A mission-based reporting system applied to an academic pathology department

We report how data from the University of California (UC) Davis mission-based reporting system (MBR) can be used to define contributions for each division within a Department of Pathology based on faculty rank and series, and to evaluate whether these contributions are in alignment with the missions of the department and the goals of the school's leadership. MBR summary reports were generated for each division within the Department of Pathology; these reports illustrated the average contribution for each faculty rank and series in each of the following missions: investigative/creative work (research), teaching, clinical service, and administrative/community service. All divisions contributed equally to the teaching mission, averaging approximately 1/3 of a faculty member's time. Research was the primary mission for faculty in both the Research and the Clinical Pathology divisions, whereas clinical service was the primary mission for Anatomic Pathology. Both Anatomic Pathology and Clinical Pathology also played a large role in the administration/community service mission. These roles were appropriate based on the division's distribution of faculty in each of the faculty series. The average contribution to both the research and administrative/community service missions were larger for the Department of Pathology than it was for the school as a whole. The Department of Pathology's average contribution to both the teaching and clinical service missions was less than the school's average. We conclude that MBR data creates unique profiles for divisions and the department and enables interdepartmental comparisons that would not be possible by other means. Within the context of our school, the present analysis illustrates that the Department of Pathology is fulfilling the expectations of the school's leadership. In a more general sense, these profiles allow appropriate monitoring of the workforce, funds flow analysis, allocation of resources, and strategic planning in an academic medical center.     

Research issues in forensic pathology: a survey of academic institutions employing forensic pathologists

In an effort to characterize research efforts in forensic pathology, a questionnaire was sent to a representative of each of the 14 academic medical centers that employ full-time faculty forensic pathologists. Responses were received from all 14 (100%) of the institutions queried, representing a total of 39 forensic pathology faculty positions; 21 positions were tenure track and 18 positions were clinical or other tracks. Of the 39 positions, 25 positions (64%) at 10 institutions required some degree of research or scholarly output. Of the 25 forensic pathologists with a research imperative, only 3 (12%) were principal investigators or co-investigators on funded forensic pathology-based projects. The major limitation cited by respondents on the performance of forensic pathology research was the lack of protected time from service responsibilities. Fellowship training in forensic pathology was available at 6 of the 14 respondent institutions. Of these institutions, 4 (67%) had a research requirement for trainees, and 4 (67%) provided research training. In conclusion, very few US medical schools currently employ full-time faculty forensic pathologists. Of these, only a small number of institutions prioritize research by these faculty members. Scant federal funds are available to support research in forensic pathology. Few forensic pathology fellowship programs provide research training. To achieve a robust research agenda in forensic pathology that is sufficient to support the needs of the criminal justice and public health systems will require a paradigm shift in the medicolegal death investigative system and investment by federal agencies.     

Factors that impact turnaround time of surgical pathology specimens in an academic institution

Turnaround time of laboratory results is important for customer satisfaction. The College of American Pathologists' checklist requires an analytic turnaround time of 2 days or less for most routine cases and lets every hospital define what a routine specimen is. The objective of this study was to analyze which factors impact turnaround time of nonbiopsy surgical pathology specimens. We calculated the turnaround time from receipt to verification of results (adjusted for weekends and holidays) for all nonbiopsy surgical specimens during a 2-week period. Factors studied included tissue type, number of slides per case, decalcification, immunohistochemistry, consultations with other pathologists, and diagnosis. Univariate and multivariate analyses were performed. A total of 713 specimens were analyzed, 551 (77%) were verified within 2 days and 162 (23%) in 3 days or more. Lung, gastrointestinal, breast, and genitourinary specimens showed the highest percentage of cases being signed out in over 3 days. Diagnosis of malignancy (including staging of the neoplasia), consultation with other pathologists, having had a frozen section, and use of immunohistochemical stains were significantly associated with increased turnaround time in univariate analysis. Decalcification was not associated with increased turnaround time. In multivariate analysis, consultation with other pathologists, use of immunohistochemistry, diagnosis of malignancy, and the number of slides studied continued to be significantly associated with prolonged turnaround time. Our findings suggest that diagnosis of malignancy is central to significantly prolonging the turnaround time for surgical pathology specimens, thus institutions that serve cancer centers will have longer turnaround time than those that do not.     

Being fully digital: perspective of a Dutch academic pathology laboratory

The introduction of fast and robust whole slide scanners has facilitated the implementation of ‘digital pathology’ with various uses, the final challenge being full digital diagnostics. In this article, we describe the implementation process of a fully digital workflow for primary diagnostics in 2015 at the University Medical Centre in Utrecht, The Netherlands, as one of the first laboratories going fully digital with a future‐proof complete digital archive. Furthermore, we evaluated the experience of the first 2 years of working with the system by pathologists and residents. The system was successfully implemented in 6 months, including a European tender procedure. Most pathologists and residents had high confidence in working fully digitally, the expertise areas lagging behind being paediatrics, haematopathology, and neuropathology. Reported limitations concerned recognition of microorganisms and mitoses. Neither the age of respondents nor the number of years of pathology experience was correlated with the confidence level regarding digital diagnostics. The ergonomics of digital diagnostics were better than those of traditional microscopy. In this article, we describe our experiences in implementing our fully digital primary diagnostics workflow, describing in depth the implementation steps undertaken, the interlocking components that are required for a fully functional digital pathology system (laboratory management, hospital information systems, data storage, and whole slide scanners), and the changes required in workflow and slide production.     

Work family balance, stress, and salivary cortisol in men and women academic physicians

Background: The stress of medical practice has been recurrently studied, but work- and family-related determinants of health by gender remain under researched. Purpose: To test the hypothesis that cortisol excretion would be affected by the perceived severity of total workload imbalance. Method: By hierarchical regression analysis, the associations between work-family balance and diurnal salivary cortisol levels by sex in academic physicians (n = 40) were investigated. Results: Men physicians reported more paid work hours per week than women physicians and women more time in childcare, but their total working hours were similar. Controlling for sex and age, the mean of the diurnal cortisol release was associated with a combined effect of sex and responsibility at home. When morning cortisol, sex, and children at home were held constant, cortisol levels in the evening were associated with responsibility at home without significant gender interaction. Conclusion: With increasing responsibility at home, women and men reacted differently with regard to cortisol responses over the day. However, in the evening, controlling for the morning cortisol, these gender differences were not as obvious. These findings highlight traditional gender patterns among both women and men physicians in the challenge of finding a balance between work and family.     

Amyloid in surgical pathology

Amyloid is defined as a proteinaceous tissue deposit that shows a typical green birefringence in polarized light after staining with Congo red, the presence of non-branching linear fibrils of indefinite length with a mean diameter of 10 nm, and a distinct X-ray diffraction pattern consistent with Pauling's model of a cross -fibril. Amyloid may deposit locally or may present as a systemic disease. The origin of amyloid is diverse: 25 different fibril proteins have been described so far. The precursor proteins differ from each other in their primary structures and functions. The only common denominator is the propensity to form anti-parallel cross -fibrils under certain circumstances. Early diagnosis of amyloid is still a major challenge in surgical pathology. Histological proof can be obtained using Congo-red staining and polarization microscopy. However, small deposits may be difficult to discern, and sensitivity can be improved using fluorescence microscopy. Classification of amyloid is mandatory, since amyloid is treatable and different treatment regimens are applied to different amyloid diseases. This review focuses on the epidemiology, clinical features, pathology and diagnosis of amyloid in surgical pathology.     

Recommendations for quality assurance and improvement in surgical and autopsy pathology

Current regulations require that departments of pathology have a structured and active program of quality assurance (QA) and quality improvement (QI), with the goals of enhancing patient safety, minimizing error, ensuring timely delivery of reports, and monitoring physician competence. Types of potential error may evolve over time and, as regulations become progressively more stringent, QA/QI programs need to be constantly updated. The Association of Directors of Anatomic and Surgical Pathology herein provides guidelines for QA and QI in surgical and autopsy pathology.     

Transvaginal ultrasonography for identifying endometrial pathology in postmenopausal women

The objective of this study was to evaluate the usefulness of transvaginal ultrasonography in postmenopausal women with a clinical indication for a dilatation and curettage (D&C). Of the 167 postmenopausal women included in the study, 88% were referred for a D&C because of vaginal bleeding and 12% of the women had other clinical indications such as myomas, gynecological pain or suspected gynecological tumors. Hormone replacement therapy (HRT) was used by 37% of the women. The women were examined with transvaginal ultrasonography before the D&C. The endometrial thickness and texture were used as indicators of endometrial abnormalities. The ultrasonographical findings were related to the histological diagnosis obtained from the D&C. Histologically, 31% of the women had an atrophic endometrium and the corresponding ultrasonographically mean endometrial thickness was 4.6 mm (range 0–14 mm). Endometrial cancer was histologically found in 10% of the women and the endometrial thickness of the malignant endometrium, measured by ultrasonography, was 13.9 mm (range 6–31 mm). All the malignancies were found in the group of women with vaginal bleeding, but only one was in the group of women on HRT. Histologically, endometrial hyperplasia was found in 6.5% of the women and endometrial polyps in 8.5% after the D&Cs. In these postmenopausal women it was demonstrated that if the endometrium was < 6 mm thick, no endometrial cancer was found at histopathological investigation. By using a cut-off point of 6 mm of ultrasonographically measured endometrial thickness for identification of endometrial pathology in our study, at least 50% of the D&Cs could be spared.     

Intradepartmental consultations in surgical pathology: Review of a standardized process and factors influencing consultation rates and practices in an academic and community hospital setting

Intradepartmental consultations (ICs) are important for quality assurance (QA) and ensuring diagnostic accuracy in surgical pathology. Few studies have reviewed pathologist factors that influence IC rates. Our study reviews IC data and factors that influence both formal (written) and informal (verbal) consultation practices among pathologists in academic and community hospital settings. Formal IC records from the academic hospital were collected and academic and community pathologists were invited to complete a survey about their IC practices. All centers had a formalized process for documenting ICs; however, 92% of academic and 90% of community pathologists also requested informal IC. The top reasons for selecting a particular colleague for IC was perceived level of expertise; however, interpersonal relationships and office proximity had a greater impact on informal IC practice. Top reasons for requesting a formal IC were mandatory (subspecialty defined) consultation and uncertainty regarding pathological findings. Advice on wording was a common reason for informal IC. Written documentation of IC aids in QA and determination of IC metrics; however, informal, undocumented ICs still occur. Reasons for IC and choice of consulting pathologist are multifactorial, and identifying these can help target quality improvement initiatives.     

Digital breast pathology: validation and training for primary digital practice

Digital pathology is a technology which is transforming the way in which breast histopathology specimens are assessed, reported and reviewed. Large scale clinical laboratory deployments of whole slide imaging systems are occurring in diagnostic pathology departments across the world, requiring laboratory and diagnostic staff to navigate new skills and workflows. Transferring from conventional light microscopy assessment of breast specimens to the use of whole slide images (WSI) can be a challenging experience. This article describes an approach to training and validation for breast consultant histopathologists, which has been used and adapted at a number of sites. Examples of types of case that are suitable for training, and some of the potential “pitfalls” of digital reporting for the novice are described, and practical advice regarding clinical digital breast workflow is shared.     

Applications and implications of whole-slide imaging in breast pathology

Technological advances in whole slide imaging (WSI) technology and artificial intelligence (AI) applications in recent years have resulted in increasing adoption of this paradigm shift technology. This brings with it many advantages, new challenges, and potential adaptations to the microscopic assessment of specimens that pathologists need to be aware of. This article describes the applications and implications of WSI within the context of the reporting of breast pathology specimens. Challenging diagnostic entities in digital breast pathology are presented and the key areas in which AI could be useful in breast pathology are highlighted.     

Residency training in anatomic pathology: looking forward in the 21st century

Residency training in anatomic pathology in the United States elicits a wide range of fundamental questions and conflicting opinions. This paper reflects the author's opinion concerning 4 questions that are often integral to these discussions and impact the outlook on training in the current century. (1) What are the goals of residency training in anatomic pathology? (2) In the face of exponential growth of information in anatomic pathology, how are residents to be trained? (3) What changes are likely to occur in the practice and training of anatomic pathology? (4) Is combined training in anatomic and clinical pathology a viable program for the 21st century?     

Critical diagnoses (critical values) in anatomic pathology

Similar to critical values in clinical pathology, occasional diagnoses in surgical pathology and cytology may require urgent contact of the physician to facilitate rapid intervention or treatment. However, there are no established critical value (critical diagnosis) guidelines in anatomic pathology. As discussed herein, the Association of Directors of Anatomic and Surgical Pathology (ADASP) believes that establishing anatomic pathology critical diagnosis guidelines represents a practice improvement and patient safety initiative. The ADASP also recognizes that a generic anatomic pathology critical diagnosis guideline such as this should only be used as a template because the list needs to be customized at each individual hospital after consultation with relevant clinical services. Based on surveys of the membership of the ADASP, this document provides examples of possible critical diagnoses in anatomic pathology.     

Pituitary pathology in erdheim-chester disease

Pituitary morphologic changes in patients with Erdheim-Chester disease have not been described in detail. We report here the histologic and immunohistochemical findings in the autopsy obtained pituitary of a 35-yr-old woman with extensively disseminated Erdheim-Chester disease. The posterior lobe was completely replaced by xanthogranulomatous infiltrates, providing an explanation for the patient’s diabetes insipidus. The anterior lobe was intact and immunohistochemistry demonstrated expression of GH, TSH, FSH, LH, and alpha subunit within the normal range. A clinically observed decrease of anterior pituitary function was interpreted as hypothalamic in origin due to massive destruction of the hypophysial stalk and compression of the hypothalamus. Prolactin immunoreactive cells were numerous, consistent with the view that prolactin cell hyperplasia resulted from the loss of hypothalamic dopaminergic inhibition. Massive Crooke’s hyalinization in the ACTH-producing cells was considered unrelated to Erdheim-Chester disease and was the consequence of treatment with pharmacologic doses of glucocorticoid hormones. It can be concluded that prolactin cell hyperplasia may be the only finding in the adenohypophysis of patients with disseminated Erdheim-Chester disease. It appears that in our patient the clinically apparent anterior hypopituitarism was not due to the lack of storage but rather to insufficient release of adenohypophysial hormones caused by the defect in hypothalamic regulation.     

Pathologists are from Mercury, clinicians are from Uranus: the perverted prospects for perceptual pathology

Clinicians and pathologists do their work, of course, in quite different ways. Because both groups are trained as physicians, however, this training commonality makes all involved seem basically to be on the same “medical team.” There are, nevertheless, some fundamental differences between the 2 groups that can on occasion cause significant difficulties in mutual understanding; there are reasons to believe that such differences are becoming more pronounced. Although the differences in viewpoints are often subtle and, therefore, seemingly not very important, these differences have very profound causes and can be profound in their effects. This narrative examines the underlying broad historical-sociological-philosophical bases for these differences with the aim of illuminating their importance to medicine and their prospective importance to pathology in particular.     

International harmonisation of clinical pathology testing for non-clinical toxicity and safety studies

International harmonisation of safety testing is currently of interest to industries and government agencies involved in the development and regulation of new drugs, chemicals, food products, and biological devices in global markets. A special meeting of an international working group representing ten professional scientific organisations involved primarily with clinical pathology testing in non-clinical toxicity and safety studies was held on conjunction with the 1993 European Comparative Clinical Pathology meeting in Nottingham, England. Delegates representing professional scientific organisations from the United States, United Kingdom, Japan, Germany, France, Italy, Israel, Canada, Sweden, and The Netherland have agreed to use the published testing recommendations of the American Association of Clinical Chemistry's Division of Animal Clinical Chemistry and the American Society of Veterinary Clinical Pathology as a starting point for scientific discussion and the development of internationally harmonised testing recommendations. Approximately 80 written revision proposals were reviewed and discussed. Technical issues that generated significant discussion included blood sampling protocols, urinalysis testing, and statistical analysis of clinical pathology data. A voting procedure was defined for resolution of technical issues. Final recommendations for international harmonisation of clinical pathology testing in non-clinical toxicity and safety studies are anticipated by the end of 1993. Originally presented at ECCP 93.