An ordinary citizen revisited
If your biopsy specimen is really small, if speed is the only thing that matters, if yours is the only sample being processed that day, if the pathologist has only your biopsy to interpret, if there are no glitches, and if the laboratory is not involved in the training of pathology residents, the result on a specimen taken at 8:00am would probably be in the hands of your physician before noon. For a reality check, I now reconstruct the life cycle from an earlier section, but in a much expanded narrative, geared around a biopsy of the breast.
I select a breast biopsy because these specimens engender the most intense emotion and anxiety, even though most breast lesions turn out to be benign. Biopsies from other sites are no less cause for worry, but in my experience, the unnerving wait for a breast biopsy result imposes the most pressure upon pathologists from patients and their doctors. Men who have had prostate biopsies, or others who may have had samples taken from the colon, stomach, skin or any other site, have as much worry about the outcome as the woman with a breast lump. However, since the fight against breast cancer has political resonance, since breast surgery is disfiguring, and because breast pathology poses its own set of morphologic challenges, this is a useful vehicle with which to illustrate a few points. The permutations on what follows are numerous, and one example cannot possibly illustrate all potential events. In the case that follows, certain realistic obstacles have been deliberately placed on the path to a diagnosis.
On a Thursday afternoon, Jane Brown, in her mid-fifties, is found by her family practitioner, Dr. Winkler to have an approximately 1.5cm lump in her left breast. He has great confidence in a breast surgeon, Dr. Helmin, whom he wants Mrs. Brown to consult. Fortunately, the surgeon is on the panel used by Mrs. Brown’s insurance company. Dr. Helmin will be out of town until Monday, when he agrees to squeeze Mrs. Brown into his schedule. With some juggling, he arranges a biopsy on Tuesday afternoon. Mrs. Brown will undergo a Mammotome® procedure, whereby a sample will be extracted under local anesthesia with a needle using a slight vacuum. She is assured that the technique will yield an accurate diagnosis. The procedure commences in Dr. Helmin’s office at 5:00pm on Tuesday, and is completed at 5:45pm. Delivery to the laboratory cannot be accomplished in Time for specimen processing to begin that evening, and the tissue is therefore held in his office overnight, being sent on Wednesday morning to a large hospital with a pathology residency program. Approximately six days have elapsed since the lump was discovered.
The interposition of a residency program adds a demanding layer to the workings of any medical department. To produce skilled future diagnosticians, we must offer residents realistic opportunities to nurture those skills. Without practice under the guidance of pathologists whose professional lives are geared towards teaching, the pool of pathologists can never be replaced. In a teaching hospital, the overall thrust of the pathology department is, of necessity, different from what one might expect in a for-profit laboratory, which has priorities oriented not only towards diagnostics but also towards very rapid result turnaround. For-profit laboratories are staffed by pathologists who have already had the benefit of training within the cocoon of the academic medical center. Not so long ago, my own department underwent a regularly scheduled inspection from The College of American Pathologists. The inspecting team was composed of representatives of a large group of hospitals that boasted a very impressive and enviable level of operational efficiency. During the summary session, I asked whether these hospitals deal with residents and was told, with a slight chuckle, that they had given up on resident training in order to achieve the goals of their private mission.
Some large academic pathology departments may be in a position to run a 24 hour laboratory, with histotechs cutting blocks and staining slides through the night. The resources, however, available to most teaching institutions, are tight, so that histotechs who will have started in staggered shifts as early as 4:30am will have largely departed by mid afternoon. A few would be on hand to nurse things through until about midnight, but the bulk of the staff will have been gone by 4:00pm. Thus, a laboratory receiving upwards of 30,000 cases annually, may only be able to run one biopsy load a day, the run commencing at about 7:30pm, with the slides available for the pathologist next morning. Therefore any specimen entering the laboratory late on Day 1 may not make that day’s 7:30pm run and would have to wait for the 7:30pm run on Day 2. Since the laboratory may not be routinely staffed on weekends, the Friday evening run would be postponed until Sunday evening. A recent innovation, a tissue processor that allows continuous rather than batch processing, is expensive but is making a gradual appearance. The “continuous” delivery of slides, however, implies that pathologists are continuously present to receive and interpret them. In an understanding world, one would imagine that the scope of experience in an academic pathology department would somehow compensate for longer reporting times. Were that it were so.
Wednesday morning. Mrs. Brown’s specimen arrives in the laboratory at 10:30am. Her data are entered into the software program, and her specimen is assigned to a specific pathologist who will receive her slides the next day.
The reason that a particular pathologist will get her specimen is because (1) responsibility for the case must reside with a qualified individual accountable for the management of the case and the diagnosis; (2) Dr. Helmin will need to know whom to approach with any questions about the biopsy; (3) the resident must know to which pathologist he or she will be reporting; (4) pathologists typically work according to a schedule that governs whether they are on duty for biopsies, larger specimens, cytology, autopsies, and so on.
Thursday morning. The resident expects the first batch of slides at 8:00am. Unfortunately, the laboratory is short-staffed, and the slides arrive at 10:30am. There are thirty cases, a total of 125 slides, among which three represent Mrs. Brown’s biopsy. The resident, a second-year trainee, examines her batch for an hour and a half. Grabbing a sandwich and a soda, she attends a mandatory noon conference that concludes at 1:15pm. In attendance is Dr. Smith, the program director, to whom she will be reporting. Dr. Smith, a senior pathologist, has been in academic practice for 25 years. He is a generalist with strength in gastrointestinal pathology. He was engaged that morning in a meeting to prepare for an inspection by the Residency Review Committee, based in Chicago. He is also pre-occupied with slides from earlier in the week. By 2:00pm, the resident has examined seventy-five percent of her cases, when she is asked by Dr. Smith to bring the slides to him for review. At 2:15pm, as they settle down at the two-headed microscope, she sees him make a brief note on a scrap of paper that he takes from his shirt pocket. “What is that?” she asks. “Oh, just my Medicare tracking.” (See Appendix 1; under CONCLUSION)
After a half hour of uninterrupted work, Dr. Smith is handed a note by a secretary, who says that she received a phone call from Dr. P, a surgeon, angrily complaining that the pathology result on the colon of one of his patients was still not available at one week after the operation, and that the patient has an appointment in his office at 3:00pm. Dr. P was very demanding, rude actually, she says, and expects a call from the pathologist. Dr. Smith suspends the session with the resident and scrolls through the computer system to find Dr. P’s patient. The report was “delayed” by the need for intradepartmental consultations and by the need to return to the colon to select additional tissue for processing; timeliness has not been helped by the fact that the colon had arrived on a late Friday afternoon, and by the interposition of two weekends. Dr. Smith extracts the case, verifies the details before putting his signature to the report, and phones the surgeon. A menu thanks him for calling the surgical group and advises him to listen carefully because the options have changed. He finds himself on hold, listening to a selection of music. After identifying himself to an individual who enquires about the nature of the call, Dr. Smith is placed on hold. Dr. P. comes on the line, and the two of them have an unpleasant conversation about turnaround time.
It is five minutes past three in the afternoon. Dr. Smith’s message light is blinking. “There are five messages in your mailbox.” By the Time that he has dealt with these, it is 3:20pm. The resident returns and they continue with the biopsies until 4:00pm, when both need to attend a lecture on placental abnormalities by a visiting professor. They resume work at 5:00pm and continue until 6:00. So far, Dr. Smith has been able to devote 130 minutes to his current biopsy load of 125 slides. Were he to have squeezed all of those slides into 130 minutes, and assuming that everything was equally easy to interpret, then he would have devoted exactly 0.96 minutes to each slide. He pushes ahead until 7:00pm, when a combination of eye-strain, mental fatigue, an aching back and hunger warn him to stop. The last slides on the microscope stage belong to Mrs. Brown. A glance tells Dr. Smith that they merit showing at the staff conference the next morning, Friday.
Many groups, including my own, convene daily sessions around a multi-headed microscope that can accommodate more than ten individuals. Here, pathologists share their difficult and even not-so-difficult problems. These conferences allow one to measure one’s interpretations against the group, although it is the individual pathologist who is ultimately responsible for the text of the final report. Anyone who does not agree with the opinion of the group may seek an opinion elsewhere, unless of course the leader chooses to assume full control of the case. The interpersonal dynamics yield animated discussion, and reflect the persuasiveness of some members versus others. This is a healthy forum that helps to keep one calibrated and informed about trends in the field. The stimulus for having such a conference is practical as well as academic, but there can be no doubt that medicolegal issues also play a role. The proceedings of the conference are recorded, and include a register of attendees. The final pathology report will usually contain a statement to the effect that the case has been examined at conference. It may be surprising, but I have seen a group of diligent pathologists arrive at a beautiful consensus that eventually turns out to be completely wrong. Such is the humbling nature of this work.
Friday morning, 10:00am. Dr. Smith brings a few cases to the conference. Six others take turns showing their cases. When Dr. Smith puts Mrs. Brown’s biopsy slide forward, it is almost noon. The issue at stake is whether her specimen shows only non-invasive cancer or whether there are minute areas of invasion. If invasion were present, she would undergo not only resection of the lump, but also a sentinel lymph node biopsy, perhaps to be followed by removal of more tissue from her axilla, and local irradiation. The group advises another investigative procedure on the specimen. As a result, additional sections will be taken from the paraffin block for treatment by a special immunologic technique. The laboratory that performs this investigation has already started its run for the day, so that Mrs. Brown’s material must wait for Monday’s run. It is unfortunate that a clear-cut diagnosis cannot be issued at once and that she is likely to have an anxious weekend.
The immunologic procedure commences on Monday, at a facility separate from the hospital. The tested slide is ready by 10:00am on Tuesday, and is packaged along with others, to be couriered back to the department of pathology. The courier picks up the batch at 11:00am and, after an intermediate stop, delivers everything to the department at 11:45am, placing the package in the pathology office. Its presence is not noticed for a while because the computer system has just been restored after being “down” for 30 minutes, and all of the secretaries are focused on getting their reports typed so that the paperwork may join the day’s stream of slides emerging from the laboratory. At 12:15pm, the office supervisor places the work from the immunology laboratory on Dr. Smith’s shelf. Much as he is interested in the additional stains, he must attend the hospital Graduate Medical Education meeting in his capacity as Program Director, for a review of the broad educational goals of the institution. The meeting formally ends at 1:00pm, but he is detained by the committee chairman, who wishes to convene an ad hoc committee to investigate a pathology resident who appears to be psychologically troubled. At 1:20pm, Dr. Smith returns to his office and sees a patchwork of pink slips fluttering on his door, telephone messages while he was away: Dr. A. wishes to discuss a placental report; Dr. B. wants the slides on Mrs. Sedgwick sent to a consultant upstate; Dr. C. wants to be paged before 1:00pm; Dr. Helmin, too, has called; the last note, about an ovarian specimen, has a request from the surgeon: “please check carefully.” On Dr. Smith’s chair lie three slide trays from a case dating back to 1997, accompanied by a request for determination of Her 2/Neu status (not available in 1997) on the patient’s breast cancer. This will entail an examination of the old report and the slides (stored off-site) in order to identify which tissue block is most suited for the test. Standing in the doorway is the supervisor of the laboratory with a question about the identity of a tissue block. By 2:30pm, Dr. Smith has cleared the deck. Numerous cases are still pending, and others continue to arrive. The final report on Mrs. Brown is ready at 3:30pm, 13 days since the lump was palpated by Dr. Helmin, eight days since the biopsy procedure was performed, and seven days since it arrived in the laboratory. Excluding the weekend, the laboratory managed to get the result out in 5 days. In biologic time, the tumor is reckoned to have started growing several years beforehand.
The course that I have described for Mrs. Brown’s biopsy represents, as far as I am concerned, a reasonable performance from an academic department, from which she obtained the benefit of talented pathologists working in concert. The reality is that breast and other pathology reports can legitimately take even much longer to emerge. The laboratory may need to cut deeper levels into one or more of the blocks, or the pathologist may need to return to an original wet specimen to select additional material for processing. Internal consultations take Time because individuals with specialized knowledge may not be available on demand. Consultations with a nationally recognized pathologist may be essential, but these people are also busy and are hard to pin down, either because they travel to distant meetings, are busy writing books, or are off somewhere doing the thinking that needs to be thought. All of these factors inevitably lengthen the turnaround time. The quality of the final opinion may be expressed in an equation that compresses the important variables into a simple formula:
