A dermatopathologist is a specialist in diagnosing skin biopsies under the microscope. Both pathologists and dermatologists may apply for certification. Dermatologists must complete additional surgical pathology training while pathologists must complete clinical dermatology training. Upon completion, eligible candidates may take the board examinations given by both the American Boards of Dermatology and Pathology. Board certification in Dermatopathology qualifies the physician specialist as a designated expert in the diagnosis of skin diseases. They work closely with pathologists and dermatologists providing consultative expertise in difficult skin lesions and biopsies. Because of their unique knowledge base, dermatopathologists often moderate conferences such as Dermatology Grand Rounds where patients with unusual skin diseases are presented in a conference setting along with the skin biopsy. The clinical findings are correlated with the biopsy findings. Dermatopathologists can also play an important role with compliance issues for office based dermatology laboratories.
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HISTOLOGICAL TYPES CHARACTERIZATION GENERAL
Interpretation of skin biopsies by general pathologists: diagnostic discrepancy rate measured by blinded review.
Trotter MJ, Bruecks AK.
Calgary Laboratory Services and Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada.
Arch Pathol Lab Med. 2003 Nov;127(11):1489-92. Abstract quote
CONTEXT: Slide review has been advocated as a means to reduce diagnostic error in surgical pathology and is considered an important component of a total quality assurance program. Blinded review is an unbiased method of error detection, and this approach may be used to determine the diagnostic discrepancy rates in surgical pathology.
OBJECTIVE: To determine the diagnostic discrepancy rate for skin biopsies reported by general pathologists.
DESIGN: Five hundred eighty-nine biopsies from 500 consecutive cases submitted by primary care physicians and reported by general pathologists were examined by rapid-screen, blinded review by 2 dermatopathologists, and the original diagnosis was compared with the review interpretation.
RESULTS: Agreement was observed in 551 (93.5%) of 589 biopsies. Blinded review of these skin biopsies by experienced dermatopathologists had a sensitivity of 100% (all lesions originally reported were detected during review). False-negative errors were the most common discrepancy, but false positives, threshold discrepancies, and differences in type or grade were also observed. Only 1.4% of biopsies had discrepancies that were of potential clinical importance. C
CONCLUSIONS: Blinded review demonstrates that general pathologists reporting skin biopsies submitted by primary care physicians have a low diagnostic error rate. The method detects both false-negative and false-positive cases and identifies problematic areas that may be targeted in continuing education activities. Blinded review is a useful component of a dermatopathology quality improvement program.
Is histological examination of tissue removed by general practitioners always necessary? Before and after comparison of detection rates of serious skin lesions.
Lowy A, Willis D, Abrams K.
Department of Epidemiology and Public Health, University of Leicester, Faculty of Medicine.
BMJ 1997 Aug 16;315(7105):406-8 Abstract quote
OBJECTIVES: To examine whether histological examination of all tissue removed by general practitioners in minor surgery increases the rate of detection of clinically important skin lesions, and to assess the impact of such a policy on pathologists' workload.
DESIGN: Before and after comparison.
SETTING: Stratified random sample of 257 general practitioner partnerships from the catchment areas of 19 English pathology laboratories.
SUBJECTS: Tissue removed in minor surgery by general practitioners during the control period (September 1992 to February 1993) and intervention period (September 1993 to February 1994).
INTERVENTION: General practitioners referred to their local pathology laboratory all solid tissue removed in all minor surgery, irrespective of their previous policy.
MAIN OUTCOME MEASURES: Numbers of specimens referred for histology by general practitioners during intervention and control periods; numbers of primary malignant melanomas, non-melanoma malignancies, premalignant lesions, and benign lesions.
RESULTS: 257/330 partnerships participated (response rate 78%). During the intervention period 5723 specimens were sent, compared with 4430 during the control period. The referral rate increased by an estimated 1.34 specimens per 1000 patient years (95% confidence interval 0.93 to 1.76, P < 0.0001). General practitioners sent 204 specimens that were malignant (including 16 malignant melanomas) in the control period and 188 that were malignant (including 15 malignant melanomas) during the intervention period (change in total number of malignancies, -1.0 per 100,000 patient years (-5.9 to 3.8, non-significant).
CONCLUSIONS: The intervention was associated with a substantial increase in laboratory workload, all of which was accounted for by increases in non-serious lesions. This observation should be taken into account when considering the merits of a policy requiring histological examination in every case.
VARIANTS UNSTAINED SLIDES
Unstained negative image patterns. A checkpoint for quality slides.
Head ES, Tschen EH.
Am J Dermatopathol 1982 Apr;4(2):143-8 Abstract quote
Before stains were available, pathologists had to rely on unstained sections viewed through crude microscopes, but they still were able to make diagnoses and discoveries. Unstained sections may still be used to advantage in making diagnoses of skin lesions quickly, accurately, and easily on the basis of negative image patterns.
Low-power scanning by conventional microscopy of freshly cute and mounted, still wet, paraffin sections of skin specimens enables the histotechnologist and dermatopathologist to accomplish three things: 1) to check orientation of the sections at an early stage, 2) to cut complete sections, and 3) to find the area or areas of pathology to cut. Furthermore, because diagnoses can be made from unstained sections, extra cuts for special stains may be ordered in advance of routine staining.
The dermato-pathology laboratory is able, therefore, to produce slides of better quality and diagnoses more accurately and quickly.
COST-EFFECTIVENESS CHARACTERIZATION GENERAL
Quality assessment of skin biopsy specimens referred to anonymous consultants.
Department of Dermatology, St Louis University Health Sciences Center, Mo, USA.
Arch Dermatol 1996 Sep;132(9):1053-6 Abstract quote
BACKGROUND AND DESIGN: Managed care organizations may direct dermatopathologic specimens to anonymous consultants. I hypothesized that the quality of the consultation decreases when there is no incentive for an anonymous consultant to actively pursue the dermatologist/consumer. Therefore, I examined 364 consecutive specimens that had been directed to anonymous consultants. The specimens were obtained from patients who consulted a university-based dermatology clinic or the office of a collaborating practitioner. The quality of consultation was evaluated in 5 areas: factual correctness, arguable differences in degree, evidence that the history had been read by the consultant, knowledge of dermatologic disease evident in the interpretative aspects of the report, and appropriate direct interaction with the referring physician when indicated.
RESULTS: There was concordance between the interpretation by anonymous consultants and the findings of my review in 66.8% of cases that involved common dermatopathologic diagnoses. There were errors in fact in 26 cases (7.1%). There were examples of failure to correlate histologic findings with clinical history, apparent lack of understanding of dermatologic disease, and failure to resolve conflicts between the histologic pattern and the clinical information.
CONCLUSIONS: I found a decrease in the quality of biopsy specimen interpretation received from anonymous consultants. Dermatologists need to maintain and/or upgrade their skills in dermatopathology to supervise the quality of interpretation obtained from anonymous consultants.
Log-in/log-out time: a quality factor for a reference laboratory--prolonged times for skin pathology processing in managed care-authorized laboratories.
Department of Dermatology, Saint Louis University Health Sciences Center, MO, USA.
J Am Acad Dermatol 1997 Jun;36(6 Pt 1):995-8 Abstract quote
Managed care organizations may divert skin biopsy specimens to commercial laboratories selected on a cost basis. Diversion to these laboratories could result in service of decreased quality for the patient and referring physician. Log-in/log-out dates were collected for all specimens submitted to managed care-authorized laboratories either from a university-based clinic or from a private practitioner's office for a period of 18 months and compared with data obtained from a local dermatopathology laboratory. A subgroup of specimens containing inflammatory diagnoses or nondiagnostic changes was also examined.
Mean log-in/log-out times were 1.338 days in the dermatopathology laboratory, 6.123 days in managed care-authorized laboratories from the university site, and 7.798 days in managed care-authorized laboratories from a practitioner's office. The differences between the dermatopathology laboratory log-in/log-out times and those of the managed care-authorized laboratories were statistically significant (p < 0.0001).
The conclusion from this study is that a quality indicator defined as time from log in to log out revealed a significant increase in interpretation time at managed care-designated laboratories. Although managed care plans can decrease their financial risk by contracting with national laboratories to provide all services for a set fee, a decreased quality of service can be demonstrated.
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Rosai J. Ackerman's Surgical Pathology. Ninth Edition. Mosby 2004.
Sternberg S. Diagnostic Surgical Pathology. Fourth Edition. Lipincott Williams and Wilkins 2004.
Robbins Pathologic Basis of Disease. Seventh Edition. WB Saunders 2005.
DeMay RM. The Art and Science of Cytopathology. Volume 1 and 2. ASCP Press. 1996.
Weedon D. Weedon's Skin Pathology Second Edition. Churchill Livingstone. 2002
Fitzpatrick's Dermatology in General Medicine. 6th Edition. McGraw-Hill. 2003.
Weiss SW and Goldblum JR. Enzinger and Weiss's Soft Tissue Tumors. Fourth Edition. Mosby 2001.
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