The Tyranny of Turnaround
The delivery of a surgical pathology report comes at the end of a long journey through the laboratory, via the deliberations of one or more pathologists, acting alone or in concert. The need for speedy diagnosis presents the academic surgical pathologist with an exceptional challenge, difficult to meet without compromising the coexistent mission of teaching and research. The mantra of the day is Turnaround Time, the rapidity with which a test result can be spun out, measured from entry of specimen to exit of report. The demand for rapid results emanates at least in part from the requirement imposed by insurance companies (through managed care) to reduce the amount of Time that patients spend in hospitals. Hospital bills to third party payers cannot be submitted until the pathology report has been finalized; and patients, of course, want quick access to their biopsy results. Private laboratories generate short turnarounds because they are unencumbered by trainees and handle much smaller specimens. Figure 5 shows (on the left) an example of a large specimen bucket of the type commonly received in major hospital laboratories, compared (on the right) with the the typical small biopsy receptacle sent to most private settings. The large and often complicated specimens are one of various factors making it harder for tertiary, teaching departments to compete on turnaround.
Although it is true that some of the strain incurred by a long wait could be lessened if pathologists were to intermittently communicate with their clinicians, this is much more easily said than done because everyone, including pathologists, is exceedingly busy. Clinicians are apt to move between locations, and surgeons are often pinned down in operating rooms. No one hangs around for a call to be returned, and the cumulative time spent on phone menus is nauseating. Some cases simply cannot and must not be rushed. Surgical pathologists are familiar with pressures exerted by VIPs, physicians or their family members, politicians, actors and so on. These pressures must be politely but firmly handled. Sometimes, what the surgical pathologist most needs is to put the slides down, go home, and have a decent night’s sleep. Things are always clearer in the morning.
Sometimes, getting a tissue diagnosis is an emergency, and for this, the laboratory will activate exceptional procedures so that an answer is available within hours. An example would be when a rapidly growing tumor threatens a vital structure, such as an airway or the spinal cord, or when the urgent use of chemo- or radiotherapy depends on a biopsy result. A legitimate issue is the actual clinical (not psychological) difference between making a tissue diagnosis of cancer on the first of the month versus the 15th or even the 20th. This is a very sensitive area and I mention it with trepidation because patients, understandably, do not want to hear this information or necessarily even care about it. Take the development of cancer. It is known that many cancers evolve over a relatively long Time, so that the moment of their discovery is only a recent fraction of their biologic history. If a patient has had symptoms referable to a tumor that has been incubating for years, and then must wait for a week or more for a surgical procedure, it is the understandable and pressing anxiety, the pressure to issue a bill, and the desire to commence treatment that conjoin to wring out a complete pathology report in less than a week. The drumbeat of turnaround erodes our ability to thoroughly analyze difficult cases, depriving us of the legitimate Time that we need to think things out.
