May 2008
Feature Story

Ann T. Moriarty, MD

Case study: A 39-year-old well-educated surgeon with seven years of practice experience called requesting to speak with a pathologist about a diagnosis.

Patient history: A 62-year-old with a previous history of caesarean section, previous appendectomy, previous hysterectomy with a 2-cm deep left inguinal lymph node detected during a CT bone-density scan. The patient insisted on further evaluation. A fine-needle aspiration was performed.

Pathologic diagnosis: Lymph node, left inguinal region, fine-needle aspiration: granulomatous inflammation. Refractile material seen in giant cells suggesting response to foreign body.

The physician’s question: “What is granulomatous inflammation? I have been trying to figure out what to tell the patient. Is it benign?”

My first response was incredulous surprise. Inflammation, acute, chronic, granulomatous. TB, histoplasmosis, sarcoidosis, foreign body, syphilis, leprosy, Brucella, and berylliosis ran through my mind in rapid succession as I called upon trivia acquired over 25 years of practice.

This factual intracerebral rampage was followed by a calm explanation that granulomatous inflammation was a benign response of cell-mediated immunity; granulomatous inflammation itself is benign. Granulomata may be seen as a response in malignant processes. However, there was no morphological evidence of cancer. Given this patient’s history of previous surgery, the finding of foreign material, and the absence of other symptoms, this was most likely a foreign body reaction. She probably needed no other intervention.

The clinician was pleased with the consultation and rang off. The pathologist was mystified. How could a young physician get through all this education and not know what a granuloma was? We all take microbiology, pathology, and clinical diagnosis. Because we’re living in the Ohio River Valley, histoplasmosis is present on everyone’s chest x-ray. Was it a lack of education or lack of motivation? Maybe the knowledge was forgotten in the “busyness” of practice and the physician was not able to look up the information. But this is a member of the plugged-in generation. A Google search of granulomatous inflammation yields pages of information about it and begins with a citation from a medical dictionary.

I was still baffled. Was this an isolated, aberrant outlier in the medical field? Or is this a trend? Are we graduating physicians who are ignorant of the very basis of disease processes?

After musing about this, I concluded that what the physician was requesting was not a consultation about the pathology report but a medical consultation. She was asking, “What should I do with this patient?” It was couched in the pathologic question undoubtedly because it was the entrée into the world of the pathologist. Her real question was probably more along the lines of: “Well, what in the world am I supposed to do with a diagnosis like this?”

The questioning physician’s daily tasks center on physical assessment and removal of surgically treatable diseases. This patient did not need a surgical excision for diagnosis, and the treatment of granulomata is not surgical. What’s a surgeon to do? Could it be that the physician did not want to consult another colleague to expose her limited knowledge? I prefer to think that she consulted with the person who was viewed as having the broadest understanding of the disease process: a pathologist. After all, it was a pathologist who first taught the young physician about granulomatous inflammation. It was a pathologist who taught the young physician about the cellular immunologic response that resulted in the unifying morphologic change in diseases causing granulomatous response. It was a pathologist who after 25 years could still rattle off the trivia learned over a lifetime of tests, lectures, and practice.

So, then, why are pathologists struggling to redefine their role in patient care? Is it because we take curbside consults and do not see patients directly? Is it that we cannot bill for our consults when they are not attached to a patient? Our professional asset is information. Pathologists have been called on to become more engaged in patient care, to step away from their microscopes and define themselves as part of the medical team. I maintain that we already are a strong part of the medical care team. Professional patient reports, participation in multispecialty conferences, telephone conversations with clinicians, e-mails, lectures, continuing medical education all define us as engaged professionals. The problem seems to be in responding appropriately to the questions our colleagues are asking. Are we really doctors or are we simply knowledge fonts? Do we know what the information means to the patient and caregiver, or do we simply dismiss the diagnosis as being the problem of some other physician (or patient)? Pathologists will be integrated into the medical team only if they take their positions as physicians who, in concert with other providers, can offer management strategies to patients.