Thursday, October 13, 2016

Constructing Comments in a Pathology Report: Advice for the Pathology Resident

In an editorial in the current issue of Archives of Pathology and Laboratory Medicine entitled Constructing Comments in a Pathology Report: Advice for the Pathology Resident, Drs. Stephen Smith and Martha Yearsley of Ohio State University provide important points to remember when crafting a surgical pathology report. Among the points the authors is one of my pet peeves: the inclusion of the statement "Clinical correlation is required." Well, OF COURSE CLINICAL CORRELATION IS REQUIRED! It is almost insulting to the clinician to state that he or she must integrate all pieces of data into the care of the patient. That is a doctor's job -- whether it be surgeon, internist, or pathologist! Here's what Drs. Smith and Yearsley have to say on the subject:

"The complex circuitry of many a pathologist's brain in the creation of pathology reports has, in many cases, reflexively routed diagnoses through a small subcortical box en route to signing out the report—a box requiring the addition of a controversial phrase: “Clinical correlation is recommended” (CCIR). The question of whether a pathologist should append this 4-word phrase is one of some depth; after all, is not the function of the pathologist to clinically correlate the specimen for evaluation? Indeed, pathology cannot be practiced in a vacuum, devoid of clinical information, lest the risk of diagnostic error become unacceptably high. So who should clinically correlate, and when?

"The answer to that question is the prudent pathologist. It is our responsibility to obtain clinical information before addressing the microscopy before us. In cases when no history is available, an effort should likely be made to contact the clinician, pending the diagnosis...

"Some cases, however, cannot avoid CCIR. Tissues exhibiting pathology with a nonspecific or undetermined etiology warrant a comment (eg, a skin biopsy exhibiting nonspecific dermal chronic inflammation). Often, it is preferred practice to augment the presentation of the differential diagnosis in these cases: 'Based on the clinical and histologic findings, a diagnosis of X is favored; however, the differential diagnosis includes…' Yet again, the prudent pathologist takes control and clinically correlates. Is CCIR needed in this context? Certainly not, given that the prudent clinician will then clinically correlate any pathologic findings presented in a report, understanding that the pathologist cannot be definitive. Indeed, perhaps CCIR is best reserved as a statement for saying 'I cannot interpret these histologic findings without directly examining the patient' or 'I do not have enough clinical information available to interpret the histologic findings before me.' Most often, this scenario arises when limited clinical history is available and nonspecific histologic findings are seen that would require an exceptional degree of assumption on the part of the examining pathologist to definitively interpret. Great caution should be taken in making such assumptions."

So, the phrase "clinical correlation is recommended" can be thought of as code for a certain degree of justified uncertainty. I don't believe that code should be used in a surgical pathology report. As in every aspect of life, telling it like it is makes the most sense.

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