Why Clear Communication Between Derm-Dermpath Is Critical for Diagnosis

Clinicopathologic correlation in dermatology remains the cornerstone of accurate diagnosis for dermatologic diseases. While most diagnoses in dermatology can be achieved on clinical grounds with the naked eye, there is a substantial number of skin maladies that require histologic analysis of the tissue. Therefore, dermatopathology represents the backbone of dermatologic diagnosis, and it is important to appreciate and never take for granted the relationship between the dermatologist and dermatopathologist. The focus of this article is on that relationship, but I would like to begin by pointing out some of the fundamental and technical processes that form the foundation of the relationship.

Relationship Between the Dermatologist and Dermatopathologist
Obtaining an accurate diagnosis using histology is a complicated, multistep process that needs to be performed with precision at every level. The entire process is a cycle that begins and ends with the patient. It starts with the patient, who presents with a cutaneous problem that requires a biopsy. The clinician performs the biopsy—obtaining a specimen of tissue—which is ultimately used to generate a slide. The slide is interpreted by the pathologist, who is a residency-trained physician, and the result is reported back to the clinician who obtained the biopsy. The cycle is complete when the clinician informs the patient of their diagnosis.

Histologic analysis begins with obtaining an appropriate specimen from an appropriate site using an appropriate tool. The clinician needs to decide where and how to take a biopsy and which tool or tools need to be used. Timing of a biopsy is also sometimes a consideration, as many rashes will appear different if they have been treated (eg, with topical corticosteroids), and other rashes will appear histologically different if they have been present for too long compared with when they just begin, such as vasculitis. Whether the diagnosis in question is a rash (widespread or localized) or a tumor (solitary or multiple), they need to be properly assessed and evaluated by the clinician. The appropriate tool to use in most cases is a sharp, flat (bendable) blade for a shave biopsy or a rounded trephine device used to perform a punch biopsy. Most skin biopsies can be performed by a shave method; however, if there is any question as to whether the pathology of the disease lies primarily in the dermis or deeper (eg, granulomatous disease, lupus erythematosus, or panniculitis), then a punch biopsy should be performed. Once this specimen is obtained, it is typically placed into formalin for fixation, and the process of slide preparation subsequently ensues when the specimen reaches the laboratory. Again, it cannot be overstated how every step in this process must be performed with precision to produce a high-quality slide for the pathologist to interpret.

Beyond the technical components of performing a biopsy for tissue analysis, I would submit that the most important aspect of arriving at the correct diagnosis is accurate communication between the clinician and the pathologist. This typically occurs via the requisition form.² In the third decade of the 21st century, that is most often an electronic communication. Although dermatologists in the United States have been somewhat slow compared with other specialists in adopting the electronic health record, as of May 2021 approximately 70% of practicing dermatologists reported using an electronic means of documenting patient records.²

Perhaps, the clearest way to communicate the nature of a biopsy is with a photograph. In the last several years, my practice has been (with rare exception) documenting every single biopsy performed with a photograph.³ This has been critical in ultimately determining the correct diagnosis on so many occasions when the histologic differential diagnosis was inconclusive. In my practice, where the dermatopathologist has access to the medical record, the dermatopathologist often refers back to the chart for a glance at the clinical photograph to render a diagnosis of, say, lichen planus-like keratosis as opposed to lichen planus in the case of a solitary papule compared with many polygonal flat-topped papules.

In the case where a photograph is not available, unless a focused and narrowed differential is in question, the communication to the pathologist should have, at a minimum, the following clinical characteristics: morphology, color, size, and distribution.
 

A Tip for Communication
Given the fundamental requirement for accurate pathologic diagnosis, the professional relationship between the clinician and pathologist is paramount. It is imperative that the clinician clearly and accurately communicates their intention to the pathologist. My recommendation to any clinician would be to take the time to get to know your pathologist—and my recommendation to any pathologist would be to take the time to get to know the clinicians with whom you are working. If a familiar relationship has not been established between the clinician and the pathologist, then a simple phone call to reach out is often appreciated.

The situation will invariably arise whereby the clinician does not completely understand the report rendered by the pathologist, and conversely when the pathologist does not understand the intention of the clinician. In these situations, the clinician needs to reach out to the pathologist or vice versa via phone (preferably) or email to clarify. Consider that the correct diagnosis is what is at stake and, ultimately, optimal care of the patient, so do not settle for an incorrect or incomplete diagnosis when the most accurate diagnosis is obtainable with simple further clarification. This obviously takes a little extra time, but remember that it is in the best interest of the patient to hone in on the most likely and most compatible histopathologic diagnosis. Making the phone call or sending the email is usually easier when a preexisting relationship has been established.

Conclusion
Obtaining the most accurate histopathologic diagnosis is a complicated and multistep process that must be executed with precision. In addition to the numerous technological aspects of creating high-quality histologic slides, the relationship between the clinician and the pathologist remains a fundamental stepping stone for arriving at the best and most appropriate diagnosis for the patient.

1. Smith SDB, Reimann JDR, Horn TD. Communication between dermatologists and dermatopathologists via the pathology requisition: opportunities to improve patient care. JAMA Dermatol. 2021;157(9):1033-1034. doi:10.1001/jamadermatol.2021.2582

2. Jason C. Understanding EHR adoption, use with medical specialties. EHR Intelligence. Published May 7, 2021. Accessed January 19, 2022. https://ehrintelligence.com/ news/understanding-ehr-adoption-use-with-medical-specialties

3. Schneider SL, Kohli I, Hamzavi IH, Council ML, Rossi AM, Ozog DM. Emerging imaging technologies in dermatology: Part I: Basic principles. J Am Acad Dermatol. 2019;80(4):1114-1120. doi:10.1016/j.jaad.2018.11.042