College of American Pathologists Notably Absent from Choosing Wisely

| November 22, 2015

choosing-wisely@2x

I recalled sharing news a couple of years ago about ASCP and the ABIM Foundation partnering together for something called “Choosing Wisely” and thought I would check in to see what this site consisted of now. I think the addition of information for patients is somewhat new in addition to information for clinicians.

According the website, choosingwisely.org, “In 2012 the [American Board of Internal Medicine] ABIM Foundation launched Choosing Wisely® with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures.

Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations of “Things Providers and Patients Should Question.” More than 70 specialty society partners have released recommendations with the intention of facilitating wise decisions about the most appropriate care based on a patients’ individual situation.

‪Consumer Reports is a partner in this effort and works with specialty societies to create patient-friendly materials to educate patients about what care is best for them and the right questions to ask their physicians. Through a coalition of consumer groups like AARP and the National Partnership for Women and Families, Consumer Reports is ensuring patients get the information they need just when they need it.

Recommendations from more than 70 specialty societies have partnered with this collaboration to advance a dialogue on “unnecessary medical tests” among “treatments and procedures”.

The College of American Pathologists (CAP), unfortunately, is not among these 70+ specialty societies.

The American Association of Blood Banks (AABB), for example, recommends against performing serial blood counts on clinically stable patients and not routinely using blood products to reverse the effects of warfarin, among a few other common recommendations that support good clinical practices. The American Society of Clinical Pathology (ASCP) has among its list, recommendations for appropriate testing for thyroid and cardiac disease as initial first steps as well as recommendations for Vitamin D and Vitamin K testing, as examples, among others.

While AABB and ASCP have pathologists and laboratorians interests at heart to promote cost-effective utilization of laboratory resources and personnel, we seem to be missing direct contributions from us as pathologists ourselves to our clinical colleagues.

And here are a few of the recommendations that I think we as a specialty society and professional college charged with “serving patients, pathologists and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine worldwide” should make to clinical colleagues:

  • Do not ask, expect, or require pathologists to perform “routine” immunohistochemistry for Helicobacter pylori on stomach biopsies obtained during “routine” upper endoscopies with normal gross findings.
  • Do provide full clinical information and clinical history on submitted anatomic pathology specimens. While we go through residency playing “Guess the Tissue” it turns out you will not bias us if you provide relevant clinical information and potentially allow us to provide more specific diagnoses for our patients.
  • Don’t ask us to perform a bunch of immunohistochemical tests or molecular tests unless they are going to impact your treatment plan or approach. Chances are the ones that do provide relevant theragnostic/prognostic data we will perform for our patients.
  • Don’t complain about us using statements such as “Clinical correlation required” when clinical information is not provided (See bullet #2). We don’t like writing this anymore than you like reading it. And us pathologists all know that “it is in the EMR and we can look it up” except for the fact that the procedure note and findings “is not in the EMR”.
  • Do ask us to review pathology reports, slides and clinical laboratory or molecular reports with our patients. Most of us provide this service at no cost to you or the patient and when referred, will spend time with the patient. If your pathologist is unwilling or unable to do this, find one who is.
  • Don’t ask us to interpret the results of dozens of analytes that are completely unrelated and potentially unnecessary in caring for a patient and you want to know what to do with an abnormal serum porcelain level after you ordered it for no logical reason.
  • Do ask us what tests may be appropriate before you order them to help manage our patients with fewer tests and more specific results to help confirm or eliminate possibilities in the clinical differential diagnosis. Just because the check box is there to order the test does not mean you should.

On a serious note, these are real issues we as a community should be addressing for patients, pathologists, physicians, physician extenders and the public for their benefit and our profession.

One recent article published last month in thepathologist.com entitled “The Invisible Doctor” with the byline “Pathologists have regressed from eminence to anonymity – how did it happen and what should we do about it?”, written by a European pathologist has some key takeaways we as US pathologists working with organizations such as ABIM and others should think about:

Contrary to a belief among our colleagues of other specialties, pathologists do not read the slide under the microscope because nothing is written in cells and tissues. Under the microscope, the pathologist interprets morphological and immunohistochemical data, integrates them with clinical, analytical, molecular and radiological data, and delivers a pathological diagnosis. The pathological diagnosis is much more than a mere result, it’s a complex interpretation of multiple and diverse data. Sometimes it is easy, sometimes is not; our job involves seeking out plenty of wolves in sheep’s clothing. We need to take responsibility to communicate this message to our medical colleagues.

For the general public, it’s important that they know, at the very least, that a pathologist’s diagnosis assigns a name to almost every disease, gives crucial information about the extent of the disease, predicts its prognosis, selects the patients that may receive expensive treatments, and evaluates a posteriori the effect of these treatments on the patient. How do we do improve public perception? We step out of our comfort zone.

What we need to do now is to work together to improve the visibility of our profession. If we don’t, its future could be in trouble. It’s impossible to change the mindset of society overnight; we need to start changing things today!

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Comments (2)

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  1. Dan Cruser MD says:

    Well said.

  2. Lee Hilborne, MD, MPH, FASCP, FCAP says:

    I appreciate Dr. Kaplan’s comments and possible suggestions for inclusion in the pathology/laboratory medicine Choosing Wisely list. ASCP was proud to be chosen by ABIM as Pathology’s representative to the Choosing Wisely campaign. While our specialty of Pathology and Laboratory Medicine has a number of different organizations, we clearly have a long history of cooperation and collaboration. In fact, the stated charge to serve patients, pathologists and the public by fostering and advocating excellence in the practice of pathology and laboratory medicine worldwide are areas where ASCP and CAP are very closely aligned. That should be no surprise given that the ASCP specifically gave birth to the CAP in 1946 (Dr. Frank Hartman was CAP’s first president after being president of ASCP in 1928-1929).

    The Choosing Wisely team has considered a number of new recommendations and we are happy to consider Dr. Kaplan’s suggestions that align with the ABIM requirements. One of the recommendations Dr. Kaplan notes (actually implicit in several) is “don’t order tests if you do not know what you will do with the results.” We actually put forward that recommendation as one of our first to the ABIM – but this recommendation was not accepted because the reviewers, while supportive, believed the recommendation was too general for the project. Further, we have been working with many other specialty societies throughout medicine who are also developing laboratory medicine recommendations that focus on their specialty-specific areas of practice. In fact, we are also looking at expanding the focus of our laboratory team to look at recommendations about what SHOULD be done, not just what should not be done (the focus of Choosing Wisely).

    In the end, the Choosing Wisely Laboratory Medicine team welcomes the input from the entire laboratory medicine community. We would welcome suggestions from all of Dr. Kaplan’s readers. If you have suggestions or recommendations, please write Edna Garcia at ASCP: edna.garcia@ascp.org. Together we will be able to drive the effective use of laboratory diagnostics to the benefit of patients, the public and pathologists and laboratory professionals.