Anonymous quotes: "I don't care what you know until I know that you care." "Quality healthcare is cost effective health care." " Health care is a local activity."

And, Mark Twain, speaking through Huckleberry Finn, "Well, then, says I, what's the use you learning to do right when it's troublesome to do right and ain't no trouble to do
wrong, and the wages is just the same?"

As a physician or patient, what is the basis of your faith that the lab and/or the pathology group you or your doctor sends specimens to will "do right"? Why do they "care"? Do they have ethical practice arrangements; will the content of their character drive them to "do right" by your patients? Will they truly strive to go beyond accuracy and be truly HELPFUL? [such an overview of our group].

Our Dr. Carter coined the term "Helter-Skelter" medicine in the early 1990s to describe practicing of all aspects of medicine too fast with too little time to think and interact and with lack of focused thoroughness and attention to details of a case or an issue. This state of affairshas come about due to reduced compensation per unit of value to all providers by insurors & governments, which leads to physicians being tempted into unethical activities to bring in money to keep practices profitable. It is driven by third party payors and governments who are determined that the practitioners of a "classical, learned profession" be forced into an industrial model that rewards based on an increased rate of production of "widgets" per unit time. (Check this link as to the potential to be different & better in our health care district [LCHSD] & combat Helter-Skelter, especially note the end of that message). And see last sentence on this current page, HERE.

We physicians (though pathologists often speak of two classes of physicians, clinicians & pathologists) must not subdivide, even within our own specialty. Physicians must get back to empasizing our commonalities, the positive effects of which are maximized in local communities. The efficiencies offered by technology can allow a return to focused & thorough medical practice by all physicians...to the point that they can really care again through "point of service practice". Caring comes about through relationships, and "point of service" is about that network of professional and layperson relationships that causes the local team to "go the extra mile" and to "do unto others as you would have others do unto you". While utilizing distant expertise & services has always had the potential for adding value, patients are best served when such expertise occurs through local practitioners who care. After all, patients must live in their local community. And the local..."point of service"...health care system must not be weakened and "hamstrung" by the primary exporting of patients or patient data from the local point of service. Otherwise, local caring expertise will fade away (the local non-exportable work is insufficient to provide enough dollars to competatively staff with quality). This is as equally true for the pathologist expertise needed to direct & lead & also provide medical services to individual patients from both the clinical lab (Laboratory Medicine) as well as the anatomic pathology lab (Pathology) [note examples...such influences as these cannot be as adequately supplied by non-pathologists or pathologists who don't care or are boxed into systems which impede their caring]. We care are hugely focused on providing excellent point of service pathology & laboratory medicine services.

Our pathology group, Pathology Associates of Lexington, P.A., began in late 1971 with the opening of [then called] Lexington County Hospital in West Columbia, S. C. Guy A Calvert, Jr., M. D. was the founding pathologist. A native of Columbia, S. C., he had been a highly effective and popular family practice physician in Greenwood, S. C., for a decade. He left Greenwood for a pathology residency at Bowman-Gray School of Medicine. His structuring of the new hospital's pathology & laboratory medicine program focused on meeting the needs of local doctors and patients...as seen through the mind of a former family doctor. 

The next partners he brought in were highly like-minded in this approach to pathology lab operation...leader emphasis being placed on each pathologist's background as regards Personal Standard of Care. In essence, point-of-service pathology was the emphasis...we just didn't have a name for it in the 1970s-80s.

 In the early 1990's, we were affiliated with a like-minded lab, PDL, of Florence, S. C. directed by pathologist Louis D. Wright, M. D. Many discussions...among all of us parties...were had about how to maintain lab/pathology quality and appropriateness of service locally in the face of distant investor-owned, for-profit, commercial megalab competition and managed care. It all boiled down to "point-of-service medical care". Dr. Wright went on...with prodigious tenacity and hard, long work...to found a network (our group being the first group to be an ally) whose trademark is "Point-of-Service Pathology"... likely to be the long-term future model for pathology and laboratory service of the highest general quality for patients.

What does the above page title mean? Beginning in the 1960's, near to the advent of the Federal Medicare Program, well-financed commercial businesses began to offer laboratory testing to doctors' offices, and such labs provided courier pickup of specimens. Because these labs could batch-test huge loads of such specimens in central test labs, their cost of testing fell well below what the physician offices or local hospital labs could do. To make it even simpler for the doctors' offices to decide to become their customers, those labs also offered anatomic pathology (tissue biopsies and cytology...such as pap smears...testing). These latter specimens became comparative-pricing benchmarks for the office doctors, and they soon began being handled as "loss leaders" by the commercial labs in order to get/keep the more lucrative, cost-reduced lab testing. 

The local pathologist (specialist physician) became dislocated from a large percentage of local life-changing diagnoses which were being made by distant pathologists who had no attachment whatsoever to the general reputation or accountability of that local community of physicians. They did not possess state licenses and were not credentialed for practice on the local hospital medical staff. No one in the local medical community even had any idea who they were.

And since local non-pathologist physicians were sometimes marking up the pathology charge from the distant commercial lab into much higher charges to their local patients, this mark-up ("client billing") arrangement became a significant revenue source for local physicians. Against all common sense and experience we have all had with human nature & certification of expertise, quality was presumed to be universal. It was often thought that problem cases did not exist; or, if problem cases did exist, they could be forwarded to expert consultant pathologists, as the need arose. Such thinking presumed correct recognition of problem cases as actually being "a problem case"by business people in the business of medicine.

"Marking up" (client billing) and many other fee-splitting and fee kick-back arrangements (pod labs, condo labs, in-house pathologist, contracted pathology services, etc.) have distorted medical practice and should be identified by "organized medicine" to the patient population as being unethical (in the vast majority of cases). Importantly, these unethical practices are unlikely to stand the light of legal examination in medical malpractice disputes. In time "unethical practices" may become politically offensive enough to stir the will of the people and their legislators to make the practices illegal. Direct billing to patients or their insurance by the person or entity actually performing services is the only always-ethical mode of billing and is the way billing must legally happen in federal programs (such as Medicare).

When screening or diagnostic biopsies are processed in a distant lab and a final resection specimen comes afterward to the local lab, the opportunity has been cancelled for the local pathologist to determine concordance between biopsy & definitive findings. So, a mixup cannot be detected. We thought we had detected a major error in 1994 in a prostate case [S-94-2339 & LMC-94-2841...all processed in our local lab] but were able to have DNA analysis to prove that the prostate biopsies and prostatectomy were the same.

The most optimal situation for patients is when local (point of service) pathologists (the community pathologists) are regularly and deeply involved with the tissue and cytology diagnoses of the local physicians. After all, both surgical & clinical pathology services are best delivered by such specialists because highest-quality support of local physicians happens when rendered by pathologists who care about and think in terms of the impact on local patients. They and the local patients are both components of...the fabric of...that local community. Pathology practiced in the absence of that foremost attention to the impact on the patient is inferior (see Dr. Ackerman's excellent book¹). All physicians are then part of an accountability network between members of a common local community. The pathologists become familiar with the manner in which patients are handled in the varying local practices. Because of these closer professional relationships, patient-care decisions can be much more patient-specific, rather than "general-standard-of-care" specific. [about "standard of care"].

Experts: Expert (usually in a distant city of another state) pathologist consultants may be "experts", but all community pathologists learn quickly that "expert" does not necessarily mean diagnostic excellence or accuracy or pertinence to a local case situation. While I mean nothing negative about expert consultants, they are not perfect; and ere are just a few examples of nationally published studies of non-agreement among experts:

1. Breast cancer: Doctor Rosai...American Journal of Surgical Pathology 15:(209); 1991: multiple cases sent to 5 experts, and there was no instance in which all agreed on the diagnosis.
2. Breast cancer: Dr. Schnitt...American Journal of Surgical Pathology 16:1133; 1992: better agreement.
3. Prostate cancer: Dr. Epstein...American Journal of Surgical Pathology 19:873; 1995: diagnostic disagreement among 7 experts.
4. Melanoma skin cancer: Dr. Farmer...Human Pathology 27:528; 1996: 10 experts disagree even on benign versus malignant, there being unanimous agreement on only 30% of cases.
5. Melanoma skin cancer: Dr. Ackerman...Human Pathology 27:1115; 1996: As part of an editorial comment about #4 "this sorry state of affairs in histopathological diagnosis is not confined to the sphere of melanocytic neoplasms; it exists in matters such as cutaneous pseudo-lymphomas versus lymphomas and vexing problems in differential diagnosis in every organ. The situation as it exists now is unacceptable and we who bear responsibility for patients must mobilize to rectify it, recognizing full well that absolute concordance can never be achieved for lesions of extraordinary difficulty diagnostically." I believe that alliances and organizations which promote and protect point of service medical practice counter-balance any deficiencies due to imperfect agreement, be it expert or non-expert.
6. Non-alcoholic fatty liver disease: Dr. Younossi...Modern Pathology 11:560; 1998: 4 pathologists expert in liver biopsy interpretation have trouble identifying key diagnostic features.
7. Pap smears: Dr. Silverman...American J. of Clin. Path. 110:653; 1998: 4 expert cytopathologists reviewed slides having the known very important diagnostic category of AGUS (which has up to an 80% chance of being associated with a neoplastic cervix lesion) in a group of 100 cases. In only 86% of cases did all 4 diagnose AGUS or a comparably important diagnosis.
8. Barrett's esophagus dysplasia vs. not dysplasia: 14 expert GI pathologists cannot achieve 100% agreement on case diagnosis even though agreeing on the criteria...Human Pathology 32:368-378, April 2001.
9. Thyroid cancer: follicular (implies that lobectomy suffices) vs. follicular variant of papillary carcinoma (implies that total thyroidectomy is needed). International panel of 8 endocrine expert pathologists evaluate 87 cases & all agree only on 50% of cases. Modern Pathology 16(1):106A, January 2003.

Pathology Second Opinions

Dear Judy: Thanks for this article about case changes due to second opinions; I looked at it. This is deceptive in that the TREATING institution is nearly ALWAYS going to get some additional "squeeze" out of a "second-opinion" review because they have their unpublished and personal experiential factors that they look for in adjusting their prognostic advice. So, I'd like to lobby for clarification as you write/speak/website about second opinions:

(1) "diagnostic second opinion" is when another opinion is obtained for purposes of "is the diagnosis correct": [a] intradepartmental opinions (we call them IPCs) may be prospectively and voluntarily sought by the diagnosing pathologist prior to issuing his/her report; [b] or the doctor may call and ask another in that group to review the case and attach an opinion as an addendum to the report. Or, the local diagnosing pathologist may want the specific opinion of a specific expert who is extramural...located somewhere else in the USA/world (all 3 of these are routinely done at LMC). "Local pathologists" quickly learn to NEVER seek a diagnostic second opinion from more than one expert...you will often end up with "expert disagreement". Many published studies exist attesting to the disturbing lack of concordance among experts...even between benign and malignant!!!

(2) "referral treatment second opinion" is one that comes about routinely as a part of tertiary-center practice...the treating experts want the case reviewed by their own pathologist who is especially familiar with what he wants to know about such cases.

It is a GREAT advantage to a community to have capable/good pathologists "at the point of care" right there in their own communities. Sincerely, EBS 2/11/03

The Key Point

The local..."point of service"...pathologist is in a better position to make up for the above types of human deficiencies by having a long-term interest in his/her reputation among community physician colleagues such that his/her intensity of effort in cases and on case quality control and case correlation in behalf of each patient is higher and more sustained. We have no doubt that there may be a small percentage of local pathologists who are inept or relatively disinterested or distracted from highest quality work. But, based on my 30 years in the field of pathology, we believe that the closer a specialist is to a patient in a community AND the closer to that patient's physician, the harder he/she tries to be particularly (not just generally) accurate, "case pertinent", and "situation helpful" to that patient and his/her doctor. This sustained intensity is extremely difficult to imagine coming long-term from the hireling pathologist working his shift in a Wall Street motivated, public-stock-holder-owned reference lab. And, yet, the reference labs certainly have their place and have provided much good service. There is a place for both in the general medical arena.

If the above point-of-service foundation is not in place, it is impossible for such as a referral pathologist to catch the clue and intervene. With modern technology, it is possible to have distant (rather than point-of-service) doctors do all sorts of things...humans are always easily lead to believe that some "expert" or source from afar is better than the local medical doctors (LMDs). Two other factors are of great importance to patients:

• GOOD DOCTOR: Your diagnosis and management decisions and local skills must be under the care of a well-trained and conscientious [case example] physician...a "good doctor".
• NOT HELTER-SKELTER MEDICINE: That good doctor needs to be (by way of a wide variety of staffing and technical support methods) relieved from the inclination (brought on by the 3rd party payment system changes and the pressures of managed-care and a high pressured, urgent society) to practice "helter-skelter medicine". [a case example]. Our LCHSD situation has the ability to bring that relief if the Board of Directors and top Administration will jell the will to set the stage above the level of the employed and closely affiliated but unemployed practitioners of the organized medical staff.

References:

1. Ackerman AB, A Philosophy of Practice of Surgical Pathology: Dermatopathology as a Model, Ardor Scribendi, Ltd., 1999, 470 pages.
2. Schwartz JN, "Joining in the Greater Conversation", CAP Today November 2007.

(posted 17 Aug. 1999; latest addition 18 April 2008)