Pathology everywhere all at once
Donald S. Karcher, MD
July 2024—Remote sign-out has become a major issue for pathologists, spurred in large part by the COVID-19 pandemic and the CAP’s advocacy efforts that led to our ability to sign out cases from other locations. The Centers for Medicare and Medicaid Services has allowed remote sign-out to continue long after the public health emergency was declared over and is considering making this a permanent rule. I recognize how popular remote sign-out has become and have enjoyed many of its advantages in my own practice. However, I also see a few possible unintended consequences that I think are very important for us to consider before we let things get too far.
Let’s start with the positives. It’s hard to imagine anything more convenient than being able to sign out cases from home, or from the office, especially for those of us who have an office far enough away from the hospital or laboratory to count as its own site under CMS rules. Remote sign-out should improve turnaround times and make it possible for pathologists working in outlying locations to report results sooner than if they had to go in person to a central laboratory to review cases. We can begin interpretation as soon as slides are digitized or able to be viewed electronically in other ways, no matter where we are. That’s tremendously powerful for getting evidence-based care to patients faster. It also expands access to pathologists who subspecialize, so within a hospital network all neuropathology cases, for example, could easily and quickly go to the neuropathologist—wherever he or she is located in that network—instead of to a more local pathologist without that subspecialty focus.
I also appreciate how much easier it is for us to get a second opinion from a colleague at another institution when we can share slides digitally. This is a boon for any pathologist looking for a fresh set of eyes on a complex case, and it’s especially important for smaller or rural hospitals that may not have certain pathology subspecialists on staff.
Before I get to my concerns, let me dispense with one key element: accuracy. As digital technology has improved in recent years, we should be able to deliver the same accuracy of diagnosis remotely as with in-person microscopy. Of course, any remote sign-out arrangement must use appropriate software and hardware and be properly validated to ensure adequate image resolution and good diagnostic equivalency.
For all these reasons, I support the continuation of remote sign-out, but I feel there should be guardrails put in place. I’m particularly concerned about how remote “remote” should be. Could someone in Oregon sign out cases for my practice in Washington, DC? If so, what’s to stop a remote, cut-rate pathology group from putting local practices at risk? This also raises the possibility of a pathology group in another country doing the same thing.
Our colleagues in the radiology field have instructive experience here: Overnight results in the U.S. are often provided by radiologists located in other countries. I could certainly see a scenario in which pathologists in the U.S. would have to worry about losing work to people in regions with a lower cost of living, whether that’s in this country or in other countries. Medicare law currently restricts payment for medical services performed in another country, but that law has been challenged legally, although so far unsuccessfully. Some private payers have similar payment restrictions, but some don’t, and Medicare law could certainly be changed in the future.
In addition, we should keep in mind that the practice of medicine is done best when the various members of a health care team have ready access to each other. Yes, we can reach each other by phone or other electronic means, but the benefits of the team interacting in person are irreplaceable.
Finally, I worry about the long-term effect of remote sign-out on our profession as a whole. Pathologists are already somewhat invisible in the hospital, but at least when we’re there in person we have a better chance of being consulted by a colleague or being able to manage a question that arises in the laboratory. When we are not seen in the doctors’ lounge or in committee meetings, it’s all too easy for our colleagues to forget about us and what we bring to the table. Relying too much on remote sign-out could make us even less visible or, worse yet, seen as dispensable.
That’s not to say we should never use remote sign-out. Clearly, it offers huge advantages to us and to our patients. Personally, I love being able to look at images electronically when I’m on call. I support remote sign-out as an option but hope that we proceed cautiously, understanding that there is no replacement for in-person interactions with our colleagues and our patients.
Dr. Karcher welcomes communication from CAP members. Write to him at president@cap.org.