Who is Reading Your Breast Biopsy? Or Liver Biopsy?

This is the first of a multi-part series on continuing issues as I see them with trying to find a balance in surgical pathology between “general” practice and “sub-specialization” that I think affects a lot of groups and departments of pathology in some way, shape or form and what it means for pathology of the future.

I have been interested in the increasing degree of sub-specialization in pathology for sometime and wrote about it in 2010 in “What is to become of the general surgical pathologist?” and re-visted the topic a few years ago with “The Death of the General (Surgical) Pathologist”.

At the risk of repeating myself, suffice it to say, like the rest of medicine, pathology has and will continue to become more sub-specialized. Some of this was born out of consumer driven choices, particularly, I think with respect to breast pathology. With all the recent news about breast pathology I thought it would be interesting to talk to a few folks and see how their practices were run with regards to sub-specialization. Some of the responses were staggering.

For the most part, a number of people (10 practicing pathologists) in a wide variety of small and large practices, academic, private and hospital-based shared a couple of common themes. Namely, they are “sub-specialized” in their practices but everyone is still expected to do “everything” because of call coverage. This means that say a specialist in head and neck cancer may still be expected to handle lung cases as well in case of after hours frozens when he/she is on call and the “lung pathologist” is not. Of course for a head and neck case, there would be a sub-specialist, in this example. So this could mean that during the week, say “non-breast pathologists” do some breast pathology cases to stay competent in breast pathology when there is not expertise and it is needed, say weekend rushes and frozen cases.

It is the delicate balance of covering after hours/weekends with fewer “generalists” and more sub-specialists. 20 years ago, breast pathology was considered part of “general surgical pathology” and you likely could not complete a residency without being well-versed in breast pathology. Hematopathology, dermatopathology, liver, neuropathology and bone/soft tissue, as examples, were perhaps already considered “non-general” but breast, GI, GU and head and neck were included in “general” sign-outs.

As patients began to benefit from dedicated breast radiologists, surgeons, oncologists, radiation oncologists, nurse navigators and “breast care centers”, pathology followed suit and breast was removed from “general” into its own sub-specialty with dedicated breast pathologists.

So what happens when you have a breast biopsy on a Friday afternoon to be read out on Saturday? Or if the breast pathologist is at a meeting when the cases are received? Again, the expectation is that a practicing pathologist in the group should and can be able to do it. Only they may not be comfortable doing so since they no longer see breast cases during the week and may only see them when the “breast pathologist” is not available.

Ditto for medical liver biopsies, for example. Often times liver pathologists read these cases Monday-Friday but a rush transplant biopsy on the weekend would necessitate either a/the liver pathologist being on call every weekend to cover their own services or the service provided by someone who has not looked at a medical liver in the past week or month or year for that matter, unless confronted with one the last time they were on call.

Large enough groups can do this if you have 4 or 5 breast or liver pathologists or a couple neuropathologists who can share weekends more than not possibly. Many groups cannot do this.

The result is someone who may only read breast or liver biopsies on their call weekends and no other time.

In other words, don’t get a breast or liver biopsy, as examples, on a Friday night or over the weekend if it is to be read at that time.

There is no easy solution for this for pathologists “to do everything and do 1 thing”, in my opinion, short of very large groups that can have depth in each subspecialty for constant coverage. Most groups cannot do this so one is left with reading a breast, liver or lung when they have to, not if they want to, feel comfortable doing so or lack interest/expertise in that area.

Pathologists and pathology need to step up to this challenge and recognize what other specialties have done – subspecialize and recognize the most value we can bring to our patients is not trying to cover every kind of case but specific cases that suits patients needs with our interests.

The next post of this series will focus on “What Defines a Sub-Specialist?”