The Pⁿ Blog is a forum for opinions, questions, controversies, and instructive discussions across the field of pathology and its relevant subspecialties.
Thursday, September 25, 2014
The September 17th issue of JAMA contains a Viewpoint editorial
by the 2014 winner of the Lasker Award, Dr. Mary-Claire King. Dr. King, as I'm sure virtually all of you know, was the first to describe the BRCA1 gene and its strong association, when mutated, with the development of breast carcinoma. The Lasker Award is viewed as and quite often IS the gateway award to the Nobel Prize.
Dr. King presents compelling evidence for screening all women, regardless of family history, at approximately 30 years of age for ACTIONABLE BRCA gene mutations. The key of course, is ACTIONABLE. Testing for BRCA1 and BRCA1 mutations should focus solely on unambiguous loss-of-function mutations with known, defined effect on cancer risk.
There are a vast number (thousands) of mutations in BRCA1/2 that are known to be associated with increased cancer risk. Almost all of these truncate or delete the host gene. In addition, there are a dozen or so amino acid substitions that result in loss of function and increased cancer risk. But there are many more amino acid substitutions that appear to have no effect at all on cancer risk.
Commercial genetic testing services have, to date, done a very poor job of distinguishing VUSs (variants of unknown significance) from actionable mutations. This is true for all tested genes, not simply the BRCA group.
A recent New York Times article
highlights the emotional and physical damage that can be done when genetic anomalies of uncertain significance are reported to patients. The article focuses on a woman who underwent testing for BRCA and was found to be negative, but in the process was found to have a mutation in a gene strongly associated with gastric carcinoma (presumably E-cadherin). In patients with a family history of gastric cancer this mutation is so strongly associated with carcinoma that prophylactic gastrectomy is strongly recommended. However, in patients with no family history of gastric cancer, like the woman in this article, the significance of this mutation is completely unknown.
Our ability to test for mutations has far surpassed our ability to understand their meaning. Just because we CAN test for something does not mean that we SHOULD test. In addition to the obvious problem of reporting mutations of unknown significance there is the ethical issue of reporting known cancer-related mutations for which there are no obvious preventative or early diagnostic measures.
Nonetheless, the argument for testing for BRCA1/2 actionable mutations in the general population is a strong one. There are a substantial number of women carrying these genes in the general population. These mutations carry a known high risk for breast and tubo-ovarian carcinomas and these risks can be mitigated with surgery and careful follow-up. Subsequent to the well-publicized prophylactic double mastectomy of a famous actress, there has been a dramatic increase in the number of women wanting BRCA testing, a phenomenon referred to as the "Jolie effect." Dr. King makes a convincing argument for extending this effect across the entire population. More genes will undoubtedly follow but only when they are well understood and appropriate preventative and screening measures are available.
Wednesday, September 03, 2014
Fall is just around the corner and it is typically the prettiest time of year in central Virginia. I can't complain about this summer which has been quite pleasant, though more than a little too dry. (OK, so I did complain just a little!) The students are back on campus creating the usual traffic jams.... there I go complaining again!
There are a lot of sad truths in this article, all of which will be quickly recognized by anyone in pathology (or any other medical specialty).
The second is an article in the CAP Today
dealing with a recent CMS proposal to use one G-code, G0416, to report all prostate biopsy services, regardless of the number of specimens, in 2015. The G-code would apply to all prostate biopsy specimens, including specimens one to nine. CMS’ intent of this proposal is to pay pathologists less for the professional and technical component work as well as global payment for interpreting prostate biopsy specimens.
...it just keeps getting better and better, doesn't it? :-)
I'm reminded of a line from "The House of God," no matter how bad it is they can always hurt your more.
Tuesday, August 05, 2014
It has been a relatively slow summer in terms of blog topics. I depend on leads from colleagues so feel free to send me an article or topic that you think should be covered. Much of the news these days is filled with stories of Ebola. I have to admit that the press seems to be doing a reasonable job of reporting the facts and not feeding into the large body of misinformation. Fortunately, this virus doesn't spread in an airborne fashion and requires direct contact with body fluids. If it or a similar virus ever acquires that ability, we'll be in BIG trouble. Imagine a virus with the infectivity of influenza and the mortality rate of Ebola! Ugh.
Which leads to one of my favorite morbid musings, regarding "how it will all end." One end is absolutely certain. In a few billion years when the sun runs out of hydrogen to burn it will become a bloated red giant star engulfing earth and reducing everything on it to a cinder. We'd better have moved by then! In the mean time we can consider the inevitability of the next substantial asteroid impact, something we could possibility alter if we could detect it in time, and my personal favorite, the next super volcano. The Yellowstone hot spot has a history of erupting every 600,000 years or so and it's overdue. The dome has been noted to be rising due to the accumulation of underlying magma, so it's just a matter of moments, in geologic time, before it happens. When it erupts much of the midwest farm belt will be covered in feet of ash.... so much for farming! But enough good cheer, let me deal briefly with two quite different medical topics.
First, the good.
Under a new law in my home state of Virginia, effective July 1, 2014, patients are protected from add-on fees to their medical bills for any form of biopsy or Pap test. Prior to enactment of the law, a physician who ordered anatomic pathology services for their patients could include additional fees over and above the cost of the service, when performed by an outside laboratory or pathologist. A physician who includes any markup charge to a biopsy or Pap test under the new law could be subject to disciplinary action by the Virginia Board of Medicine.
The bill unanimously passed the Virginia legislature and was signed into law this year by Governor Terry McAuliffe. American Medical Association ethics policies do not condone markup business practices, but until the new law was enacted there was no legal prohibition in the state. Virginia is now the 25th state to outlaw markup billing practices on pathology services. The legislation, House Bill 893, was sponsored in the legislature by Delegate Christopher P. Stolle (R) of Virginia Beach and Norfolk, and supported by the Virginia Society of Pathologists and the College of American Pathologists.
As we all know, widespread markup practices by gynecologists led to the explosive growth of Pap mills and all the associated problems and regulations we'd like to forget.
Now the bad.
Just when I was feeling good about the above and not contemplating asteroid collisions, another colleague sent me a copy of the United Healthcare Laboratory Benefit Management Program Administrative Protocol for the state of Florida, effective Oct. 1, 2014. The web URL is too long for a hyperlink, so here it is in full form:
This document outlines the requirements for reimbursement for laboratory tests in the state of Florida. I direct your attention in particular to pages 6 & 7. Note that United Healthcare requires that in order to receive reimbursement, among other things, all malignant skin lesions must be signed out by a subspecialty certified dermatopathologist, all cytology specimens (not just Gyn), must be signed out by a boarded cytopathlogist, etc. Following this subspecialty requirement table is a long list of pathologic diagnoses for which a documented second review is required for reimbursement. This list is too long to even summarize here, other than to say that virtually every atypical, in situ, or malignant lesion requires second review, often by a subspecialty certified individual, before reimbursement will be allowed.
Essentially, we have a third party payer attempting to limit reimbursement by setting arbitrary and irrational standards of care. Part of the definition of any "profession," in addition to the requirent for special skills and often advanced training, is that it is a closed and self-regulating group. Entry is gained by meeting appropriate training requirements and certification testing. The profession is self regulating, setting its own standards and enforcing them. I guess that doctors are no longer professionals. Unfortunately, this argument could have been made on other grounds much earlier.
...now I'm back thinking about asteroid collisions. :-)
Tuesday, July 15, 2014
If you've followed this blog for a while, or if you scan the backlog of my posts, you'll find that in the past I have discussed the issue of telepathology across state lines and the varying ways states have interpreted interstate medical consultations. A review of the complex state interpretations can be found in an on-line review article in the March 2014 issue of the American Journal of Surgical Pathology
Virtually all states interpret the practice of medicine as occurring where the patient is located, rather than where the physician (pathologist) is located. It is clear, therefore, that primary pathologic diagnosis requires a license in the state where the material and patient reside. As discussed previously, though, whether one needs a medical license to render a physician requested consultation on a patient's material obtained in another state is highly variable and often poorly defined in the state's medical rules.
On big step in the right direction would be the possibility of multistate licensure. The Federation of State Medical Boards (FSMB) has begun an initiative in that direction and it appears to be gaining tremendous support at both the state and federal levels. A recent article on MedPage
discusses this initiative.
The details of such a multistate compact for licensure are not yet clear and are still in a state of flux. In the current draft, it would be required that the applicant be board certified, not traditionally a state requirement, and be free from active disciplinary action. Licensure in a primary state would be required first, followed by application for the interstate licensure. The state of principal licensure would evaluate the physician's credentials for participation in the multistate compact and, once approved, other states would license the physician across the compact without further review.
One unanswered question, likely to remain so until this intiative becomes final, is the fees involved. Anyone who maintains multiple state licenses (I have three), knows that these can be recurring non-trivial expenses. Would this interstate license have a single fee, or would it only serve as a credentially vehicle with the physician still required to pay state licensing fees for every state in which he/she wished to practice? I suspect the latter.
Regardess, given the non-bounded, interconnected world in which we live, this is an idea that is long overdue to be enacted. If this passes it will clearly be a step in the right direction, improving medical care overall, especially in sparsely populated and underserved areas where direct patient care and expert consultations, clinical or pathologic, may be hard to obtain.
Thursday, June 26, 2014
One of my colleagues sent me an excellent article by Dr. Ben Brown examining the real adjusted income of physicians, taking into account accumulated debt and interest, earning time lost during 20+ years of educational training, long work hours, lack of overtime pay, etc.
for article link.
Dr. Brown begins his article:
"Physicians spend about 40,000 hours training and over $300,000 on their education, yet the amount of money they earn per hour is only a few dollars more than a high school teacher. Physicians spend over a decade of potential earning, saving and investing time training and taking on more debt, debt that isn’t tax deductible. When they finish training and finally have an income, they are taxed heavily and must repay their debt with what remains. The cost of tuition, the length of training and the U.S. tax code places physicians into a deceptive financial situation."
The author leads the reader through a calculation of adjusted net hourly wages for an internist working almost 60 hours a week, starting after training at age 29 and retiring at age 65 with a gross income of about $205,000/year and paying off over $600,000 in debt and interest over 20 years. It works out to $34.46/hr over their career.
Similar calculations applied to a high school teacher assuming debt for a bachelors degree, 10 weeks off for summer and 2 weeks off for Christmas yields a figure of.....wait for it....... $30.47/hr!
While most would agree that teachers are greatly underpaid an even larger percentage of the general population would argue, I suspect, that physicians are grossly overpaid. Against this background, the author also discusses the effect of ever present Medicare fee reductions.
By the way, when similar calculations are applied to dentists, the adjusted gross pay is $61.91/hr! ( I KNEW I picked the wrong medical profession!). For nurses it comes out to $24.43/hr. Should nurses really be paid less than teachers? Food for thought.
Finally the article ends with an interesting table listing the USMLE scores, %AOA, and number of publications of residents according to subspecialty. Pathology is in the middle of the pack. The brightest seem to be attracted to plastic surgery, dermatology, and otolaryngology. Interesting! Keep this article in mind the next time one of your neighbors makes a snide comment about your income! :-)