Characteristics of a bad pathologist

[pathslides]

We all know what makes a good pathologist. One of the reasons for a surplus of unemployed peeps is due to too many "bad" pathologists. I am curious, in your working/personal experience, what are the characteristics/red flags that encompass a bad pathologist?

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[tiredguy]

starting even in residency, their co-residents did not enjoy working with them. it seldom improves from there.

 

[coroner]

On paper (before meeting them)
1. Inability to pass boards 5+ years post training i.e. board ineligible
2. Excessive job-hopping in a relatively short amount of time
3. Lack of references who'll vouch for them (this may get downplayed if some places feel sorry
for them and are hoping to unload them to become someone else's problem)
4. Multiple malpractice cases against them
5. Other legal issues e.g. DUI, felonies, hospital privilege suspensions, loss of medical license by the state, etc.

After working with them
6. Language/communication skills: the practice won't allow them to answer phone calls from clinicians, transcriptionists are slowed down and/or have
multiple errors because they can't understand their dictations, reports aren't clear and concise
7. Competence: having to open the GI book and take an hour to sign out a tray of colon polyps, clinicians are skeptical of their diagnoses and constantly request 2nd opinions on their cases after they've been signed them out, frequently asking colleagues to look at slides for them that are very basic, lack of decisiveness
8. Work ethic: leaving specimens to gross for next person, dumping slides on others' desk, constantly asking colleagues to cover them to leave early but they're unwilling to do so in return, missing admin meetings when it's their turn, etc.
9. Personality: self-explanatory...

One of the reasons for a surplus of unemployed peeps is due to too many "bad" pathologists.

Fixed that for ya. Cut residency slots in half and this problem will take care of itself...

 

[Dave CX]

Fuzzy and meaningless "diagnoses". The previous pathologist for one of my practices used the following for 90% of his stomach biopsies:
"mild non-specific chronic inflammation with vascular ectasia and reactive epithelial changes".

 

[deleted314957]

Fuzzy and meaningless "diagnoses". The previous pathologist for one of my practices used the following for 90% of his stomach biopsies:
"mild non-specific chronic inflammation with vascular ectasia and reactive epithelial changes".

Indeed. I think the most inane words in pathology are "mild non-specific chronic".
The clinicians just laugh at/ignore it.

 

[Thrombus]

Fuzzy and meaningless "diagnoses". The previous pathologist for one of my practices used the following for 90% of his stomach biopsies:
"mild non-specific chronic inflammation with vascular ectasia and reactive epithelial changes".

Given that CMS may not pay for routine HP stains, even when the GI doc requests/demands it, I can see why one may use this in the stomach.

 

[pathstudent]

In my experience it is the pathologist that is last to show up in the morning and whose biggest concern is what time they can get the f.u.c.k. out of there.

Leading be example doesn't work for these people. You are the sucker they are looking for. The only remedy is threats of firing if they don't turn it around.

 

[gbwillner]

All great so far. I will add two:

1. They don't ask for help/2nd opinion on difficult cases, and get defensive when asked to explain their diagnosis;
2. they never admit when they are wrong

 

[jupiterianvibe]

1. They'll go along with whatever hare-brained thing a surgeon or administrator wants them to, just to "keep the peace", when it means providing substandard care. But the unfortunate thing is, these are precisely the people administrators like hiring.

2. They'll lie about things, like reviewing slides for cancer cases.

 

[yaah]

Good lists above!

Good pathologists know what they don't know.
Bad pathologists don't know what they don't know.
Bad pathologists are not respected by clinicians and often don't respect the clinicians they serve.

The key point is that it's better to recognize what a good pathologist is, and try to do that. Don't try to just not do what the bad pathologist does.

Ask yourself what pathologists you have met (or know about) that are well respected and successful - what is it about them that garners respect? You will probably find humility but also confidence, humor but also sincerity, thoroughness but also efficiency, expertise but also balance. And respect is mutual.

 

[WEBB PINKERTON]

1. They'll go along with whatever hare-brained thing a surgeon or administrator wants them to, just to "keep the peace", when it means providing substandard care. But the unfortunate thing is, these are precisely the people administrators like hiring.

2. They'll lie about things, like reviewing slides for cancer cases.

What pathologist does put up resistance anymore? Almost all of us just do whatever we have to do to keep peace or keep the lab doors open. We all are guilty of being horrible gate keepers, allowing wasteful testing to be done. If we put our foot down and resist, there is a never ending supply of shady labs to take our place and keep the waste train a-rolling.

 

[Unsatisfactory]

A far as I can tell I've never worked with a bad pathologist. They all seemed reasonably good at the job. Some I liked more than others but no one I would call a bad pathologist. I've been doing this for 20 years so maybe my standards are low. I don't know.

 

[Alteran]

All great so far. I will add two:

1. They don't ask for help/2nd opinion on difficult cases, and get defensive when asked to explain their diagnosis;
2. they never admit when they are wrong

These two are the most serious in my opinion. Respectable groups don't hire board ineligible pathologists and I'm not so worried about the pathologist who takes an hour to go through a tray of GI biopsies as long as the work gets done.

I'm more worried about the pathologist who thinks they know much more than they do (especially out of the gate) and is adamant about it. I still show cases around liberally, as do my far more seasoned colleagues, and at the end of the day we all get to the best correct diagnosis we can get to in these difficult cases. The situation you don't want to be in goes something like this: you're reviewing another pathologist's case that's come up for tumor board in 3 days, you don't agree with the diagnosis at all (as in its not a tumor), was not QA'd, and you come to find out that the patient has already started treatment.

 

[27G]

These two are the most serious in my opinion. Respectable groups don't hire board ineligible pathologists and I'm not so worried about the pathologist who takes an hour to go through a tray of GI biopsies as long as the work gets done.

I'm more worried about the pathologist who thinks they know much more than they do (especially out of the gate) and is adamant about it. I still show cases around liberally, as do my far more seasoned colleagues, and at the end of the day we all get to the best correct diagnosis we can get to in these difficult cases. The situation you don't want to be in goes something like this: you're reviewing another pathologist's case that's come up for tumor board in 3 days, you don't agree with the diagnosis at all (as in its not a tumor), was not QA'd, and you come to find out that the patient has already started treatment.

The other end of the extreme is the pathologist that shows every single case or brings their entire workload to be reviewed by others. Or the pathologist that does not formulate a specific question about the case on which they want a second opinion..... always overwhelmed, do not have a systematic way of working up a case.... do not understand their role as a physician and not a technician....do not understand how the sample was procured or anything about the variety of services that are sending biopsies to the lab. Sits on a case like they are hatching an egg..... used the word atypia in greater than 60% of their topline dx.... or suspicious....

 

[Diana Prince]

What are your thoughts on these issues:
1. The pathologist signed out a bone marrow as marginal zone lymphoma. The patient was treated. Three months later, I signed out the subsequent bone marrow as acute lymphoblastic leukemia. The original bone marrow was actually involved by acute lymphoblastic leukemia.
2. The pathologist only submits seven cassettes on a 3 cm follicular neoplasm of the thyroid with a thickened capsule. The pathologist does not think further sampling of the capsule is indicated to exclude follicular carcinoma.
3. Breast cases are signed out as invasive lobular carcinoma without e-cadherin staining. E-cad staining of the excision show invasive ductal carcinoma.
4. A patient has an extensive family history of breast and ovarian cancer. When the cystic/solid fallopian tube with attached ovary, that has been enlarging over several month, is received, only two sections are submitted.
5. When fully staffed, the pathologist takes weeks of time off, on short notice, without telling all members of the group. I end up re-scheduling my flights on short-notice to accommodate this pathologist's sudden decision to take vacation.

 

[deleted314957]

My thoughts?
That pathologist is the boss/owner/contract holder

 

[tiredguy]

My thoughts?
That pathologist is the boss/owner/contract holder

it's funny because it's true

 

[path24]

You are a commodity. Know your role.

Seriously, I would be looking for a new job.

 

[medgator]

Is it a concerning practice to have pathologists not stage a cancer appropriately on their final reports?

I often see incorrect T stage and/or ajcc stage grouping on the finalized reports. Makes me wonder about the rest of their abilities when they can't even take the time to pick up an ajcc staging manual and issue a correct stage. This applies to a group of pathologists that works at one of the hospitals I see patients at.

 

[medgator]

3. Breast cases are signed out as invasive lobular carcinoma without e-cadherin staining. E-cad staining of the excision show invasive ductal carcinoma.

.

Seems like the least egregious issue if i had to pick one. Certainly they have different behaviors than lobular but management doesn't change much

 

[jupiterianvibe]

Is it a concerning practice to have pathologists not stage a cancer appropriately on their final reports?

I often see incorrect T stage and/or ajcc stage grouping on the finalized reports. Makes me wonder about the rest of their abilities when they can't even take the time to pick up an ajcc staging manual and issue a correct stage. This applies to a group of pathologists that works at one of the hospitals I see patients at.

the low standards in selecting pathology residents has lasting implications.

 

[Alteran]

What are your thoughts on these issues:
1. The pathologist signed out a bone marrow as marginal zone lymphoma. The patient was treated. Three months later, I signed out the subsequent bone marrow as acute lymphoblastic leukemia. The original bone marrow was actually involved by acute lymphoblastic leukemia.

A half-way properly trained 1st year wouldn't confuse B-ALL for MZL. Did said pathologist even look at the slides or flow cytometry (assuming he/she knew how to properly interpret it)?

 

[Asteroid Body]

I am personally peeved by the pathologists that put too much stock in IHC results for lesion classification. IHC may be an objective measurement but is certainly not a gold standard. I cringe every time I am reviewing a case signed out as "___ with neuroendocrine differentiation" just because their dirty, inappropriately-titered synaptophysin stain was focally positive. I have seen patients be excluded from clinical trials for this kind of nonsense.

 

[Asteroid Body]

What are your thoughts on these issues:
3. Breast cases are signed out as invasive lobular carcinoma without e-cadherin staining. E-cad staining of the excision show invasive ductal carcinoma.

See my previous post about IHC.... and PMID 18379416
Aberrant expression of E-cadherin in lobular carcinomas of the breast. Am J Surg Pathol. 2008 May;32(5):773-83.

 

[cmz]

See my previous post about IHC.... and PMID 18379416
Aberrant expression of E-cadherin in lobular carcinomas of the breast. Am J Surg Pathol. 2008 May;32(5):773-83.

There are exceptions to every so-called "rule." To argue Diana Prince's earlier statement, if you're going to sign out a case as invasive lobular carcinoma on a core biopsy perhaps... maybe some people practice by always throwing an e-cad IHC "just in case." After all, there's a bit of morphologic overlap between a garden variety poorly-differentiated invasive ductal and an invasive lobular. Yes, it's well known that a small percentage of invasive lobulars MAY in fact show aberrant expression of e-cadherin. You can still create a carefully crafted comment explaining that although e-cadherin is positive (and you can quantify and characterize the location and intensity of staining if you want), you cannot reasonably exclude the possibility of invasive lobular carcinoma (based on patient demographics, etc). Or you can just grab your balls and make a diagnosis. Management of these two entities are different, but I've seen far far worse.

 

[Asteroid Body]

There are exceptions to every so-called "rule." To argue Diana Prince's earlier statement, if you're going to sign out a case as invasive lobular carcinoma on a core biopsy perhaps... maybe some people practice by always throwing an e-cad IHC "just in case." After all, there's a bit of morphologic overlap between a garden variety poorly-differentiated invasive ductal and an invasive lobular. Yes, it's well known that a small percentage of invasive lobulars MAY in fact show aberrant expression of e-cadherin. You can still create a carefully crafted comment explaining that although e-cadherin is positive (and you can quantify and characterize the location and intensity of staining if you want), you cannot reasonably exclude the possibility of invasive lobular carcinoma (based on patient demographics, etc). Or you can just grab your balls and make a diagnosis. Management of these two entities are different, but I've seen far far worse.

Why not just sign out the biopsy as "invasive carcinoma with ductal and lobular features" if it's hard to tell, and defer to excision? Without knowing more about that case, I don't automatically assume it is a bad pathologist that signs out a breast biopsy as ILC without an Ecad and the excision turns up Ecad positive. It could have actually been correct diagnosis and most cost-effective practice. The ER/PR/HER2 is most important anyway for management obviously.

 

[LADoc00]

Good pathologists know what they don't know.
Bad pathologists don't know what they don't know.

This was told me to many many years ago and I actually repeat it often. There is no more true statement in this profession.