July 2010

Stephen N. Bauer, MD

How pathology reports communicate

Modern medical practice is an information-dense endeavor. Finding the best ways to make use of new knowledge takes time, and finding the time without compromising the quality of our work calls for intentional thinking about how we collect and communicate what we know.

There has been a marked increase in the complexity of pathology reports, and the diagnosis field now includes other clinically important elements. True, presenting the diagnosis is still the first purpose, but we use our reports to emphasize important prognostic features as well as suggest possible comorbidities, recommend additional tests, and translate findings that affect treatment. A structured report format provides a reminder to include all of the important pathologic features for each case. The pathology report is more than a vehicle for our diagnoses; it is also a bridge between our work and that of our colleagues.

I’ve heard a lot about pathology reports since the release of the new cancer protocols, implying as they do that each report element should appear on a separate line. Currently, the CAP Laboratory Accreditation Program recommends use of the synoptic format, although it is not required, and the American College of Surgeons recommends the synoptic format for accredited cancer programs. I am not a fan of the proposed format, although I suspect my reluctance will lessen with experience. I find lengthy synoptic sections difficult to read, but this problem will be ameliorated if the synoptic section does not include elements that are not important. I wouldn’t mind including a synoptic section for the less important elements, but I don’t like them cluttering up the critical data that should be displayed with the diagnosis.

The big picture is that while transition to a synoptic format may absorb time and energy when both are in short supply, consistently reported, seamlessly aggregated, and readily retrieved information for physicians will justify the transitional inconveniences. In the long run, synoptic reports will make pathology data more useful to more people.

Going forward, our ability to share, store, and work with health information in a variety of systems will accelerate progress in countless ways. However, ensuring seamless transfer of the data in our reports to those with whom we wish to share the data will require that information systems be able to handle the information as data rather than text. In some systems that requires a separate data field for each data element. I’d like to see XML-formatted reports with SNOMED tags that would make the report a searchable, flexible document.

As chairman of the CAP Council on Scientific Affairs, Paul Valenstein, MD, is well acquainted with the cancer protocols. He has pointed out that malignant diagnoses make up a relatively small part of our reports and that those who would rather not employ the synoptic format need not use it for their other cases. He also points out that synoptic reports can include a narrative section where we can record elements we feel are important but are not included in the standard synoptic section. The narrative section accommodates ambiguities and possibilities. Here, a pathologist might mention concerns or provide explanations that the referring physician has not yet considered. In the case of significant uncertainty, the report can prompt a conversation involving primary care physicians, consulting specialists, family members, and other pathologists.

This summer, the Cancer Committee is completing the first one-page work aids for the cancer protocols. These single-sheet downloadable Word documents will highlight the essential elements for each of the 10 most frequently reported cancers. The Cancer Committee plans to continue to develop the work aids until there is one for every circumstance in which cancer protocols are applicable.

The panels developing cancer protocols have always included community pathologists, and community pathologist usability panels will review the work aids. Input from the membership, however, can further improve them. When you begin to use the new cancer protocols and work aids, please take part in their refinement by sharing your comments via the CAP Pathology and Laboratory Quality Center Web page.

Dr. Valenstein has an interest in communication generally and pathology reports in particular. He published an interesting article on the topic in the January 2008 issue of Archives of Pathology & Laboratory Medicine. He says that when all reports are designed with clear headlines that identify key findings, when information is consistently positioned from report to report, and when the language is clear and the page free of clutter, it is much easier for busy physicians to find and absorb what they need. Also, he adds, as patients show more and more interest in seeing their reports, pathologists might mention the CAP patient education Web site, mybiopsy.org, where sections on each type of cancer provide background, vocabulary, visuals, and possible questions to ask their clinicians.

Last month, I mentioned an intriguing book, A Whole New Mind, by Daniel Pink, who sets out the theory that success in the modern age is largely about the ability to relate to others and to synthesize information by employing a balance of analytical and emotional intelligence. Pink also talks about the impact of intelligent design (for example, that attractive hospital rooms have been associated with less need for pain medication). He describes the poor design of the so-called butterfly ballots used in Palm Beach County, Fla., that were blamed for controversial results in the 1980 presidential election. He makes the point that bad design can have serious consequences.

By the same token, good design can have beneficial consequences. The effort we make to refine and synthesize information in our pathology reports fosters progress in patient care, research, and public health. And the care we take in creating reports sends a message to our colleagues about our respect for their time, their intelligence, and the importance of their work.