L ike a stagehand behind the action of a play, your pathology lab provides critical support to your patient care. The information the lab provides often has a major impact on treatment decisions. But how accurate are the results your lab provides? Are qualified clinicians interpreting your specimens? Can you get through to the pathologist if you have a question? In this article, we’ll provide practical advice for getting the best results from your lab. First though, let’s look more closely at why lab results are important. Serious Consequences You’re well aware that a misread specimen can have serious consequences for patient care. Years ago, one attitude about dermatology specimens was “It’s only skin,” says Wilma F. Bergfeld, M.D., F.A.C.P., head of dermatopathology in the Department of Pathology at the Cleveland Clinic Foundation. She is also a practicing dermatologist in the Department of Dermatology there. The sometimes small size of specimens also led to some trivialization of reading them, she notes. But the deadly nature of melanomas, for instance, proved that attitude wrong. Besides patient care, poor lab results can lead to legal liability. That you didn’t know who read a slide is no protection from a lawsuit, says Clay J. Cockerell, M.D., clinical professor of dermatology and pathology at the University of Texas Southwestern Medical Center at Dallas. He’s also medical director at Dermpath Diagnostics, a division of AmeriPath, a pathology management services company. You can’t be held liable for another specialist’s malpractice, says Phillip Williford, M.D., associate professor of dermatology and director of dermatologic surgery at Wake Forest University School of Medicine, Winston-Salem, NC. But the cold reality is that you’ll in all likelihood be named in any lawsuit resulting from a misread slide. What’s more, with more patients being consumer-oriented, they may ask who will read their specimen, according to Dr. Cockerell. They may even be willing to pay out of pocket to have their specimen read by a lab they may feel more comfortable with. Case in Point Even though Georgetown University has its own dermatopathology lab, about 40% of specimens are sent to outside labs, says C. Lisa Kauffman, M.D., F.A.C.P., chief of dermatology at Georgetown and also associate professor of medicine, dermatology, and pathology. Dr. Kauffman is also director of the dermatopathology lab. In one example, about three years ago, a surgery resident asked her to electrodesiccate and curette a small basal cell carcinoma (BCC) on the resident’s nose. The specimen was read at an outside lab, which identified it as malignant but didn’t comment on the margins or whether the BCC was aggressive. Reviewing the slide herself, Dr. Kauffman found an aggressive, infiltrating tumor present at several margins. Without reading the slide, Dr. Kauffman might have treated the resident superficially, she said. In the end, a Mohs surgeon removed five layers of the resident’s skin. Depending on Dermatopathologists One huge key to accuracy involves the expertise of the person who’s reading your slide. Clinicians are divided about whether dermatology specimens should be read by dermatopathologists or general pathologists. Some argue that board-certified dermatopathologists are best equipped to read slides, especially those that present challenges in interpretation. A lab strictly dedicated to skin pathology and staffed by board-certified dermatopathologists represents the best lab for dermatologists, says George Hollenberg, M.D., director of laboratories at Acupath Laboratories in New Hyde Park, NY. If a dermatologist is going contract with a specific lab, he or she needs to make sure, during contract discussions, that the lab has a board-certified dermatopathologist on board to read skin specimens, says Dr. Bergfeld. Dr. Bergfeld says that she has the best of both worlds. Her office at the Cleveland Clinic resides in the anatomical pathology department. She can consult with other pathology colleagues to improve what she can do, though she uses herself as the primary dermatopathologist. This, she feels, represents the ideal setting – where a dermatopathologist has an association with general pathologists who have specific expertise in soft tissue tumors, cytology and lymphomas. In this way, she can easily consult with colleagues. Another View The position that only board-certified dermatopathologists can read specimens is a bit extreme, argues Ralph J. Tuthill, M.D., of the Department of Anatomic Pathology, Section of Dermatopathology at Cleveland Clinic Foundation. There may well be, he notes, general pathologists with enough interest and experience in dermatopathology to do a “more than satisfactory job on interpreting these cases.” In particular, a general pathologist who has access to consultation with a board-certified dermatopathologist would be acceptable, he says. In the ultimate analysis, it’s not the label of the person who peruses the tissue that matters but his or her competence, says A. Bernard Ackerman, M.D., director of the Ackerman Academy of Dermatopathology, New York City. Some dermatopathologists, he notes, may be less competent than general pathologists who may not have their boards in dermatopathology. As a general principle, however, Dr. Ackerman advises that a board-certified dermatopathologist is best equipped to render diagnosis with precision of a skin lesion that poses a problem in diagnosis histopathologically. It’s most important, he says, that HMOs and other insurance carriers be alert to permitting any pathologist who is competent in dermatopathology to read sections, whether that’s a dermatopathologist or general pathologist. While certifications do matter, a practicing dermatologist is well-advised to inquire into the training of the person reading sections of tissue taken by the dermatologist, he says. The worst offenders, he says, are dermatologists who read their own sections on their own patients but aren’t highly qualified to do so. This can represent a “terrible conflict of interest,” Dr. Ackerman notes, though it may be acceptable if both the patient and dermatologist are aware of the practice. Challenging Lesions Expertise becomes even more crucial in lesions that are difficult to interpret. Some subtle skin disorders, such as mycosis fungoides, require a very educated pathologist in skin to make the histologic diagnosis, says Brian Adams, M.D., associate professor in the Department of Dermatology at the University of Cincinnati Medical Center. Virtually only dermatopathologists, says Dr. Hollenberg, can interpret inflammatory skin diseases, such as psoriasis. Also challenging are blistering disorders, such as bullous pemphigoid, pemphigous, and epidermolysis bullosa acquisita. Likewise, Dr. Williford has no problem with general pathologists reading specimens, but believes the advantage of having a dermatopathologist read specimens comes with inflammatory skin diseases. With those cases, subtle differences in reaction patterns can lead to different diagnoses, he notes. On the “Low End” Related to these issues and worrisome to various clinicians are pressures by managed care organizations (MCOs) to use “low end” labs. Some MCOs will require physicians to send specimens to a specific lab that may or may not have an individual with expertise in dermatology, says Dr. Cockerell. Dr. Williford says he would opt out of contracts where he was afraid the tissue was being sent to a “low end” lab. He would fear that these labs might not give complete service and pose a malpractice risk. Some large labs, Dr. Williford says, employ many pathologists that must read a certain number of specimens to meet productivity goals. This overflow of specimens sometimes doesn’t allow the “cognitive effort” that a particular case might require, he notes. On a contrary note, a low-end or commercial reference lab has a huge liability if it turns into some kind of “industrial mill of pathology,” notes an official from the College of American Pathologists. He suspects that it’s a “rare exception” when one encounters that issue. He also notes that quality is the main driving force behind these labs’ efforts, not liability. MCOs are becoming more aware of this issue, says Dr. Cockerell. They’re realizing it’s penny wise and pound foolish to alienate dermatologists, he says. How Much Is Too Much? Besides the qualifications of the clinician reading the specimens, another concern involves the sheer number of specimens pathologists are called to read. “Everyone who can hold a scalpel is biopsying,” says Dr. Bergfeld, in a bit of hyperbole. But the simple fact is that there are more biopsies that need to be read in pathology labs. How much is too much for any one pathologist? That depends on a variety of factors, says Dr. Cockerell. Those include the pathologist’s comfort and confidence in reading a good number of specimens, as well as the lab’s efficiency and level of automation. Another factor: whether the lab is getting specimens from a referral practice, which likely will present more complex cases for interpretation. No benchmark exists beyond which he starts to worry, says the official from the College of American Pathologists. Only in gynecologic cytopathology are workloads imposed, he says, and there only on screening, not diagnosis. Only large national pathology groups or reference labs are going to push volume requirements, says Charles Root, Ph.D., of MCF Compliance in Chicago. Anytime you deal with a local group of pathologists, you’re generally not going to push the envelope that much, he says. One risk with large national labs, he notes, is you may not be sure where your specimens are being processed. The more sophisticated labs will send them where they have the capacity. One specific estimate comes from Dr. Tuthill, who estimates a pathologist can accurately read about 75 specimens per day. As a board-certified dermatopathologist, he sometimes reads more than that, but finds it stressful to do so. He does note that he has other responsibilities besides reading specimens. Communication Is Key Knowing the expertise of those reading your specimens and the volume they read per day can help you get the best service for yourself and your patients. Another important factor involves communication. As a dermatologist, you’re not sending out a simple blood test, for instance, to a nameless lab, says Dr. Adams. On the contrary, you need to know who the pathologists are and work with them. It’s your duty, he says, to call the lab once you know where your specimens are being sent. You need to get to know how they approach skin lesions. Some specimens can present subtleties that are quite difficult, says Dr. Williford. Arriving at a correct diagnosis requires a good treating physician who can relay information to a pathologist. There must be some “ease of communication between the clinician and pathologist,” says Dr. Adams. Lines have to be open both ways, so that you can call the pathologist to ask questions about a result, and the pathologist can call you when he needs clarification. More Questions In getting to know your lab, you’ll want to explore other areas. Check their quality control, says Dr. Bergfeld. Know their charges, and also ask about their business plan. Find out if special studies are available, such as immunophenotyping and polymerase chain reaction. (See Tests of the Future on page 34.) Also make sure that the lab complies fully with Medicare regulations, says Dr. Root. You may get tarred with the same brush as the lab it if has Medicare problems. Ensure the lab has a compliance officer. Check accreditation as well. About 17,000 labs are accredited by private, not-for-profit organizations, according to the College of American Pathologists. The College accredits about 6,500 of these, the vast majority of those being clinical labs. Raising Complaints If you’re not happy with the quality of service from a lab you use, you can take various steps. Some dermatologists, says Dr. Cockerell, have written to MCOs and expressed their complaints. Solutions fall into various areas, he suggests. First, the MCO may agree that you can send the specimen to the lab you want. Another solution is that you can insist that the lab have on staff a board-certified dermatopathologist. That’s not a substitute, though, for having someone read your specimens whom you know and trust, he notes. You can try to contact the insurance company or lab and demand that a dermatopathologist see your biopsies, notes Dr. Hollenberg. Another tactic that can help your case: stamp the requisition “Must be seen by dermatopathologist,” he suggests. Crucial Support Though behind the scenes, specimen reading is a crucial part of providing excellent dermatologic care. Given the importance of this task, you have to ensure that you’re getting accurate results.
Are You Confident in Your Lab’s Accuracy?
L ike a stagehand behind the action of a play, your pathology lab provides critical support to your patient care. The information the lab provides often has a major impact on treatment decisions. But how accurate are the results your lab provides? Are qualified clinicians interpreting your specimens? Can you get through to the pathologist if you have a question? In this article, we’ll provide practical advice for getting the best results from your lab. First though, let’s look more closely at why lab results are important. Serious Consequences You’re well aware that a misread specimen can have serious consequences for patient care. Years ago, one attitude about dermatology specimens was “It’s only skin,” says Wilma F. Bergfeld, M.D., F.A.C.P., head of dermatopathology in the Department of Pathology at the Cleveland Clinic Foundation. She is also a practicing dermatologist in the Department of Dermatology there. The sometimes small size of specimens also led to some trivialization of reading them, she notes. But the deadly nature of melanomas, for instance, proved that attitude wrong. Besides patient care, poor lab results can lead to legal liability. That you didn’t know who read a slide is no protection from a lawsuit, says Clay J. Cockerell, M.D., clinical professor of dermatology and pathology at the University of Texas Southwestern Medical Center at Dallas. He’s also medical director at Dermpath Diagnostics, a division of AmeriPath, a pathology management services company. You can’t be held liable for another specialist’s malpractice, says Phillip Williford, M.D., associate professor of dermatology and director of dermatologic surgery at Wake Forest University School of Medicine, Winston-Salem, NC. But the cold reality is that you’ll in all likelihood be named in any lawsuit resulting from a misread slide. What’s more, with more patients being consumer-oriented, they may ask who will read their specimen, according to Dr. Cockerell. They may even be willing to pay out of pocket to have their specimen read by a lab they may feel more comfortable with. Case in Point Even though Georgetown University has its own dermatopathology lab, about 40% of specimens are sent to outside labs, says C. Lisa Kauffman, M.D., F.A.C.P., chief of dermatology at Georgetown and also associate professor of medicine, dermatology, and pathology. Dr. Kauffman is also director of the dermatopathology lab. In one example, about three years ago, a surgery resident asked her to electrodesiccate and curette a small basal cell carcinoma (BCC) on the resident’s nose. The specimen was read at an outside lab, which identified it as malignant but didn’t comment on the margins or whether the BCC was aggressive. Reviewing the slide herself, Dr. Kauffman found an aggressive, infiltrating tumor present at several margins. Without reading the slide, Dr. Kauffman might have treated the resident superficially, she said. In the end, a Mohs surgeon removed five layers of the resident’s skin. Depending on Dermatopathologists One huge key to accuracy involves the expertise of the person who’s reading your slide. Clinicians are divided about whether dermatology specimens should be read by dermatopathologists or general pathologists. Some argue that board-certified dermatopathologists are best equipped to read slides, especially those that present challenges in interpretation. A lab strictly dedicated to skin pathology and staffed by board-certified dermatopathologists represents the best lab for dermatologists, says George Hollenberg, M.D., director of laboratories at Acupath Laboratories in New Hyde Park, NY. If a dermatologist is going contract with a specific lab, he or she needs to make sure, during contract discussions, that the lab has a board-certified dermatopathologist on board to read skin specimens, says Dr. Bergfeld. Dr. Bergfeld says that she has the best of both worlds. Her office at the Cleveland Clinic resides in the anatomical pathology department. She can consult with other pathology colleagues to improve what she can do, though she uses herself as the primary dermatopathologist. This, she feels, represents the ideal setting – where a dermatopathologist has an association with general pathologists who have specific expertise in soft tissue tumors, cytology and lymphomas. In this way, she can easily consult with colleagues. Another View The position that only board-certified dermatopathologists can read specimens is a bit extreme, argues Ralph J. Tuthill, M.D., of the Department of Anatomic Pathology, Section of Dermatopathology at Cleveland Clinic Foundation. There may well be, he notes, general pathologists with enough interest and experience in dermatopathology to do a “more than satisfactory job on interpreting these cases.” In particular, a general pathologist who has access to consultation with a board-certified dermatopathologist would be acceptable, he says. In the ultimate analysis, it’s not the label of the person who peruses the tissue that matters but his or her competence, says A. Bernard Ackerman, M.D., director of the Ackerman Academy of Dermatopathology, New York City. Some dermatopathologists, he notes, may be less competent than general pathologists who may not have their boards in dermatopathology. As a general principle, however, Dr. Ackerman advises that a board-certified dermatopathologist is best equipped to render diagnosis with precision of a skin lesion that poses a problem in diagnosis histopathologically. It’s most important, he says, that HMOs and other insurance carriers be alert to permitting any pathologist who is competent in dermatopathology to read sections, whether that’s a dermatopathologist or general pathologist. While certifications do matter, a practicing dermatologist is well-advised to inquire into the training of the person reading sections of tissue taken by the dermatologist, he says. The worst offenders, he says, are dermatologists who read their own sections on their own patients but aren’t highly qualified to do so. This can represent a “terrible conflict of interest,” Dr. Ackerman notes, though it may be acceptable if both the patient and dermatologist are aware of the practice. Challenging Lesions Expertise becomes even more crucial in lesions that are difficult to interpret. Some subtle skin disorders, such as mycosis fungoides, require a very educated pathologist in skin to make the histologic diagnosis, says Brian Adams, M.D., associate professor in the Department of Dermatology at the University of Cincinnati Medical Center. Virtually only dermatopathologists, says Dr. Hollenberg, can interpret inflammatory skin diseases, such as psoriasis. Also challenging are blistering disorders, such as bullous pemphigoid, pemphigous, and epidermolysis bullosa acquisita. Likewise, Dr. Williford has no problem with general pathologists reading specimens, but believes the advantage of having a dermatopathologist read specimens comes with inflammatory skin diseases. With those cases, subtle differences in reaction patterns can lead to different diagnoses, he notes. On the “Low End” Related to these issues and worrisome to various clinicians are pressures by managed care organizations (MCOs) to use “low end” labs. Some MCOs will require physicians to send specimens to a specific lab that may or may not have an individual with expertise in dermatology, says Dr. Cockerell. Dr. Williford says he would opt out of contracts where he was afraid the tissue was being sent to a “low end” lab. He would fear that these labs might not give complete service and pose a malpractice risk. Some large labs, Dr. Williford says, employ many pathologists that must read a certain number of specimens to meet productivity goals. This overflow of specimens sometimes doesn’t allow the “cognitive effort” that a particular case might require, he notes. On a contrary note, a low-end or commercial reference lab has a huge liability if it turns into some kind of “industrial mill of pathology,” notes an official from the College of American Pathologists. He suspects that it’s a “rare exception” when one encounters that issue. He also notes that quality is the main driving force behind these labs’ efforts, not liability. MCOs are becoming more aware of this issue, says Dr. Cockerell. They’re realizing it’s penny wise and pound foolish to alienate dermatologists, he says. How Much Is Too Much? Besides the qualifications of the clinician reading the specimens, another concern involves the sheer number of specimens pathologists are called to read. “Everyone who can hold a scalpel is biopsying,” says Dr. Bergfeld, in a bit of hyperbole. But the simple fact is that there are more biopsies that need to be read in pathology labs. How much is too much for any one pathologist? That depends on a variety of factors, says Dr. Cockerell. Those include the pathologist’s comfort and confidence in reading a good number of specimens, as well as the lab’s efficiency and level of automation. Another factor: whether the lab is getting specimens from a referral practice, which likely will present more complex cases for interpretation. No benchmark exists beyond which he starts to worry, says the official from the College of American Pathologists. Only in gynecologic cytopathology are workloads imposed, he says, and there only on screening, not diagnosis. Only large national pathology groups or reference labs are going to push volume requirements, says Charles Root, Ph.D., of MCF Compliance in Chicago. Anytime you deal with a local group of pathologists, you’re generally not going to push the envelope that much, he says. One risk with large national labs, he notes, is you may not be sure where your specimens are being processed. The more sophisticated labs will send them where they have the capacity. One specific estimate comes from Dr. Tuthill, who estimates a pathologist can accurately read about 75 specimens per day. As a board-certified dermatopathologist, he sometimes reads more than that, but finds it stressful to do so. He does note that he has other responsibilities besides reading specimens. Communication Is Key Knowing the expertise of those reading your specimens and the volume they read per day can help you get the best service for yourself and your patients. Another important factor involves communication. As a dermatologist, you’re not sending out a simple blood test, for instance, to a nameless lab, says Dr. Adams. On the contrary, you need to know who the pathologists are and work with them. It’s your duty, he says, to call the lab once you know where your specimens are being sent. You need to get to know how they approach skin lesions. Some specimens can present subtleties that are quite difficult, says Dr. Williford. Arriving at a correct diagnosis requires a good treating physician who can relay information to a pathologist. There must be some “ease of communication between the clinician and pathologist,” says Dr. Adams. Lines have to be open both ways, so that you can call the pathologist to ask questions about a result, and the pathologist can call you when he needs clarification. More Questions In getting to know your lab, you’ll want to explore other areas. Check their quality control, says Dr. Bergfeld. Know their charges, and also ask about their business plan. Find out if special studies are available, such as immunophenotyping and polymerase chain reaction. (See Tests of the Future on page 34.) Also make sure that the lab complies fully with Medicare regulations, says Dr. Root. You may get tarred with the same brush as the lab it if has Medicare problems. Ensure the lab has a compliance officer. Check accreditation as well. About 17,000 labs are accredited by private, not-for-profit organizations, according to the College of American Pathologists. The College accredits about 6,500 of these, the vast majority of those being clinical labs. Raising Complaints If you’re not happy with the quality of service from a lab you use, you can take various steps. Some dermatologists, says Dr. Cockerell, have written to MCOs and expressed their complaints. Solutions fall into various areas, he suggests. First, the MCO may agree that you can send the specimen to the lab you want. Another solution is that you can insist that the lab have on staff a board-certified dermatopathologist. That’s not a substitute, though, for having someone read your specimens whom you know and trust, he notes. You can try to contact the insurance company or lab and demand that a dermatopathologist see your biopsies, notes Dr. Hollenberg. Another tactic that can help your case: stamp the requisition “Must be seen by dermatopathologist,” he suggests. Crucial Support Though behind the scenes, specimen reading is a crucial part of providing excellent dermatologic care. Given the importance of this task, you have to ensure that you’re getting accurate results.
L ike a stagehand behind the action of a play, your pathology lab provides critical support to your patient care. The information the lab provides often has a major impact on treatment decisions. But how accurate are the results your lab provides? Are qualified clinicians interpreting your specimens? Can you get through to the pathologist if you have a question? In this article, we’ll provide practical advice for getting the best results from your lab. First though, let’s look more closely at why lab results are important. Serious Consequences You’re well aware that a misread specimen can have serious consequences for patient care. Years ago, one attitude about dermatology specimens was “It’s only skin,” says Wilma F. Bergfeld, M.D., F.A.C.P., head of dermatopathology in the Department of Pathology at the Cleveland Clinic Foundation. She is also a practicing dermatologist in the Department of Dermatology there. The sometimes small size of specimens also led to some trivialization of reading them, she notes. But the deadly nature of melanomas, for instance, proved that attitude wrong. Besides patient care, poor lab results can lead to legal liability. That you didn’t know who read a slide is no protection from a lawsuit, says Clay J. Cockerell, M.D., clinical professor of dermatology and pathology at the University of Texas Southwestern Medical Center at Dallas. He’s also medical director at Dermpath Diagnostics, a division of AmeriPath, a pathology management services company. You can’t be held liable for another specialist’s malpractice, says Phillip Williford, M.D., associate professor of dermatology and director of dermatologic surgery at Wake Forest University School of Medicine, Winston-Salem, NC. But the cold reality is that you’ll in all likelihood be named in any lawsuit resulting from a misread slide. What’s more, with more patients being consumer-oriented, they may ask who will read their specimen, according to Dr. Cockerell. They may even be willing to pay out of pocket to have their specimen read by a lab they may feel more comfortable with. Case in Point Even though Georgetown University has its own dermatopathology lab, about 40% of specimens are sent to outside labs, says C. Lisa Kauffman, M.D., F.A.C.P., chief of dermatology at Georgetown and also associate professor of medicine, dermatology, and pathology. Dr. Kauffman is also director of the dermatopathology lab. In one example, about three years ago, a surgery resident asked her to electrodesiccate and curette a small basal cell carcinoma (BCC) on the resident’s nose. The specimen was read at an outside lab, which identified it as malignant but didn’t comment on the margins or whether the BCC was aggressive. Reviewing the slide herself, Dr. Kauffman found an aggressive, infiltrating tumor present at several margins. Without reading the slide, Dr. Kauffman might have treated the resident superficially, she said. In the end, a Mohs surgeon removed five layers of the resident’s skin. Depending on Dermatopathologists One huge key to accuracy involves the expertise of the person who’s reading your slide. Clinicians are divided about whether dermatology specimens should be read by dermatopathologists or general pathologists. Some argue that board-certified dermatopathologists are best equipped to read slides, especially those that present challenges in interpretation. A lab strictly dedicated to skin pathology and staffed by board-certified dermatopathologists represents the best lab for dermatologists, says George Hollenberg, M.D., director of laboratories at Acupath Laboratories in New Hyde Park, NY. If a dermatologist is going contract with a specific lab, he or she needs to make sure, during contract discussions, that the lab has a board-certified dermatopathologist on board to read skin specimens, says Dr. Bergfeld. Dr. Bergfeld says that she has the best of both worlds. Her office at the Cleveland Clinic resides in the anatomical pathology department. She can consult with other pathology colleagues to improve what she can do, though she uses herself as the primary dermatopathologist. This, she feels, represents the ideal setting – where a dermatopathologist has an association with general pathologists who have specific expertise in soft tissue tumors, cytology and lymphomas. In this way, she can easily consult with colleagues. Another View The position that only board-certified dermatopathologists can read specimens is a bit extreme, argues Ralph J. Tuthill, M.D., of the Department of Anatomic Pathology, Section of Dermatopathology at Cleveland Clinic Foundation. There may well be, he notes, general pathologists with enough interest and experience in dermatopathology to do a “more than satisfactory job on interpreting these cases.” In particular, a general pathologist who has access to consultation with a board-certified dermatopathologist would be acceptable, he says. In the ultimate analysis, it’s not the label of the person who peruses the tissue that matters but his or her competence, says A. Bernard Ackerman, M.D., director of the Ackerman Academy of Dermatopathology, New York City. Some dermatopathologists, he notes, may be less competent than general pathologists who may not have their boards in dermatopathology. As a general principle, however, Dr. Ackerman advises that a board-certified dermatopathologist is best equipped to render diagnosis with precision of a skin lesion that poses a problem in diagnosis histopathologically. It’s most important, he says, that HMOs and other insurance carriers be alert to permitting any pathologist who is competent in dermatopathology to read sections, whether that’s a dermatopathologist or general pathologist. While certifications do matter, a practicing dermatologist is well-advised to inquire into the training of the person reading sections of tissue taken by the dermatologist, he says. The worst offenders, he says, are dermatologists who read their own sections on their own patients but aren’t highly qualified to do so. This can represent a “terrible conflict of interest,” Dr. Ackerman notes, though it may be acceptable if both the patient and dermatologist are aware of the practice. Challenging Lesions Expertise becomes even more crucial in lesions that are difficult to interpret. Some subtle skin disorders, such as mycosis fungoides, require a very educated pathologist in skin to make the histologic diagnosis, says Brian Adams, M.D., associate professor in the Department of Dermatology at the University of Cincinnati Medical Center. Virtually only dermatopathologists, says Dr. Hollenberg, can interpret inflammatory skin diseases, such as psoriasis. Also challenging are blistering disorders, such as bullous pemphigoid, pemphigous, and epidermolysis bullosa acquisita. Likewise, Dr. Williford has no problem with general pathologists reading specimens, but believes the advantage of having a dermatopathologist read specimens comes with inflammatory skin diseases. With those cases, subtle differences in reaction patterns can lead to different diagnoses, he notes. On the “Low End” Related to these issues and worrisome to various clinicians are pressures by managed care organizations (MCOs) to use “low end” labs. Some MCOs will require physicians to send specimens to a specific lab that may or may not have an individual with expertise in dermatology, says Dr. Cockerell. Dr. Williford says he would opt out of contracts where he was afraid the tissue was being sent to a “low end” lab. He would fear that these labs might not give complete service and pose a malpractice risk. Some large labs, Dr. Williford says, employ many pathologists that must read a certain number of specimens to meet productivity goals. This overflow of specimens sometimes doesn’t allow the “cognitive effort” that a particular case might require, he notes. On a contrary note, a low-end or commercial reference lab has a huge liability if it turns into some kind of “industrial mill of pathology,” notes an official from the College of American Pathologists. He suspects that it’s a “rare exception” when one encounters that issue. He also notes that quality is the main driving force behind these labs’ efforts, not liability. MCOs are becoming more aware of this issue, says Dr. Cockerell. They’re realizing it’s penny wise and pound foolish to alienate dermatologists, he says. How Much Is Too Much? Besides the qualifications of the clinician reading the specimens, another concern involves the sheer number of specimens pathologists are called to read. “Everyone who can hold a scalpel is biopsying,” says Dr. Bergfeld, in a bit of hyperbole. But the simple fact is that there are more biopsies that need to be read in pathology labs. How much is too much for any one pathologist? That depends on a variety of factors, says Dr. Cockerell. Those include the pathologist’s comfort and confidence in reading a good number of specimens, as well as the lab’s efficiency and level of automation. Another factor: whether the lab is getting specimens from a referral practice, which likely will present more complex cases for interpretation. No benchmark exists beyond which he starts to worry, says the official from the College of American Pathologists. Only in gynecologic cytopathology are workloads imposed, he says, and there only on screening, not diagnosis. Only large national pathology groups or reference labs are going to push volume requirements, says Charles Root, Ph.D., of MCF Compliance in Chicago. Anytime you deal with a local group of pathologists, you’re generally not going to push the envelope that much, he says. One risk with large national labs, he notes, is you may not be sure where your specimens are being processed. The more sophisticated labs will send them where they have the capacity. One specific estimate comes from Dr. Tuthill, who estimates a pathologist can accurately read about 75 specimens per day. As a board-certified dermatopathologist, he sometimes reads more than that, but finds it stressful to do so. He does note that he has other responsibilities besides reading specimens. Communication Is Key Knowing the expertise of those reading your specimens and the volume they read per day can help you get the best service for yourself and your patients. Another important factor involves communication. As a dermatologist, you’re not sending out a simple blood test, for instance, to a nameless lab, says Dr. Adams. On the contrary, you need to know who the pathologists are and work with them. It’s your duty, he says, to call the lab once you know where your specimens are being sent. You need to get to know how they approach skin lesions. Some specimens can present subtleties that are quite difficult, says Dr. Williford. Arriving at a correct diagnosis requires a good treating physician who can relay information to a pathologist. There must be some “ease of communication between the clinician and pathologist,” says Dr. Adams. Lines have to be open both ways, so that you can call the pathologist to ask questions about a result, and the pathologist can call you when he needs clarification. More Questions In getting to know your lab, you’ll want to explore other areas. Check their quality control, says Dr. Bergfeld. Know their charges, and also ask about their business plan. Find out if special studies are available, such as immunophenotyping and polymerase chain reaction. (See Tests of the Future on page 34.) Also make sure that the lab complies fully with Medicare regulations, says Dr. Root. You may get tarred with the same brush as the lab it if has Medicare problems. Ensure the lab has a compliance officer. Check accreditation as well. About 17,000 labs are accredited by private, not-for-profit organizations, according to the College of American Pathologists. The College accredits about 6,500 of these, the vast majority of those being clinical labs. Raising Complaints If you’re not happy with the quality of service from a lab you use, you can take various steps. Some dermatologists, says Dr. Cockerell, have written to MCOs and expressed their complaints. Solutions fall into various areas, he suggests. First, the MCO may agree that you can send the specimen to the lab you want. Another solution is that you can insist that the lab have on staff a board-certified dermatopathologist. That’s not a substitute, though, for having someone read your specimens whom you know and trust, he notes. You can try to contact the insurance company or lab and demand that a dermatopathologist see your biopsies, notes Dr. Hollenberg. Another tactic that can help your case: stamp the requisition “Must be seen by dermatopathologist,” he suggests. Crucial Support Though behind the scenes, specimen reading is a crucial part of providing excellent dermatologic care. Given the importance of this task, you have to ensure that you’re getting accurate results.
