In the interim since last week's blog regarding the DCIS controversy in the New York Times, there has been a flury of activity in the pathology community on this topic, both with regard to the article's content and in particular to the CAP's unilateral decision to institute a certification program against the wishes of the American Board of Pathology (ABP) and virtually every other pathology society or organization in the United States. It should be emphasized that the ABP is the only officially recognized certifying agency for our specialty in this country. There's a reason why every medical specialty charters and recognizes one official certifying agency; it assures uniform quality and avoids the chaos of multiple, often competing "boutique" certifications. If an organization not chartered to provide recognized certifications develops a "voluntary certification program" likely to dramatically increase their revenues, is this a conflict of interest? Is the primary motivation educational, to improve patient care, or to enhance monetary gain? Likewise, if pathologists developing the certification program stand to materially increase their own consultation practices because of their leadership in the program and because only a relatively small number of pathologists is likely to meet their case load requirements, is this a conflict of interest? I encourage you to read this statement
signed by officials of the USCAP, ASCP, ADASP, APC, and ASIP.
On my local level, the "patient requests second opinion" breast consults have increased in the last week and at least one of my departmental colleagues has received a call from a patient regarding her diagnosis of high-grade DCIS, to inquire if she were board certified and saw over 250 breast cases per year! ...gee, I wonder where the patient got that number from? To help deal with this situation we are in the process of developing an informational summary for patients detailing how our diagnostic breast service functions. In particular every breast biopsy with any atypical or malignant findings is always reviewed by at least two separate attendings (the primary pathologist and the attending reviewing cases for the breast tumor board), a resident and a board certified fellow in our gynecologic/breast fellowship. Borderline or otherwise problematic cases are frequently reviewed by several additional attendings to reach a consensus diagnosis.
In the July 21st issue of Newsweek
a follow-up article approaches this topic in a somewhat more balanced fashion, though it also touts the CAP's certification program and emphasizes the need for more pathologists to be trained as breast cancer specialists. I would not argue with a request for more and better training and funding fellowships through philanthropies would always be appreciated. That's precisely how our gynecologic/breast fellowship exists at U.Va. However, neither article really gets to the fundamental issue of "gray zone" pathology and diagnoses of assertion without meaningful biologic behavioral differences to support the assertion. As one of my colleagues stated, "experts disagree but non-experts make errors."
Although I haven't seen the case described in the original New York Times article, the text certainly suggests that this was NOT a gray-zone case and represented a below standard-of-care error that was not likely to be made by any competent, ABP certified and reasonably experienced surgical pathologist. In that regard, I suspect that there's nothing particularly special about the fact that this was a breast case, and the hospital employing this pathologist might do well to have random cases from other organ systems in their files reviewed. The case also highlights the significant problem of solo practice. It's hard to imagine not being able to walk down the hall and share a problematic case with several colleagues. Even the best of us needs our colleague's expertise and continues to learn from them.