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EDITORIAL
Year : 2015  |  Volume : 9  |  Issue : 1  |  Page : 1-3

Pathologist-clinician collaboration: A marriage of necessity toward improving the quality of patient care


Department of Pathology, Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria

Date of Web Publication21-Aug-2015

Correspondence Address:
Dauda Eneyamire Suleiman
Department of Pathology, Ahmadu Bello University Teaching Hospital, Shika, Zaria, Kaduna State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-3131.163325

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How to cite this article:
Suleiman DE. Pathologist-clinician collaboration: A marriage of necessity toward improving the quality of patient care. Ann Nigerian Med 2015;9:1-3

How to cite this URL:
Suleiman DE. Pathologist-clinician collaboration: A marriage of necessity toward improving the quality of patient care. Ann Nigerian Med [serial online] 2015 [cited 2019 May 21];9:1-3. Available from: http://www.anmjournal.com/text.asp?2015/9/1/1/163325

The objective of medicine has been eloquently summed up by Stow in his early 20 th century write-up titled: "The correlation of clinician, pathologist and layman." He stated that.
"Medicine has two fundamental objects in view, of equal and vital importance: First, the immediate relief of human suffering and the restoration of the individual to his normal standard of health; second, the protection and maintenance of the members of society in this normal state." [1]

While Stow's assertions remain valid, it is perhaps pertinent to make an addendum to the aforementioned key objectives: Medicine should continually seek new ways to improve the quality of patient management and care.

Collaboration between the pathologist and clinician has been found to be indispensable in improving the quality of patient care especially in, but not limited to, the area of cancer management and care. [2] Even though some sort of communication or collaboration exists between pathologists and their clinical colleagues, it is often circumstantial and usually occasioned by clinicopathological discrepancies recognized by the clinician. What is more sinister is the deliberate withholding of pertinent clinical information by the requesting physician who tries to justify this act by claiming that he/she would be preempting the pathologist by giving all the necessary clinical details. This practice is not only frustrating to the pathologist but is also a very dangerous for the patient with potentially enormous medical, legal, and financial consequences. [3],[4]

The nature of pathology is such that it is heavily dependent on the input of clinicians who are supposed to be fully aware of the limitations and potentials of the specialty. [3] It is, therefore, very pertinent that pathology requisition forms are filled by the clinician who is most familiar with the case and the case not be delegated to the most junior member of the team as is the case most often. Inadequate clinical information has been shown to result in increased diagnostic errors and increased frequency of amended reports. [4] In a study carried out by the College of American Pathologists to address specimen identification and accessioning, 2.4% of cases submitted to surgical pathology had no clinical history provided on the request forms at all while a subsequent study observed that 10% of the amended surgical pathology reports resulted directly from additional clinical information unknown to the pathologist at the time of original sign-out. [4],[5]

Inadequate clinical information has also been identified as the underlying cause of malpractice suits against pathologists, with Troxell and Sabella documenting that it contributed to about one-fifth of diagnostic errors in a review of such situations. [4],[6] There are not enough immunohistochemical stains or computer programs that will fully protect the patient and the pathologist from the errors that inevitably arise from inadequate clinical information; close rapport between the pathologist and clinician is therefore, a necessary step in minimizing this ill. [3],[4],[7],[8] It is vital that surgeons (and indeed all clinicians) ask pathologists questions relating to aspects of the patient's care, especially where he/she does not have a clear idea on the best decisions to take in a particular clinical situation. As Ackerman aptly stated in an earlier edition of Rosai and Ackerman's Surgical Pathology,
"A good surgeon has not only technical dexterity (a fairly common commodity), but also, more importantly, good judgement and a personal concern for his patient's welfare. The surgeon with a prepared mind and a clear concept of the pathology of disease invariably is the one with good judgement. Without this background of knowledge, he will not recognize specific pathologic alterations at surgery nor will he have a clear concept of the limitations of his knowledge, and therefore he will not know when to call the pathologist to help him. Without this basic knowledge, he may improve his technical ability but never his judgment. One might say that with him his ignorance is refined rather than his knowledge broadened." [3]

Furthermore, the clinicians should not hesitate to ask for clarifications or explanations from the pathologist in cases where there is no correlation between clinical and histological diagnosis or where the clinician is unaware of a particular pathological entity.

The responsibility for ensuring improved communication/collaboration does not end with the clinician. The pathologist must strive to ascertain the expectations of the clinician in a given case and try to meet them. He/she must provide a report that is not only diagnostically accurate but also timely. He/she must avoid unnecessary histological jargon that has no clinical relevance. Rather, he/she should concentrate on areas that bear a significant relation to therapy and prognosis. [3],[9] As Richard Reed correctly noted, "a competent [pathologist] is not simply a storage site for microscopic verbiage. It is not enough to be able to recite by rote the microscopic findings once the clinical diagnosis is established. The ability to offer clinical differential diagnoses from the interpretation of microscopic findings is the mark of the mature [surgical] pathologist. In addition, he may record data that are prognostically significant or offer suggestions for pertinent clinical tests. The ability to recognize cytological and histological features is simply a beginning. The ability to integrate microscopic findings into a meaningful interpretation is the distinguishing characteristic of a pathologist and is the art of pathology." [3]

The diagnosis line in a pathologist's report must exhibit supreme clarity and the choice of word is of paramount importance in this regard. Any ambiguity can obviously lead to misinterpretation by the clinician of what the pathologist intends to convey, with disastrous consequences. [10],[11]

The practice of pathology is closely affiliated to many branches of medicine including but not limited to all the surgical specialties, internal medicine, dermatology, neurology, diagnostic radiology, radiation therapy, and medical oncology. [3] As to the field of radiology in particular, various specialists have made the bold call that the field could be merged or integrated with pathology. [12],[13] However, apart from this, is the recognition that although the study of radiology deals with shadows and the study of pathology with substance, the correlation of those shadows with the gross substance strengthens the diagnostic skill of the radiologist, explains errors in radiologic interpretation, and instils humility rather than dogmatism. [3]

The pathologist must, in addition to knowing his/her field thoroughly, have a strong background in clinical medicine as this will allow him/her to understand the clinician's needs and appropriately respond to them. Beyond stating whether a lesion is benign or malignant, he/she must make comments on the extent of the disease, adequacy of excision, and the requirements for additional therapy and prognoses, among others.

Various strategies have been suggested in a bid to improve communication between the clinician and pathologist. Interdepartmental or clinicopathological conferences would be quite useful in this regard. More specifically, the establishment of multidisciplinary teams (MDTs) will improve communication between different specialities and by extension, improve the standard of care. This is since cooperation and collaboration are greater when each discipline understands the roles, possibilities, and limitations of the other ones, allowing a trusting relationship to be developed between the specialities. [13],[14] MDTs between pathology, radiology, and other clinical specialties also add quality to diagnosis and patient management decisions. [15]

Apart from the aforementioned strategies, simple phone calls or face-to-face interaction between pathologists and clinicians is a very reliable way of resolving conflicts, promoting rapport, fostering trust between colleagues and ensuring that pathologists provide the clinicians with clinically-relevant diagnoses..

Finally, both clinicians and pathologists alike must understand that there are limitations to histologic diagnosis. Improved communication/collaboration will minimize the frustration that the clinician experiences after obtaining a biopsy in the hope of receiving a precise pathological diagnosis only to receive instead a diffuse statement of circumstances. [16] This particular point is further buttressed by Oscar Rambo's article on the limitations of histologic diagnosis. He writes that:
"Pathologists are physicians and human beings. They have as great a capacity for error and susceptibility to subjective distractions as other practitioners of the art of medicine. A mystic perversion prevails among those clinicians who believe that the pathologist, given only a piece of a patient's tissue, has all of the other ingredients necessary to produce a statement of absolute truth at the end of his report. More dangerous to mankind is a pathologist with the same concept…

Incomplete communication between the clinician and pathologist may make diagnosis difficult or impossible. To perform intelligently, a consultant must know all the facts that have any bearing on the case. To render a diagnosis from an inherently puzzling bit of tissue with only vague knowledge of its source and no concept of the clinical problem is as fool-hardy as to undertake an appendectomy on the basis of hearsay evidence that the patient has a pain in his belly." [3],[4]

From the foregoing, it is obvious that the merits of improved physician-pathologist collaboration far outweigh whatever disadvantages that may arise from such interactions. It is therefore, recommended that pathologists and clinicians alike explore new ways and strategies to improve this interaction and by extension, minimize patient harm and improve the quality of patient care.

 
   References Top

1.
Stow B. Correlation of clinician, pathologist and layman. JAMA. 1908;LI:191-4.  Back to cited text no. 1
    
2.
Scolyer R, Stretch J, McCarthy S, Thompson J. Collaboration between clinicians and pathologists: A necessity for the optimal management of melanoma patients. Cancer Forum 2005;29:80-84.  Back to cited text no. 2
    
3.
Rosai J, editor. Rosai and Ackerman′s Surgical Pathology. 10 th ed. Philadelphia: Mosby, Elsevier; 2011. p.1-20.  Back to cited text no. 3
    
4.
Nakhleh RE, Gephardt G, Zarbo RJ. Necessity of clinical information in surgical pathology: A college of American pathologists Q-probes study of 771 475 surgical pathology cases from 341 institutions. Arch Pathol Lab Med 1999;123:615-9.   Back to cited text no. 4
    
5.
Nakhleh RE, Zarbo RJ. Amended reports in surgical pathology and implications for diagnostic error detection and avoidance: A College of American Pathologists Q-Probes study of 1,667,547 accessioned cases in 359 laboratories. Arch Pathol Lab Med 1998;122:303-9.   Back to cited text no. 5
    
6.
Troxel DB, Sabella JD. Problem areas in pathology practice: Uncovered by a review of malpractice claims. Am J Surg Pathol 1994;18:821-31.   Back to cited text no. 6
    
7.
Lerch MM. Cooperation between clinicians and pathologists. Verh Dtsch Ges Pathol 2001;85:87-90.   Back to cited text no. 7
    
8.
Nakhleh RE. Quality in surgical pathology communication and reporting. Arch Pathol Lab Med 2011;135:1394-7.   Back to cited text no. 8
    
9.
Crook M. Clinical governance and pathology. J Clin Pathol 2002;55: 177-9.   Back to cited text no. 9
    
10.
Heffner DK, Adair CF. Clarity on the diagnosis line (the devil is in the details). Ann Diagn Pathol 1999;3:187-91.   Back to cited text no. 10
    
11.
Lindley SW, Gillies EM, Hassell LA. Communicating diagnostic uncertainty in surgical pathology reports: Disparities between sender and receiver. Pathol Res Pract 2014;210:628-33.   Back to cited text no. 11
    
12.
Sorace J, Aberle DR, Elimam D, Lawvere S, Tawfik O, Wallace WD. Integrating pathology and radiology disciplines: An emerging opportunity? BMC Med 2012;10:100.   Back to cited text no. 12
    
13.
Howell WLJ. Radiology and Pathology Time to Integrate. UBM Medica Network. Available from: http://www.diagnosticimaging.com/. [Last accessed on Aug 10, 2015].  Back to cited text no. 13
    
14.
Ruhstaller T, Roe H, Thürlimann B, Nicoll JJ. The multidisciplinary meeting: An indispensable aid to communication between different specialities. Eur J Cancer 2006;42:2459-62.   Back to cited text no. 14
    
15.
Kane B, Luz S, O′Briain DS, McDermott R. Multidisciplinary team meetings and their impact on workflow in radiology and pathology departments. BMC Med 2007;5:15.   Back to cited text no. 15
    
16.
Legg MA. What role for the diagnostic pathologist? N Engl J Med 1981;305:950-1.  Back to cited text no. 16
    



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