Should we give pathologist's histories?

Re: Should we give pathologist's histories?

Charlotte Marshall — Sat, 10 Oct 2009 15:46:26 GMT

I totally agree about generic computer generated responses. The one that always irritates me is all my culture and sensitivity results telling me on the bottom of the sheet what antibiotics are indicated for Pseudomonas when they haven't grown it!

Re: Should we give pathologist's histories?

Laurence Webb — Sat, 10 Oct 2009 11:38:47 GMT

[quote user="Gareth Gareth"]However what really annoys me is when you submit a detailed history and you get a generic comment which contains sections which indicate your history clearly hasn't been read, or they ask questions regarding history which they should know from your submission. This seems to happen mostly in big labs where one sample goes to one place and another somewhere else.

[/quote]

That is precisely the reason that we've started sending a lot of our external lab work to a different lab recently. Generic 'press the button' answers didn't give me any confidence that the results were being interpreted well. Examples include bloods with raised urea and normal creatinine suggesting that we check urine SG when urinalysis has already been requested and anaemias being described as non-regenerative despite there being reticulocytes and hypochromic macrocytic red cells lost my confidence.

Generally we use IDEXX for their non-interpreted profiles (they are very cheap so good value for money for monitoring uncomplicated hyperthryoids etc) and TDDS for more complicated stuff as their interpretations are far superior in my opinion. Their histology/cytology seems very good although we've used Abbey in the past and have been very happy with their service.

As an aside one of our nurses boss in her previous job had an alternative reason for not giving histories - his argument was that he was paying for them to tell him what was wrong not the other way around. A bit like the helpful client who comes in and in reply to your opening question of 'what seems to be the matter' says 'Dunno, that's why I came here' then stares at you.

Re: Should we give pathologist's histories?

Gareth C. — Sat, 10 Oct 2009 11:25:38 GMT

I think some history must be necessary. If send off a skin lump and it looks neoplastic to the histologist surely its important for them to know how quickly its grown, where its from etc. Or a gut mass, were there others, were the lymph nodes affected? I couldn't do my job without taking a history. But i see your point about history influencing what we/they see. Human GP's rely about 90% on history.

However what really annoys me is when you submit a detailed history and you get a generic comment which contains sections which indicate your history clearly hasn't been read, or they ask questions regarding history which they should know from your submission. This seems to happen mostly in big labs where one sample goes to one place and another somewhere else.

Re: Should we give pathologist's histories?

Mike Martin — Fri, 02 Oct 2009 13:12:26 GMT

[quote user="Mike Martin"]

What I do dislike, is when a pathologist steps into the realms on advising on management/treatment.

[/quote]

And I should of course say the converse. I don't do cytology! (or histology). The only time I look down a microscope is to hunt for wriggling lungworm larvae.

Re: Should we give pathologist's histories?

Gordon Pepper — Fri, 02 Oct 2009 12:32:55 GMT

Sure the temptation is there to change your findings if they don’t fit with the history. However, I personally like to think our pathologists here at Eastalt, where we specialise in histology, have enough experience and confidence with their findings not to allow this to happen. It may of course cause the pathologist to have another look and/or get a second opinion and/or speak with the vet. Therefore, by having the history to refer to actually benefits all involved i.e. animal, owner, vet, and pathologist.

Regards

Gordon

Re: Should we give pathologist's histories?

Alex Gough — Thu, 01 Oct 2009 19:34:41 GMT

That sounds to me the ideal way of doing it Gordon. But is there a temptation to go back and change your findings if it doesnt fit with the history?

Alex

Re: Should we give pathologist's histories?

Gordon Pepper — Thu, 01 Oct 2009 15:15:38 GMT

We are a specialist histopathology company, when we receive samples from vets we do prefer to have a small relevant history of the animal to aid us in a diagnosis. Our pathologist tend to first examine the sample and attempt to draw a conclusive diagnosis. However after this has been completed it can be compared with the history provided to ensure the diagnosis is consistent with any prior history the vet is aware of. If for example the two sources do no correlate, our pathologists will often phone the vet directly to discuss the findings to ensure the correct information is conveyed.

I hope this helps

Many Thanks

Gordon

Re: Should we give pathologist's histories?

Mike Martin — Thu, 01 Oct 2009 14:40:56 GMT

[quote user="Mike Martin"]

What I do dislike, is when a pathologist steps into the realms on advising on management/treatment - an area in which they have very limited experience.

[/quote]

So I have an example today. For reasons of confidentiality best I say not too much, but...

This is a dog with a cough referred with a suspect bronchial FB. Primary vets had done a BAL - which sounds like reasonably good sample. The report by the comm'lab and recognised cytologist, described the findings very well and the initial comment is good. This should be job-well-done! But then.... goes verbose into management and treatment, including discussing what drugs to use + some vague generic advice on weight loss too!

This cytologist has gone too far (in my opinion) and I mostly disagree with the advice given. So why worry? Whats the problam? Well, for me, its not fair on the dog (and owner) if their vet were to follow such inaccurate advice.

Re: Should we give pathologist's histories?

Mike Martin — Mon, 21 Sep 2009 09:24:33 GMT

Another reason to give a history is when asking the pathologist to look for something they might ordinarily miss. eg. Pneumocytis in a BAL sample. I bet if I sent a sample to 10 pathologists without telling them that was my clinical suspicion, then no more then 2 would see it. If I tell them to look for it, then that might bump up to 5-7 maybe (?).

If they do see it, then it makes the diagnosis as opposed to a biased opinion.

Re: Should we give pathologist's histories?

Alex Gough — Fri, 18 Sep 2009 08:04:08 GMT

Well after a tour of Axiom laboratories last night, they did point out that in certain cases, the history is necessary so they can decide what to look for eg which stain to use, which antibiotics to test for sensitivity. So I guess it is important, but I still wonder about how to decrease subjectivity in medicine/veterinary medicine. Maybe it isn't possible, and that's why it's an art as well as a science!

alex

Re: Should we give pathologist's histories?

Alex Gough — Thu, 17 Sep 2009 12:50:26 GMT

I agree totally. What I'm wondering is how easy it is to subconsciously influence what you see, that makes up the first part of the report. I'm sure we all do it to some extent, go back and recheck that aortic velocity, because the murmur you heard suggested it should be higher for example. But I wonder if it would be good practice to produce the first part of the report blinded, and then read the history. Maybe we should even consider applying it to our physical examinations. Check the animal before the owner tells you what is wrong, then take a history, then go back and check again in the light of the history. I know its always frustrating when you ask for a history and you ask whats wrong with an animal and they say well you're the vet you tell me! However, I do think a lot of veterinary medicine is subjective, especially at the coal face as it were, and anything we can do to reduce bias and increase objectivity is worth considering.

Alex

Re: Should we give pathologist's histories?

Mike Martin — Thu, 17 Sep 2009 11:26:23 GMT

Whether it's histopath, cytology, ECG, radiography, etc..... the first part of any report should be an objective description of what was provided and what was seen. And this part should not be influenced by the history.

The second part is the comment on what is found, taking the history into account, and their experience. This will be biased by the history provided. Its often helpful for vets to be provided with a differential list.

What I do dislike, is when a pathologist steps into the realms on advising on management/treatment - an area in which they have very limited experience.