Point of Service Pathology

[you are now reading a page on Dr. Shaw's personal website]

Our pathology group, Pathology Associates of Lexington, P.A., began in 1971 with the opening of Lexington Medical Center [LMC] (then called Lexington County Hospital) in West Columbia, S. C. That hospital  is now the anchor of the Lexington County Health Services District (LCHSD). Guy A Calvert, Jr., M. D. was the founding pathologist. A native of the nearby capitol city of Columbia, S. C., he had been a highly effective and popular family physician in Greenwood, S. C., for a decade. He left there for a pathology residency at Bowman-Gray School of Medicine. His structuring of the LMC pathology program focused on the needs of local doctors and patients...as seen through the "mind's eye" of a former family doctor.

Patient's trust their local "clinician" doctor, and those clinical doctors, likewise, need a way to trust the physicians leading & executing the delivery of specialty and ancillary medical services such as "pathology". The surrogate for that type of trustworthiness is trusting in those services to be performed locally (and when necessary, trusting the local experts to properly select distant supplementary providers). Clinical doctors sense trustworthiness (1) as they develop local working relationships and (2) as they regularly see evidence of thoroughness of valuable (not mundane or trivial) effort by the pathologist.

The next partners (Shaw & Carter) he brought in were highly like-minded in this approach to a Dept. of Pathology & Laboratory Medicine 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 back then.

 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 investor-owned, primarily-for-profit, commercial mega-lab 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 (not practices of medicine) 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, those labs also offered anatomic pathology (tissue biopsies and cytology...such as pap smears...testing), too. These latter specimens became comparative-pricing benchmarks for the office doctors, and the charges on such (example: Pap smear) soon began being handled as "loss leaders" by the commercial labs (businesses) 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 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. By the way, such detachment is still widely prevalent in the USA.

And since local physicians were sometimes marking up the charge from the distant commercial lab into much higher charges to their local patients, this mark-up arrangement ("client billing") became a significant revenue source for local clinical physicians (marked up client billing on anatomic pathology...biopsies...is illegal in S. C.). 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 even the presence of problem cases by business people in the business of medicine. Such self-serving thinking becomes justified by clinicians by their thinking that "quality is a given" because the labs have certification...yet they know full well that quality IS NOT a given in any other sphere of life. Such thinking is rarely in the best interest of the actual patient.

The most optimal situation for patients is when local (point of service) pathologists who are good doctors and (1) actually care about quality and (2) care about the people of their community and (3) are regularly and deeply involved with the tissue and cytology diagnoses of the local physicians. It is also protective of quality for the local community when the pathologists are thoroughly involved in all other aspects of the hospital or local-practice lab. 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, care decisions can be much more patient-specific, rather than "general standard-of-care" specific. [about "standard of care"]

ADDITIONAL COMMENTS:

Experts: The accurate & efficient execution of the practice of any general or specialist area of human medicine is incredibly complex and difficult. It is a shame that society has lead the public to expectations of perfection. Expert 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 case situation. Here 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 16:1133-1143; 1992: better agreement.
   
3. Prostate cancer: Dr. Epstein...Johns Hopkins used specially prepared slides of 25 cases and sent them to 7 top prostate experts: all agreed that 13 cases were not cancer and that one case was cancer. There were split decisions on the other 11 (many of those 11 cases included a spectrum of atypical cell changes called PIN). Am. J. Surg. Path. 19(1995):873-886.
   
4. Melanoma skin cancer: Dr. Farmer...Human Pathology 27:528-531; 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 vs. papillary. AJCP 117:19-21, 2002.
   
10. 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.
    
11. Gestational trophoblastic disease: to differentiate between harmless hydropic products of conception and molar products of conception is very important but notoriously problematic. A fine study showed that five experts had problems making the correct diagnosis. American J. of Surg. Path. 29:942-947, 2005.
    

Pathology Second Opinions:

In a letter I wrote to my friend and helper & publisher of materials for husbands & women with breast cancer, "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 treating doctor may call and ask another in that local pathology 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 that treating expert wants to know about such cases.

It is a GREAT advantage to a community to have capable/good pathologists "at the point of care"..."at the point of service" 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. I 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 community based pathology, I believe that the closer a specialist is to a patient in a community AND the closer to that patient's physician is to him/her, 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 long-term from the hireling pathologist working his shift in a Wall Street motivated, public-stock-holder-owned commercial-venture lab. And, yet, those labs certainly have their place in our society 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 to "discordance" 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 ("LMD"s). 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 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". [case example] 

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(posted 17 Aug. 1999; latest addition 25 March 2008)