Below, you’ll find a list of links to some excellent Pathology-related websites from professional organizations, to study cases, to blogs.  These are all sites that I’ve found useful over the past three years as a resident at Albany Medical Center, and, hopefully, they can be of use to you as well!
(Note: none of the following links are sponsored; I just like them.)

Obviously, this list is far from comprehensive, and if you have more links that you find useful, please post them as a comment below, as I’m sure we are all always looking for additional great online resources!

Organizations:

• College of American Pathologists
• United States and Canadian Academy of Pathology
• American Society for Clinical Pathology
• American Board of Pathology

Journals:

• Modern Pathology (included with USCAP membership)
• Archives of Pathology (included with CAP membership)
• Journal of Pathology Informatics
• PubMed (for completeness’ sake)

Helpful Websites (not exclusive):

• Pathology Outlines (Great for IHC Stains/CD Markers, also COW)
• Pathology Links (Good link farm)
• Hopkins Unknown Conference (Registration required, free membership)
• PathMax (Another Pathology link farm, many links are out of date now, however)
• UPMC CP COM (Check AP case of the month too)
• TraQ Program (Case studies)
• USCAP (Excellent site for AP educations material)
• ASCP Journal Online (Electronic access included with American Society of Clinical Pathology membership, free for residents, good articles for rounds presentations and board preparation)
• May Clinic Online Labs (Free, registration required. Check hot topics and management strategies videos.)
• Derm 101 (Registration required. Some free, some not. One of the better derm sites)
• PathConsultDDx (Good site for differential)
• U of Utah (Gross images and tutorials)
• California Tumor Registry (Super anatomical pathology case of the month)
• Lab CE (MCQs for CP)
• Kansas State U Parasitology (Good tutorial for parasites)
• Cytology Stuff (for cytology study)
• UT Houston Coag Studies (cases for study coagulation)

Books with online resources (require purchase/registration):

• Sternberg’s Diagnostic Surgical Pathology
• Robbins Pathologic Basis of Disease
• Weedon (Dermatopathology):
• Rosen’s Breast Pathology
• Diagnostic Pathology: Genitourinary
• Gastrointestinal Pathology
• Flow Cytometry and IHC for Hematologic Neoplasms
• AFIP Fascicles

A couple “smiley” faces from a bone marrow we reviewed a few months ago.  I haven’t posted in a while, but promise to publish a couple interesting cases soon!

These things happen. It was going to cost me an extra 10-15 minutes.

An equally elderly customer about 5 people behind me yelled out “This is what your healthcare is going to look like”.

I disagree. We can only hope healthcare reform allows for what I consider a normally efficient service.

For some of the shortcomings of the US mail, with its rigid policies and procedures I can count on 1 finger the number of times an intended delivery or sent item was not received over several decades of using the US mail for pen pals, college applications, med school applications, licensing forms and business transactions. Of course, e-mail and other electronic services have minimized the necessity for traditional “snail mail” services which has affected the bottom line for the quasi-governmental organization. I find the need for delivery confirmation or certified letters to be negligible given the time and accuracy of mail delivery.

Let’s assume some components of the healthcare reform do look governmental or quasi-governmental if you don’t have “private insurance”. Having worked and received care in military, VA and large academic institutions, my experience is that quality overall is the same, the speed (meaning wait time from definitive diagnosis to definitive care/management) varies greatly with access issues and beaurocratic inefficiencies sometimes causing delay between getting seen and getting treated. While commerical hospitals are not immune from their own inefficiencies, generally access is simplified and referrals are timely.

So, while your health and your mail are not the same, if 42 cents buys you 2-3 day delivery at the expense of a few minutes to get it going, perhaps cost can be controlled with quality outcomes with reasonable wait to get the necessary service particularly for those who would not normally be afforded these services or for whom alternatives are not available.

Would it be so bad if healthcare ran like the post office?

In May of last year I came down with what I thought was a community acquired pneumonia. This was about the time of the first reported cases of H1N1 and out of fear of quarantine at the time for what I was sure was not H1N1 I avoided doctors and hospitals. After trying a couple courses of antibiotics prescribed by a colleague, without relief, I found myself at an “express care” facility on a weekend morning desperate for relief from my symptoms of fever, cough and chest pain.

After completing a short medical history, I was seen by a nurse practioner with minimal waiting who was professional yet focused her questions and examination on the current problem. Within a few minutes I had prescriptions for another course of antibiotics and medication to relieve the cough and subsequent chest pain.

“Are you going to do a chest x-ray?” “No.

“Sputum culture?” “No, why?”

“Referral to infectious disease or pulmonary?” “Huh?”

By the next morning, my symptoms were gone. Of course, this likely would have resulted had I not seen this healthcare provider but for fifty bucks that my employer sponsored healthcare plan paid for I feel like it was time well spent and was able to sleep through the night for the first time in a couple of weeks.

Some time after this I asked a pulmonary colleague had I been seen by him or one of his colleagues what may have transpired. At the least he claimed a chest x-ray and consideration of bronchoscopy and possible PFT testing to exclude other underlying conditions. Seems like a stretch compared to what I needed and with the treatment being an inexpensive visit, antibiotic and cough supressant.

During my acute illness one of our fellows presented with acute flank pain to the ER on the same weekend. After sitting in pain for four hours in the ER it was determined he had a kidney stone and conservative managment was warranted. An ultrasound and CT later, twelve hundred bucks for the ER visit plus radiology costs. No pain relief. By the next week after conservative measures failed and he underwent additional urology consultations, lithotripsy and eventually surgical removal of the stone. Tack on another five grand. A post-op follow up, subsequent IVP and his bills were pushing $10K. This does not count time off from work and lost productivity. The insurance covered a minority of the expenses.

While I am not a pulmonologist or urologist and do not manage acute clinical conditions I wonder what may have happened if my colleague had gone to see the nurse practioner on the weekend as I did. Save the ER costs for same diagnosis, perhaps some more immediate relief of symptoms, quicker appropriate referral as this could not be managed in their setting and definitive care rendered with less delay and patient suffering.

Perhaps this model can be expanded. What is the real cost of healthcare by being overly investigative or delaying definitive care at the expense of conservative measures? It is obviously a difficult balance without the medicolegal implications either way.

I think that we should be looking at outcomes and a cost per outcome (or expected outcome) as function of dollars spent as a significant factor in terms of appropriately providing care while insuring the standards of care are met.

Would I have benefited from a more extensive work up? Would the outcome been different? Probably not. While it may not have been contraindicated and not harmful, or low risk, the costs beyond using emperical data may not justify a similar outcome.

Physicians are driven by data. But what is the data worth as a function of its cost?

I know what you’re thinking: an amyloid angiopathic bleed, or perhaps a hypertensive bleed, in a patient with Alzheimer disease. That’s what I was thinking until I saw in the chart that abnormal white matter changes on MRI prompted the neurologist to order Notch3 genetic testing on the patient, which surprisingly came back positive for a mutation. The patient therefore carried a clinical diagnosis of Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL), despite the fact that she had no clear family history indicative of this disease and despite the advanced age of symptom onset. At autopsy, there was no evidence of amyloid angiopathy on Congo red stain. She did appear to have the PAS-positive vessel wall deposits that would be consistent with a diagnosis of CADASIL (see photomicrographs below). Plus, it is hard to refute a positive genetic test. The Notch3 test has excellent specificity, from what I hear. Also, I hear that there was some Korean study showing a relationship between CADASIL and brain hemorrhage. If anyone has any other ideas about what might be the diagnosis in this case, I would love to hear from you.

-How do we as pathologists make these diagnoses?
-What do they mean for the patient in terms of cancer risk?
-What is/are the optimal strategies for follow-up so that if cancer does eventually develop it is caught at an early, curable stage?

These questions are shortly discussed at www.oncopathology.blogspot.com

He concludes in his editorial:

“Where, then, does this leave the status of Web 2.0 with respect to medical issues? One may appropriately state that its potential for education and practice enhancement is real and considerable. It is also true that electronic publications of scientific data are easier than ever and more widely disseminated than hard-copy contributions. However, definite problems exist regarding the veracity of some e-articles in medicine, proliferation of “charlatanesque” entries in the electronic medical literature, misconceptions about the production of “personalized” e-medical data, and the lack of compatibility and accessibility of computerized information from one medical system to another. These issues must be resolved before Internet-centered facts can be integrated confidently into diagnostic and therapeutic paradigms.”

The two papers in AJCP this month are available below:

Pathology in the Era of Web 2.0. William E. Schreiber MD and Dean M. Giustini MLS, MEd.

Abstract:

In the past few years, the term Web 2.0 has become a descriptor for the increased functionality of Web sites, including those with medical content. Most physicians do not know what Web 2.0 means or how it can impact their work lives. This review provides some background on the evolution of Web 2.0 and describes how its features are being incorporated into medical Web sites. Some potential applications of Web 2.0 in pathology and laboratory medicine are discussed, as are the issues that must be considered when adopting this new technology.

Pilot Study of Linking Web-Based Supplemental Interpretive Information to Laboratory Test Reports. Brian H. Shirts, MD, PhD, Adi V. Gundlapalli, MD, PhD and Brian Jackson, MD.

Abstract:

Electronic medical records have the ability to link to reference material, providing clinicians with immediate access to information relevant to patient care. Adding relevant links to laboratory test results could add value while minimizing the volume of ancillary text presented.

We provided Web-based universal resource locator (URL) links with all results of 7 laboratory tests ordered at ARUP Laboratories (Salt Lake City, UT). URL links provided were modified 7 months later, and use between initial and subsequent URLs was tracked to establish frequency and duration of access to supplemental Web information.

Monthly Web-site hit rates for individual tests varied from 0.00% to 3.00% (median, 0.12%). Rare and specialty tests averaged higher hit rates. There was no decay in hit rate 9 months after URLs were removed from test reports.

We conclude that links to reference material are accessed by clinicians. The use of Web links months after links were no longer published raises an important issue of long-term maintenance and the resources required to support these features.

January 15, 2010

Dear Colleagues,

All of us are reading and watching the devastating news and seeing the wrenching pictures from Haiti in the aftermath of the terrible earthquake earlier this week. As a physician, I read the news and looked at the images with grief, with shock, and with a strong desire to reach out to the struggling people, injured and terrified. But, as a pathologist, I also realize that there is little I would be qualified to do in Haiti today, besides comfort those who are alive and have suffered loss and provide rudimentary first aid.

The CAP Foundation does have a way that you can help Haiti in this hour of need.

Our Humanitarian Grant program has sponsored several pathologists who have done wonderful laboratory outreach work in Haiti in the past. We are working with these pathologist-humanitarians to identify the areas where the CAP Foundation can help Haiti with short-term immediate support and the longer term struggles ahead. I urge you to join me in donating to the CAP Foundation, where pathologists will be part of providing laboratory services, humanitarian efforts, and medical aid during Haiti’s moment of crisis and beyond.

I know that each and every one of you would go to Haiti, comfort the survivors, give medical care, and help laboratories cope with the medical situation. And, if you are a pathologist who is planning to join an established relief mission to Haiti, please contact the CAP Foundation and tell us your story. But, we are also acutely aware that there will be incredible needs, short and long term, that will require funding, supplies, and equipment, for health care and laboratory services. By donating to the CAP Foundation Haiti Relief Effort, pathologists can contribute what is needed most, when it is needed most, to provide these desperately needed services.

To help the CAP foundation provide support to the impoverished nation of Haiti, use this link:

http://www.cap.org/apps/cap.portal?_nfpb=true&_pageLabel=foundation_page

and donate today.

Sincerely,

Jennifer Hunt, MD, MEd, FCAP
Interim President
CAP Foundation

This happens about once a year each year I have been in practice. Sometimes they are physicians, sometimes not and occassionally they are pathologists. It makes no difference in reviewing their slides beyond some of the terms used or amount of histology they may or may not know. During the course of each of these encounters I seem to make the same statement – “This is your cancer”.

Whatever was said up to that point and perhaps in some cases after that statement, I find that patient’s get what they sought from the visit to “their” pathologist. While few have doubted the accuracy of the diagnosis, grading or staging of their disease, they want affirmation that what was read by the lab represented their biopsy and the pathologist confirmed that this cancer was their disease. In some cases I have come to learn that this may have been the first time a physician mentioned the word “cancer” to them since the biopsy. Inevitably, they also check the slide labels to confirm their name is on them to dispel any doubt they may still have about ensuring the slides belonging to them and the appropriate diagnosis for the appropriate patient.

Shortly after the patient sat down opposite me at the double headed microscope in my office and I began trying to recover his slides along with three office assistants, the same questions as in the past arose in my mind. Is this appropriate to be reviewing the slides with the patient? What if the slides cannot be found immediately to review in a timely fashion? What questions may arise and how will I address those?

These occurrences also remind me that every number is a life. Every accession number, order number and slide is a life. In the course of a large signout on any given day it may be easy to lose sight of that fact and patients become “accessions” or “cases”.

When patients come to your office, it affirms they are not a “case” or a “biopsy”.

This particular patient asked if I remembered his slides during the course of reading slides from the week prior. Was their anything unusual about his slides? Did I show his slides to anyone else?

At the time, I honestly could not recall. His was one of 50 or so “cases” that day. Nothing was out of the ordinary. I diagnosed several new malignancies that day including several of the same kind of tissue he had biopsied. Nothing was out of the ordinary with that particular group of slides or any particular patient’s sample that I could recall from a week ago.

Once we retrieved the slides from the file and surgical pathology report, I reviewed the patient’s slides with him and when getting to the appropriate focus told the patient “This is your cancer”.

A grateful patient thanked me for my time. While I may not have remembered the “case” at the time, this is one patient I will not forget.