[Histonet] Surgical Volume vs. number of tests

[Stephen Peters M.D.]

Dear Pat, 
 I will offer a pathologists point of view. The actual percent cases which will need immuno
 will vary depending on several factors. 
First the case mix. You are in an academic center. I would expect you would have a 
larger percentage  of demanding cases than a small private hospital. For example if you 
did only hernias, gallbladders and seb kers, you would not need any immunos. If you are 
doing all lymphomas and  and soft tissue tumors you would have a %100 immuno
 rate. 
Experience and degree of specialization of the pathologists will play a role.
 In many situations the less experienced people tend to order a bit more than the more 
experienced people because of the lack of confidence that comes  with experience. This is a natural evolution of the life of the pathologist much as your experience has tought you to find the simplest path.
More academic pathologists with subspecialties may study certain cases in more 
depth because of their fields of interest. 
Also being an academic center with residents pathologists will often order more 
complete panals even though the diagnosis is clear for the benifit of the residents
 experience.
 Taking those facts out of the equation, I would be surprised if everyone reading this has 
not experienced increasing percentages of immuno requests over the past years.
 The number of antibodies required to carry out what would be considered 
" standard of practice" by our friends in the legal profession has grown enormously.  And 
they will continue to grow. They are extremely helpful and represent one of the most 
significant advances in our profession. But have no fear. I predict the day is coming when 
your percentage of immunos will start to creep down only to be replaced by more 
specific, more intellectually demanding, and probably more expensive molecular methods!  
 
As far as trying to discourage over utilization, that is a budget vs. medical care  issue and
 is under the perview of your medical director. It is his job to optimize care 
while keeping to the budget. You  would have to be an experienced surgical pathologist
 to even begin make this judgement. One thing you could do to see if there is a particular culprit is to audit the ordering patterns of the different pathologists. Your computer system may be able to give you this easily.If you believe somebody is being wasteful with ordering
 of studies it is your job to bring it up with your superiors. When it works its way up, it can 
be looked at by a someone who can evaluate the situation from both sides. 
If there is an undo amout of tests being ordered this could possibly be reduced by 
more intradepartmental consultation. Sometimes sharing cases before immunos are 
ordered can prevent over ordering. It can also backfire and end up getting you more requests! When I show one of my cases to colleagues invariably I end up ordering a few more stains to 
satisfy their curiosity.
If the hospital is pressuring you from the budget side then take a good hard look at where you
can save without jeopardizing patient care. I would rather them take away the heat and the toilet paper than force me take guesses by cutting back on necessary studies. 
 


Stephen Peters M.D. 
Vice Chairman of Pathology
Hackensack University Medical Center 
201 996 4836
 
Pathology Innovations, LLC 
410 Old Mill Lane, 
Wyckoff, NJ 07481 
201 847 7600 
www.pathologyinnovations.com