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
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
Western Pathology Consultants
Regional West Medical Center