Total joints in view: to tilt at or to toss

Even without slashing fees, examining hips is not a money-printing enterprise, points out Nicole D. Riddle, MD, staff pathologist, Tampa (Fla.) General Hospital. With a billing code of 88304, hips, in and of themselves, are on par with appendices, gallbladders, and benign skin cysts, she says. “It’s not that we’re trying to churn out hips to get rich,” says Dr. Riddle, who is also an assistant professor of pathology, University of South Florida, Tampa.

Dr. Bachner can attest to that. Several years earlier, some of his surgical colleagues proposed changing the policy. At that time, Dr. Bachner used data from Dr. Klein’s study to bolster his position. He also did two surveys of his own, sending questionnaires to members of both the Association of Pathology Chairs and the Association of Directors of Anatomic and Surgical Pathology. Of the 46 responses, about 80 percent said they did routine histologic examination. Of the personal comments he received, Dr. Bachner says most were from those who felt it was beneficial both clinically and for QA. But when he summarized his findings for his colleagues, he tried to construct a pie chart to illustrate the financial implications. The software wouldn’t accept the number he plugged in for the cost of pathology. “It was so small,” he explains.

Dr. Klein recalls an incident at another institution when a senior resident asked him about findings on a femoral head—osteoarthritis, as it turned out. After he explained the pathology in detail, his colleague said this was her first encounter with such a case. Dr. Klein learned, much to his surprise, that all femoral heads as well as knees were being thrown out. “It practically took an act of Congress to get the surgeons to begin sending that stuff,” he says. Change came only when a new physician in chief was appointed at the institution. Dr. Klein approached her only after ascertaining that he had the support of his department chair. When Dr. Klein explained the QA and medical-legal implications, the practice changed. “Of course, what made the real difference in getting the support of the chair was explaining that $400,000 a year of potential professional billings were getting thrown out,” he says. “I got the backing, but it wasn’t because he was interested in femoral heads.”

In practices where money is less of an issue, Dr. Richard says, so-called little cases might seem like more trouble than they’re worth. “They might possibly say, ‘Oh, the last thing I want to do is look at 20 slides of arthroscopy shavings.’ ”

Dr. Bachner dittos that point. Though he successfully lobbied to retain the practice at UK a few years back, more recently his own department decided to forego routine histopathologic examinations of all total joint arthroplasties. “Much to my chagrin,” he says. Instead, they put together a series of indications on gross examinations for performing microscopic exams on hips and knees. “Time will tell how that works out,” says Dr. Bachner. His colleagues are busy, he notes, and are looking for ways to concentrate their efforts in areas they deem more relevant than total joint exams. He speaks politely and chooses his words carefully.

When he speaks of the topic more generally, his personal—“And I stress the word ‘personal’ ”—feeling is less circumspect. It’s easy to question the usefulness of longtime medical practices, he says, and once you question and discontinue one practice, it only becomes easier to jettison other tasks. “This represents another move toward the dumbing down of medicine,” says Dr. Bachner.

Asked by CAP TODAY about responses to the paper, Dr. Klein jokes about turning off the reporter’s recording device first. He then plunges ahead with a lengthy narrative: how they submitted it to several nonpathology publications first and were met with both disdain and enthusiasm; how he feared the results might reflect badly on the surgical colleagues he highly respects; how he battled what he considered to be prejudicial peer review from one journal.

Such perils aren’t exclusive to publishing. Pathologists are careful not to point accusatory fingers at their colleagues either inside or outside the lab. But a certain frustration creeps into many conversations. As in the 2016 presidential election, when many voters struggled with how, or if, to address complicated and incendiary issues of gender, race, religion, and class, pathologists sometimes find themselves wondering how to talk about the total joint specimens. How best to ask important but possibly sensitive questions?

The histopathologic exam serves as a check on a surgeon’s work, but as Dr. Richard points out, not all orthopedic surgeons welcome having a pathologist peering over their shoulder.

Many do, of course. Philip Branton, MD, consultant, Biorepositories and Biospecimen Research Branch, National Cancer Institute, and chair of the CAP’s Biorepository Accreditation Program advisory group, says he’s never worked at an institution where an orthopedic surgeon has questioned the practice of joint examinations. “Maybe I was just incredibly lucky and worked with unique sets of clinicians,” he muses. He recalls having exactly zero arguments with clinicians about specimen evaluation. Surgeons’ attitudes were more one of relief, he says: Once it leaves the OR, it’s your guys’ problem, went the thinking.

Reactions can vary with specialty. With obstetrician-gynecologists, says Dr. Richard, “There isn’t a specimen they take out that doesn’t go to pathology.” Even Fallopian tubes that appear completely normal will make their way to pathology, since surgeons are concerned about small changes that may not be evident to them.

The current CAP policy leaves pathologists and medical staff to decide locally which surgical specimens to submit and which to exempt. Dr. Richard, who is speaker of the CAP House of Delegates, says this remains the best approach. But in calling for physicians at each institution to decide as a group, pathologists may feel they’re at a disadvantage, he acknowledges. Who has the bigger department, surgeons or pathologists? Who brings in the most money? Who has the administration’s ear? “If the orthopod says he doesn’t want to do something, and there are 50 orthopods and 10 pathologists, I’ll be honest, that’s not one you’re going to take to the administration—unless you say, ‘I need your help because your insurance policy is at risk,’ ” says Dr. Richard.

Even in less fraught circumstances, surgeons might push back: What’s the benefit compared to the time I have? Tell me what problem you’re solving. Tell me what you’re helping me with if I say yes.

Dr. Richard spins out such a scenario with the detail and inflections of someone who’s heard it all before. It’s almost like a tiny theatrical performance. To wit:

Pathologist: We do this for everybody, for patient safety. If something comes out of the body, it comes through our department. And there’s a risk-management element.

Surgeon: I’ve never been sued for any of my arthroscopic surgeries.

Pathologist: Wonderful. That’s fantastic. All the same, if you miss a septic joint, what’s your risk on that?

Surgeon: Well, nobody’s ever sued me.

Pathologist: No, but the discussion might be different if some of your patients had known you might have identified it earlier.

Surgeon: You see a thousand arthroscopies and you might only find one.

Pathologist: That’s a valid point. Let’s turn it around—how long is that patient septic if the diagnosis is delayed? What’s the greatest risk?

Dr. Riddle has her own riff (also complete with voices) on such conversations. She suspects that some surgeons who say exams are unnecessary because findings are rare “are smart enough to realize they shouldn’t say they don’t want to give money to pathology.” But others are less careful with their words. “I’ve had people say, ‘It’s X amount of dollars—why should I?’ Or, they tie both rationales together: ‘It’s X amount. Why should I when they rarely find anything?’ ”

She also takes aim at the circular reasoning used to say findings are rare. How do you know if you don’t look? she asks. Specimens are routinely submitted for examination at Tampa General Hospital, and she and her colleagues have found polyomavirus, hematopoietic malignancies, and metastatic tumors, all previously unknown.

Are surgeons happy these are caught? Dr. Riddle pauses for an interesting interval. “Usually.” Pause. “Of course. They want what’s best for the patient.” But, she says, some personalities deal better with mistakes than others. And some of those others “get upset when we find something and surprise them with it.”

That may be human nature, but Dr. Richard urges pathologists to keep the larger picture in mind. “We’re guardians of the galaxy here, if you will,” says Dr. Richard. “We’re trying to prevent potential threats, hoping they never come to fruition.” The biggest mistake pathologists make in these discussions, he says, is making it a personal issue. Avoid these useless detours, he says. “It needs to become a matter of having a serious discussion that takes finances out of it and goes directly to patient care and safety.” Put another way, if you want to drive from San Francisco to Los Angeles, follow the coast—there’s no need to hit Fresno or Bakersfield.

Focus on the data, Dr. Bachner says, starting with the DiCarlo/Klein paper. “It’s clearly the best paper in the field. There’s nothing even near it in terms of breadth and scope.”

Dr. Branton, who is past chair of the CAP Surgical Pathology Committee, weighs in with a cautionary thought. “My personal philosophy would be that if you don’t examine specimens, you’re doing so not at your own peril but at your patient’s peril. Sooner or later something is going to be missed.”

When the what-if talk subsides, the matter of actually doing histologic exams can seem almost like an afterthought. How difficult is the task?

Dr. Klein’s place of practice gives him an unusual take on matters. Special Surgery, an all-orthopedic institution, handles 20,000-some orthopedic—soft tissue or bone—specimens a year, nearly all of which undergo a microscopic examination. A defined institutional exclusion list eliminates a few specimens, such as tiny osteophyte bunions. (“Even so, a few surgeons want them done,” Dr. Klein says.) Otherwise, pathologists will take that closer look. “If they revise a prosthesis and there’s tissue attached to [it], we evaluate that tissue. We want to see if there’s metal or cement. We want to see if there’s possibly an infection. If there’s particle disease, we want to see the size and type of the particles because we want to give them some idea of why the prosthesis wore out. There’s a whole variety of things to evaluate.”

Is this a realistic approach for pathologists at less-specialized institutions? Dr. Klein thinks so; the big reason they don’t, he says, “is lack of interest.” That’s followed by technical and clerical challenges. “It takes motivation to decalcify tissues,” he says.

Those who are motivated may not always be acting efficiently, he suggests. When he consults on total joints removed from outside cases, he says he invariably sees five to seven slides, sometimes none of which demonstrate the area described grossly as having degenerative disease. “And yet they’ve made half a dozen histologic slides of material that’s been decalcified.”

“In our institution we make one decalcified section per case. One,” Dr. Klein says. “That’s the routine. Very exceptionally we’ll do two or three, but that’s only if a patient has ochronosis or some incredibly interesting pathologic condition.” But to document a degenerative disease or just about any other kind of joint pathology, only two sections are needed, says Dr. Klein, one from the diseased surface and one synovial tissue, to pick up inflammatory joint diseases or other undiagnosed conditions.

“You just need to document the right places,” Dr. Klein continues. “With a total knee, you can take two or three bits of hard tissue and put them in one decalcified cassette, and you have the entire story.” He also suggests that the decalcification process can be streamlined “if people are motivated enough. You can literally do the fixation and decalcification at the same time if you use the right solution.” While such solutions are generally not commercially available and must be made by the pathologist or technologist, “They shorten time from receipt of tissue to diagnosis by two days.”

Then there’s the issue of carpentry. To make the sections, “How do I saw them?” Dr. Klein asks. “Do I use a band saw, which is dangerous?” It may not make sense to invest in expensive, specialized equipment unless the institution sees a fair amount of osseous specimens, he says. Otherwise, a safe, albeit arm-tiring, double-bladed hacksaw is the best option. “We used to cut all our gross specimens with a butcher band saw. That was dangerous. You could cut your fingers off. I know bone pathologists who’ve injured themselves on those blades.” Currently he and his colleagues use a saw with no teeth, a metallic blade with a diamond carbide edge. “It’s an expensive saw, but it won’t cut you. You literally have to press your hand against it while it’s running full blast, and then it will only nick your skin.”

What about places with lower volumes? “It’s my opinion that all total joints should be sectioned,” Dr. Klein says. “Whether they should be sectioned by someone in a small community hospital, that’s another issue.” It might be worth considering sending samples to regional centers. “Personally, I think that’s the way to go. I think it’s much safer for patients and for public health data.”

Dr. Riddle takes a more sanguine view. “Any surgical pathologist working anywhere in the United States should have the training and capability to do this.” Indeed, she sounds like a DIYer on a home improvement project: “All you need is a handsaw.”

Dr. Bachner falls somewhere in the middle. Many pathologists are uncomfortable with orthopedic pathology, he says. Pathologists tend to experience it in two ways: hip and knee resections (“They find this somewhat of a chore—it’s a nuisance,” he says) and bone tumors (“Most are afraid of bone tumors, because they’re rare and they don’t have a lot of experience with them”).

Yet there’s plenty to be gained, it would appear, from maintaining or developing the practice of examining total joint arthroplasties.

Dr. Branton could not state matters more simply. “I think throwing bones in the trash is a bad idea.” (Sorry, Martin McDonagh.) Certainly it could arouse the curiosity of a malpractice lawyer. Joint examination is good, conservative medical practice, he says.

“We should look at everything that comes out of the patient,” Dr. Riddle agrees. “It’s our job.” Knocking the proverbial fat lady aside, she adds, “Nothing is final until pathology looks at it.”
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Karen Titus is CAP TODAY contributing editor and co-managing editor.