land.

 

[icpshootyz]

Calling on all malignancies is certainly stupid, given how long most malignancies have taken to develop to the point that they were biopsied. However, our clinicians and cancer center demand it. My derm clients want to be called on all new melanomas and rare malignancies (not BCC/SCC). We ended up adopting a service our hospital radiologists use where you record a message and it gets blasted to whatever format the clinicians choose - voicemail, email, text, pager - and the system records when the clinician listened to or read the message for confirmation. So we do have to waste time recording silly messages, but at least there is concrete documentation for any complaints.

 

[LADoc00]

Calling on all malignancies is certainly stupid, given how long most malignancies have taken to develop to the point that they were biopsied. However, our clinicians and cancer center demand it. My derm clients want to be called on all new melanomas and rare malignancies (not BCC/SCC). We ended up adopting a service our hospital radiologists use where you record a message and it gets blasted to whatever format the clinicians choose - voicemail, email, text, pager - and the system records when the clinician listened to or read the message for confirmation. So we do have to waste time recording silly messages, but at least there is concrete documentation for any complaints.

our clinicians and cancer center demand it.

Thats the real reason, that's the reason pathstudent calls. They demand it not for patient care reasons because that defies reason, there is no communication scenario, NONE where a phone call telling you a set of details and facts is superior to a written and referable record of the same facts and details. The phone call is plagued by error, miscommunication and misremembering and timing. That's literally scientific research backed by actual common sense. There is zero patient care benefit in any study I have ever seen. If you can refute this with science, then by all means present the data and statistical analysis.

They "demand" it because they can, it's a power thing. They have met the pathologists from your group in person and feel you and your group are lower in the Dominance Hierarchy than them. Lower social and professional status, that's where you are now. And like essentially all animals on Earth, dominant people will exercise their higher status in ways that are socially acceptable. Hence your obedient compliance with their demands.

Note this is VERY different than doing something to EARN business. That isnt what you are implying. And if you are at a cancer center within a hospital, you are already have an exclusive service contract and arent earning crap by being obedient.

When my clinicians call me they apologize for bothering ME. If they are really interested in a diagnosis that isnt out, they call me and I dont answer the phone right away. I never reinforce the idea I am sitting around at their beckon call waiting for them. They wait for me to call them back and never vice versa. Sometimes I even let them call me twice before I pick up. This serves to reinforce the idea I am always business, always reviewing lab work, always reading new research.

You will heavily sabotage your own professional status, your potential for increased medical directorship payments and your own personal happiness with your career choice if you follow the path of the Beta.

 

[jupiterianvibe]

our clinicians and cancer center demand it.

Thats the real reason, that's the reason pathstudent calls. They demand it not for patient care reasons because that defies reason, there is no communication scenario, NONE where a phone call telling you a set of details and facts is superior to a written and referable record of the same facts and details. The phone call is plagued by error, miscommunication and misremembering and timing. That's literally scientific research backed by actual common sense. There is zero patient care benefit in any study I have ever seen. If you can refute this with science, then by all means present the data and statistical analysis.

They "demand" it because they can, it's a power thing. They have met the pathologists from your group in person and feel you and your group are lower in the Dominance Hierarchy than them. Lower social and professional status, that's where you are now. And like essentially all animals on Earth, dominant people will exercise their higher status in ways that are socially acceptable. Hence your obedient compliance with their demands.

Note this is VERY different than doing something to EARN business. That isnt what you are implying. And if you are at a cancer center within a hospital, you are already have an exclusive service contract and arent earning crap by being obedient.

When my clinicians call me they apologize for bothering ME. If they are really interested in a diagnosis that isnt out, they call me and I dont answer the phone right away. I never reinforce the idea I am sitting around at their beckon call waiting for them. They wait for me to call them back and never vice versa. Sometimes I even let them call me twice before I pick up. This serves to reinforce the idea I am always business, always reviewing lab work, always reading new research.

You will heavily sabotage your own professional status, your potential for increased medical directorship payments and your own personal happiness with your career choice if you follow the path of the Beta.

as much as this tirade is laced with redpill speak, i agree completely.

but then again in my practice im the one calling the clin staff getting info from them because they cant be assed enough to fill out the consult form appropriately.

some of the clinical docs i trust less than a starbucks barista. those i call with stuff because i doubt they understand the significance of it.

my peeve is with RUSH(not the band, but the thing that referrers write on their requisition) WHAT THE **** IS A RUSH? In clin medicine there's elective, urgent and emergency. WTF IS RUSH? IT IS NOT A FORMAL, DEFINABLE CLINICAL URGENCY LEVEL. The only thing I can think of is that its put there to grease the wheels of the machine for $$$. Cant do the next step without the diagnosis and time is money. EFF THAT!

 

[icpshootyz]

our clinicians and cancer center demand it.

Thats the real reason, that's the reason pathstudent calls. They demand it not for patient care reasons because that defies reason, there is no communication scenario, NONE where a phone call telling you a set of details and facts is superior to a written and referable record of the same facts and details. The phone call is plagued by error, miscommunication and misremembering and timing. That's literally scientific research backed by actual common sense. There is zero patient care benefit in any study I have ever seen. If you can refute this with science, then by all means present the data and statistical analysis.

They "demand" it because they can, it's a power thing. They have met the pathologists from your group in person and feel you and your group are lower in the Dominance Hierarchy than them. Lower social and professional status, that's where you are now. And like essentially all animals on Earth, dominant people will exercise their higher status in ways that are socially acceptable. Hence your obedient compliance with their demands.

Note this is VERY different than doing something to EARN business. That isnt what you are implying. And if you are at a cancer center within a hospital, you are already have an exclusive service contract and arent earning crap by being obedient.

When my clinicians call me they apologize for bothering ME. If they are really interested in a diagnosis that isnt out, they call me and I dont answer the phone right away. I never reinforce the idea I am sitting around at their beckon call waiting for them. They wait for me to call them back and never vice versa. Sometimes I even let them call me twice before I pick up. This serves to reinforce the idea I am always business, always reviewing lab work, always reading new research.

You will heavily sabotage your own professional status, your potential for increased medical directorship payments and your own personal happiness with your career choice if you follow the path of the Beta.

Of course you'd devolve into alpha-beta nonsense, the beloved fantasy of jocks everywhere that perceive themselves to be "alpha" (whatever that means). Considering the entire theory that was based on was disproven, I'll just roll my eyes now.

 

[LADoc00]

Of course you'd devolve into alpha-beta nonsense, the beloved fantasy of jocks everywhere that perceive themselves to be "alpha" (whatever that means). Considering the entire theory that was based on was disproven, I'll just roll my eyes now.

alpha/beta behavior is just terminology easy to grasp quickly nowadays but substitute confident/agreeable or assertive/submissive etc. There is no theory there, its a reference frame built from observational psychology. It cant be "disproven". You sound like those crazies on college campuses that claim the "theory of there being actual genders have been disproven". Um okay..once again Im not telling you how to practice pathology, Im offering my particular insight. I hope most of the forum readers out there DONT follow my advice. The fewer of us at the top of the food chain means more resources $ shared out to me.

I love the "beloved fantasy of jocks everywhere" though, that is funny stuff. Im imagining some shredded 20 year old Chad with a bare chest and 6 pack abs wearing a lab coat and postulating evolutionary psychology in the Thinker position....

I find that most who chaff at such ideas are often Elliott Rodger-types but I hope you are more locked on.

 

[WEBB PINKERTON]

I don't know how some of you have time to push much glass between making all these phone calls and wasting time putting images on reports. We need to end both practices.