Having weathered the gauntlet that is/was my inpatient pediatrics rotation, I have been kind of off the radar. But, lucky me, I just happened to land having family medicine during the one month that has a holiday that Americans have no justification for or idea about its origin: Labor Day!. The 1 extra day this weekend did leave me less sleep deprived to the point where I feel 'encouraged' to write for you, dear readers. So, I want to relate a story from the clinic.
While I was on the EHR software at my Family Medicine rotation site affiliated with not-to-be-named medical center recently, I came across... a somewhat awkwardly worded pathology report. The phrase found in the pap smear cytology report at the end of a reasonably long paragraph was simply: Trichomonas vaginalis. Not positive for Trichomonas vaginalis, not trichomonad organisms are visualized, just name dropped the bug and out.
At first I wasn't really sure what to make of this, whether it was positive/negative or just a transcription error. So, after looking up the appropriate treatment (metronidazole), I brought it up on presenting to the attending/preceptor with the 3rd year resident, sayin' "hey, this lady was [insert] positive for Trichomonas on the pathology report". Only to get a... "we only treat that if the patient is symptomatic." I mean, having T. vaginalis on the path report was simply pretty just served as a record that the pathologist saw it under the scope, it didn't add to a potential diagnosis. To the clinician, unless the patient is clinically symptomatic it's almost as if that line/information wasn't there. So it's really more of a record 'that we saw it', so to speak.
So this got me thinking about priorities, and layout of a pathology report. In terms of priorities, what is a clinician most likely going to want to know from the report? When it comes to gynecology specimens, clearly any tissue diagnosis be #1 priority. Then Cytology and HPV results. Additional comments or interesting facts can be saved for a comment at the end of the report. Maybe that the pathologist saw Trichomonas should have been reported in a 'not clinically useful/relevant' section (i.e. comment) instead of in the main report. This is why being a well-rounded doctor makes the best doctors (and pathologists), in being able to prioritize information in terms of clinical relevance.
I have to say, I kind of hate descriptive diagnoses and I'm sure clinicians do too. It feels like (and probably is) a cop out on the part of the pathologist. It is kind of a cover for, "hey I don't recognize how this fits into the bigger picture" or "I simply don't know what this entity is, so I'll just describe it for now". Which is probably not very satisfying from the standpoint of the clinician, or Ob/Gyn let's say, reading the report. From what I understand, pathologists and gynecologists had to sit down at a table and mutually agree upon terms understandable to both their specialties to agree on a shared language in order to communicate in said reports. Otherwise, I wonder if it would all be descriptive?
This brings me to my final point which I noticed with some regularity, and I'm only speaking to my personal experience right now is... Some gynecologists make themselves look pretty bad in the eyes of pathologists. I can't tell you how many times over the course of the year where I would be sitting at sign out with the pathologist and a slide with almost no tissue whatsoever graces our presence. Most of the time it would be signed out as an 'insufficient' or 'inadequate' specimen... Though it's really embarassing and really a waste of everyone's time when there is a fleck of tissue on the slide and the gynecologist still submits it like it's a bona-fide specimen. It makes me wonder, do they bill for more when they obtain/send a 'specimen' when there really isn't any? Because it doesn't fool me. Just because you put a piece of gauze in a formalin jar, doesn't mean there was anything on it... and I'm pretty sure they know this as well as we do. It's not hard to see that there's almost nothing with the naked eye. It's additionally extremely aggravating for the person grossing the specimen when it is a tiny... tiny... specimen, and it causes a whole lot of hulabuloo when there really isn't any specimen to be found or it gets "lost".
So, all I get from this is some gynecologists and pathologists make life harder for the other, though they have a very dependent working relationship. i.e. one cannot function without the other. Therefore, I think it is important to maintain good communication with all parties involved and make sure the working relationship is appropriate and congenial. That way one gives/receives feedback and collaboration happens to improve patient care. After all, we need each other.
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