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March 2017, Volume 67, Issue 3

Letter to the Editor

Skeletons in the closet…. Apprehensions of a histopathologist

Asim Qureshi  ( Pathology Department, Shifa International Hospital, Islamabad, Pakistan. )

Anatomical pathology is one branch of medical science where the signed out report becomes a legal document whether you like it or not. The signing out pathologist has nightmares on any difficult or challenging case even months after it has been signed out.
There a few institutions in the country with heavy work flow namely Aga Khan University hospital, Shaukat Khanum cancer hospital, Shifa International hospital and Armed forces institute of Pathology. These centers are tackling more than twenty thousand surgical pathology cases annually in fact the first two are dealing with mammoth workload of fifty thousand or more specimens per year. With this work flow and demanding clinicians there are chances of missing important parameters in the anatomical pathology report. It is therefore need of the day to implement quality control measures in the departments to minimize error. These will alleviate the anxiety of junior pathologists.
College of physicians and surgeons Pakistan has recognized various programmes in histopathology but not all get a chance to get training in the big institutions. There are a small number of people returning home after completion of their training in North America and Europe as well. All these junior pathologists when they start sign out in these big centers are exposed to the wrath of clinicians, patients and now governing bodies like Pakistan Medical & Dental Council (PMDC). PMDC has very recently and rightly taken over the role of a governing body looking at irregularities of medical practice. This professional monitoring was very much needed as a preliminary step before any case is taken to the court of law it has to be discussed in a professional body.
Various mechanisms have been developed in the above mentioned institutions to help and provide an umbrella to the junior pathologists for handholding in their early years. One mechanism is (DCC) departmental consultation conference carried out daily at Aga Khan University Karachi, the only JCIA accredited hospital until now. This meeting is held at the multi head microscope (18 heads); every consultant is allowed to bring difficult cases. The senior most pathologist sits at the driving seat and all the cases are discussed one by one. The group at Aga Khan University is diverse with specialty interests, about half the cases are solved in the first instance, another quarter are solved on deeper levels and Immunohistochemical stains as advised by the group and  only few less than ten percent remain unresolved and go with a differential diagnosis.1
Shaukat Khanum cancer hospital has the largest histopathology department in the country with more than seventy thousand specimen workload. One unique mechanism of minimizing error is peer review. This may be in the form of consultation before the report is signed out as there are pathologists with specialized interest (haemato-pathologists, soft tissue and bone experts People with overseas experience in head and neck and gastro intestinal pathology). The second form of peer review is after the report has been signed out. This has helped to pick up minor mistakes in the reports.2 The largest cancer center boasting to have a separate tumour board for all system and organ cancers has a separate pathologist designated to present and review the cases before the meetings. So any treatment offered in the hospital may it be surgery, chemo or radiotherapy the case will be reviewed diligently as later it will be the responsibility of the board for any treatment being offered to the patient.3
Another form of multi header meeting is intradepartmental consultation conference carried out at Shifa international hospital. This specialized center deals with transplant cases and has the largest hepatic transplant facility in the country and second only to SUIT in renal transplant. The difficult cases at this center are different in a way that quite a few of these are transplant pathology cases and an urgent report is required to start intervention. Although there are designated renal and hepato-biliary pathologists in the department. All these cases are reviewed on the multithreaded, thereby giving a chance to the younger colleagues to learn these unusual presentations.4
In these circumstances there is need to develop a handholding process by which the pathologists feel comfortable when they sign out. This process can be extended to other neighboring institutions.
Disclaimer: None to declare.
Conflict of Interest: None to declare.
Funding Disclosure: None to declare.


1. Khurshid A, Ahmad Z, Qureshi A. In-house daily consensus conference: an important quality control/quality assurance activity--experience at a major referral center. Indian J Pathol Microbiol. 2009; 52:325-7.
2. Qureshi A, Loya A, Azam M, Hussain M, Mushtaq S, Mahmood T.Study of parameters to ensure quality control in histopathology reporting: ameta-analysis at a tertiary care center. Indian J Pathol Microbiol. 2012; 55:180-2.
3. Kronz JD1, WestraWH. The role of second opinion pathology in the management of lesions of the head and neck. Curr Opin Otolaryngol Head Neck Surg. 2005; 13:81-4.
4. Kronz JD1, Westra WH, Epstein JI.Mandatory second opinion surgical pathology at a large referral hospital. Cancer. 1999; 86:2426-35.

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