College of American Pathologists
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  Letters - June 2005




July 2005

The article in the May 2005 issue regarding digital imaging in anatomic pathology reports (Digging its way in: lab digital imaging) addressed very well the various pros and cons of this technology. One issue that was not directly discussed is the possibility that images on a pathology report may increase the liability of an incorrect diagnosis for our customers, the clinicians. Imagine this analogy: You receive a chest radiograph report from your radiologist indicating a normal exam and the fancy report includes a nice digital image. The only problem is that the image shows a 10-cm mass in the right lung. All readers of CAP TODAY would recognize the contradiction of the report and the image and would be held accountable in any resulting malpractice claim. Nearly all recipients of our reports have had some training in pathology, at least at the medical school level, and they would likely be held liable to some degree in most jurisdictions. Despite the many stated advantages of digital technology, I am concerned that we are developing a new area for malpractice attorneys to extract dollars from the health care system. Perhaps the resources of the College could be used to explore this concern.

Kent G. Zimmerman, MD
Clin-Path Associates
Tempe, Ariz.

Cytology exam

I agree completely with the position of the CAP and state and national societies about the inappropriateness of the MIME cytology proficiency exam. We do not practice pathology under the conditions the test requires. If MIME does not think it appropriate for pathologists to show their cases to each other, I would refer them to an essay by Jerry B. Harvey, PhD, titled "Encouraging Future Managers to Cheat" in The Abilene Paradox and Other Meditations on Management.

Vagueness is an innate property of our existence and thus pervades the lives of all humans, especially the practice of medicine, yet it's a concept that MIME appears to have ignored in constructing the exam.

We use as our measuring stick the size of an intermediate cell nucleus, an intact neutrophil, or both. Is the measuring stick we choose on each slide perfectly preserved and without any air-dry artifact? Is the nucleus we are evaluating, as possibly atypical, twice as large as our measuring stick (and thus ASC-US, a diagnosis we make every day in real life but one that MIME does not allow)? Is it three times as large (and thus LSIL)? Are we sure? (Often we are not 100 percent sure for any number of reasons, including transformational cells with features of both squamous and endocervical glandular cells [criteria are different for squamous versus glandular dysplasia], various degrees of obscuring material such as blood or inflammation, and the difficulty of conceptualizing two or three times a certain size [extrapolating as we do to three dimensions from the more two-dimensional field we examine]).

The slides that I reviewed as part of my MIME exam were not all "slam-dunk" classic cases. Some were paradigms of vagueness. Of course, humans and their diseases are vague, but the MIME test was not designed to allow for vagueness. Each slide had one and only one correct interpretation, according to MIME.

To those of us in the field of pathology and cytology, intraobserver variability (the likelihood that the same observer will render a different interpretation on the same slide at different times) is well known. We also know that on some cases, no amount of training will make that intraobserver (or interobserver) variability go away. A certain amount of variability is an innate property of vagueness. The inevitability of intraobserver variability seems to be unknown to MIME.

To require a score of 90 percent on vague slides is inappropriate. MIME and CMS have lost sight of the purpose of and the system that is Pap testing. They seem to start out with this basic (and tacit) assumption: All pathologists and cytotechnologists don't really care what happens to patients who have Pap tests or whether they (pathologists and cytotechnologists) get the "right" answer. To "bring us into line" and to "get our attention," we are required to take an exam that does not test us in the way we practice our profession. Furthermore, if we fail the exam, we cannot sign out gyn cytologies until we do pass it. (And we have to travel to Indianapolis at our own expense, and that includes the expense of being away from our practices for enough time to have otherwise signed out many cases, thereby stressing our colleagues and practices.)

The diagnosis of cervical neoplastic disease depends not only on pathologists and cytotechnologists but also on the clinicians who obtain the sample and, importantly, on the patients themselves, relying as the system does on the need for patients to return for repeat exams at various intervals. The goal of the system is to reduce to a level as low as possible the morbidity and mortality of cervical neoplasia. To isolate one facet of that system is inappropriate and, as for any system not evaluated and tweaked as a whole, will lead to a higher failure rate than if the system is evaluated appropriately.

As a pathologist, I would encourage MIME and CMS to make an alternative assumption: All pathologists and cytotechnologists care very much about the patient at the end of each Pap test, and they try very hard to make the "right" diagnosis every time. Of course, as practitioners of our profession, we are mindful of and have a much better understanding of the strengths and limitations of the system as we practice it. In my opinion, participation in the ASCP Star and CAP Pap and similar programs is a much more realistic way to assess the system and keep pathologists and cytotechnologists current. We take those programs seriously and learn from each test event.

Cris J. Anderson, MD
Staff Pathologist
Western Pathology Consultants
Regional West Medical Center
Scottsbluff, Neb.