What's the most annoying thing about pathology?

[DropkickMurphy]

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One of the new pathologists here locally (he's been here about 3 months and according to the chief whom I deal with all the time (he's a forensic pathologist so our paths cross due to my line of work) "he might be out the door before he sees number 4") was complaining about the call schedule- just like the one thread on here. So it got me to wondering: what is (in all of your opinions) the most annoying thing about pathology? Is it really the call schedule or is it something else entirely?

 

[AngryTesticle]

One of the new pathologists here locally (he's been here about 3 months and according to the chief whom I deal with all the time (he's a forensic pathologist so our paths cross due to my line of work) "he might be out the door before he sees number 4") was complaining about the call schedule- just like the one thread on here. So it got me to wondering: what is (in all of your opinions) the most annoying thing about pathology? Is it really the call schedule or is it something else entirely?

- Being pestered by clinicians

 

[DropkickMurphy]

I should send you the list my friends and I came up with while working as RT's in the military: "47 fun things to do with the code pager"

About 28 of them would result in the total utter destruction of a pager....

 

[AngryTesticle]

I should send you the list my friends and I came up with while working as RT's in the military: "47 ways to fun things to do with the code pager"

About 28 of them would result in the total utter destruction of a pager....

Sounds fun. I'll print it out.

 

[DropkickMurphy]

Addendum of Rage? I have to see that one....

I'll try to find my list and get it to you.

 

[yaah]

The most annoying things about pathology:

1) Inappropriate frozen sections that hinder your ability to make a final diagnosis
2) Platelet approvals
3) People who don't know what pathologists do or why we do it but yet expect everything to get done according to their wishes and at their time frame.

 

[DropkickMurphy]

The most annoying things about pathology:

1) Inappropriate frozen sections that hinder your ability to make a final diagnosis
2) Platelet approvals
3) People who don't know what pathologists do or why we do it but yet expect everything to get done according to their wishes and at their time frame.

Define "inappropriate"?

 

[DarksideAllstar]

Inappropriate usually consists of an intraoperative consultation that will have absolutely NO IMPACT on what they will do during that surgery.

For example, I received a frozen on a lymph node for a renal cell carcinoma. Reason for said frozen: hem-onc wants to plan course of post-op treatment (said they get more of drug x if the node is positive). Didn't change a damn thing surgically, in fact they were closing when I reported it back 10 minutes later (I at least figured they would take some more nodes, but they already had those out when they called). I have run into many surgeons who do not use the frozen results to manage their patients intraoperatively, rather, they like to have a diagnosis for their patient when they see them that afternoon in recovery.

I think the worst is when your attending will read these non-sensical frozens. I remember talking with a surgeon when I first started in July for like 5 minutes about why he was getting this thing, only for my attending to cave and allow it (and telling me that there is no reason for this). It makes it hard to tell the surgeon "inappropriate" when your attending wont back you up.

 

[AngryTesticle]

Inappropriate usually consists of an intraoperative consultation that will have absolutely NO IMPACT on what they will do during that surgery.

For example, I received a frozen on a lymph node for a renal cell carcinoma. Reason for said frozen: hem-onc wants to plan course of post-op treatment (said they get more of drug x if the node is positive). Didn't change a damn thing surgically, in fact they were closing when I reported it back 10 minutes later (I at least figured they would take some more nodes, but they already had those out when they called). I have run into many surgeons who do not use the frozen results to manage their patients intraoperatively, rather, they like to have a diagnosis for their patient when they see them that afternoon in recovery.

I think the worst is when your attending will read these non-sensical frozens. I remember talking with a surgeon when I first started in July for like 5 minutes about why he was getting this thing, only for my attending to cave and allow it (and telling me that there is no reason for this). It makes it hard to tell the surgeon "inappropriate" when your attending wont back you up.

Word up man. Regarding your renal cell carcinoma story, I experienced an identical event this past Friday. Surgeon wanted a diagnosis on a metastatic RCC to a lymph node in the chest wall. The diagnosis we gave him was "consistent with metastatic RCC." What difference did this make in surgical management? None. I suppose that if the lymph node was negative for tumor, he might have dug around a little more. However, based on reading pre-op notes there were no other suspicious lesions except for this enlarged node. Doing the frozen was easy. But having to stay in the hospital just for this one case was the difference between me going home at 6 pm versus 8 pm. Wasn't very thrilled about this 😉

 

[yaah]

And in addition, diagnoses are more appropriately made with fixation and the time taken for good histologic sections. The frozen is basically a throwaway that is only glanced at during the real signout, and only to make sure nothing weird showed up on the slide that wasn't on frozen. The unfortunate thing is that if it is a small lesion (like thyroid or something) the bulk of the lesion is on frozen, and the final diagnosis becomes that much more difficult.

This is why breast frozen section has mercifully become much less common over the last few years. Surgeons have been taught now that doing a frozen on breast lesion destroys a lot of margins and diagnostic tissue.

 

[AngryTesticle]

And in addition, diagnoses are more appropriately made with fixation and the time taken for good histologic sections. The frozen is basically a throwaway that is only glanced at during the real signout, and only to make sure nothing weird showed up on the slide that wasn't on frozen. The unfortunate thing is that if it is a small lesion (like thyroid or something) the bulk of the lesion is on frozen, and the final diagnosis becomes that much more difficult.

This is why breast frozen section has mercifully become much less common over the last few years. Surgeons have been taught now that doing a frozen on breast lesion destroys a lot of margins and diagnostic tissue.

Absolutely! Can't agree with you more. I think that freezing can screw up antigens for some impox as well. Nothing is worse than having to freeze some little biopsy to realize that suddenly you're faced with doing a metastatic cancer of unknown primary workup. First of all, freezing and cutting the frozen sections can end up in wasting a diagnostically useful specimen. The frozen section slides tell you only a limited amount of information. The benefits are far outweighed by the cons of a frozen section ESPECIALLY if any further workup is required and the frozen section does NOT impact surgical management.

 

[yaah]

We actually had one today - for some bizarre reason a gyn surgeon decided to do a frozen on an EMC (D&C). Thing was, it was done with hysteroscopy and they weren't doing anything abdominally, so it wasn't like if they got cancer on the EMC they would have gone straight to hysterectomy. This woman is 38, desires fertility, and had a prior biopsy with FOCAL changes that were atypical and suspicious but not diagnostic. So what does this surgeon do? A frozen on half of the EMC. Guess where we saw atypical cells? That's right, on the permanents of the frozen. And now they are distorted enough and enough artifact so we can't really tell what the heck it is. (Could just be tubal metaplasia).

We cannot figure out why they sent this for frozen. The only thing we can come up with is the patient is a lawyer and they wanted a quick diagnosis. Wonderful. Now we have to pull the old slides, hopefully compare them, and come up with a non-specific way of saying she needs to be followed closely and probably biopsied again. And put in a comment about all the frozen section artifact.

 

[Doctor B.]

Most annoying thing about pathology? Apheresis.

 

[Doctor B.]

We actually had one today - for some bizarre reason a gyn surgeon decided to do a frozen on an EMC (D&C). Thing was, it was done with hysteroscopy and they weren't doing anything abdominally, so it wasn't like if they got cancer on the EMC they would have gone straight to hysterectomy. This woman is 38, desires fertility, and had a prior biopsy with FOCAL changes that were atypical and suspicious but not diagnostic. So what does this surgeon do? A frozen on half of the EMC. Guess where we saw atypical cells? That's right, on the permanents of the frozen. And now they are distorted enough and enough artifact so we can't really tell what the heck it is. (Could just be tubal metaplasia).

We cannot figure out why they sent this for frozen. The only thing we can come up with is the patient is a lawyer and they wanted a quick diagnosis. Wonderful. Now we have to pull the old slides, hopefully compare them, and come up with a non-specific way of saying she needs to be followed closely and probably biopsied again. And put in a comment about all the frozen section artifact.

It is our job as pathologists to educate the surgeons on when to do frozens and when not to. A frozen section is not some test you order like a CBC. It is a pathology consult. Problem is, it's sometimes hard to explain this to a surgeon in a diplomatic manner. I'll admit, it takes some backbone to tell a surgeon that he/she shouldn't be freezing a certain specimen but sometimes it has to be done in the best interest of the patient.