Our Secret Language

My wife and I both work at tertiary care academic centers in the Chicago area – she is a pulmonary and critical care physician; I am a pathologist. Because of our proximity, it is quite common for patients to transfer back and forth between our hospitals. While I was still in training, she mentioned one evening over dinner that she had seen my name on a pathology report. Extremely exciting news. Patient privacy prevented us from discussing too many specifics, but I was itching to know what type of tumor it had been. Unfortunately, it turned out to be an autopsy report. The patient had transferred from her hospital to mine – transferred to die, I thought. I was the primary prosector, and she had received a courtesy report. This was even more exciting. I was very proud of my autopsy reports. I always made a special effort when putting the pieces of the autopsy puzzle together, so I felt that my summaries were quite good and I was eager to hear some praise. “So…?” I asked.

“You guys didn’t find a cause of death,” she replied casually, while passing the salad.

“But I’m sure I alluded to something in the description,” I pressed.

“Oh, I just read the summary,” she said, through a mouthful of food. “No one reads the entire report – you know that, right?”

“Of course, of course,” I lied. “So where’s the report?” I was hoping she had committed a huge HIPAA violation and brought it home for me to frame.

“I shredded it.”

“Like my hopes and dreams,” I muttered.

Yes, I exaggerate to make a point. I understood; she had patients crashing in the intensive care unit – bleeding, suffering from strokes… The pearls of my microscopic descriptions were of no value to her. But surely they would be of importance to my fellow pathology comrades… right?

I went on to become the hematopathology fellow at my institution. That one year taught me depths of pathology I hadn’t even known existed. Sitting at the microscope, learning from the gurus with whom I was fortunate enough to train, was an exceptional experience – and an inspiring one. It made me want to be the best, so that I could show them all they had made a worthy investment in me. Our reports at the time were very long – three pages on average and works of art, each and every one. Pathologists from around the country would send us cases in consultation that were so difficult they considered them non-diagnosable; my mentors would solve the mysteries and send back detailed reports, revealing the secrets of the cases in their microscopic descriptions.

Were those reports appreciated? The diagnoses certainly were, but the reports noticeably less so. Every so often, we met pathologists from other hospitals – and they would jokingly make fun of the length of our reports. “Who has time for that?” “No one reads them” “What good is that description?” “Don’t say more than you need to!” “The more you say, the more a lawyer will have to use against you!” “I would prefer a faster report to a longer one…” And the clinicians were no better. They would tell me, “No one reads this stuff, Kamran,” “I can’t even tell where the diagnosis is,” or even, “Why don’t you just say clinical correlation is recommended and get it over with?” All heartbreaking reactions to reports that I considered a labor of love.

I’ll admit that writing the reports could be tiring. It was a busy service, and by the end of the umpteenth report of the day, I was exhausted. But when I began to lose my energy, I would pause and listen. From the open door of the small fellows’ office, I could hear my mentors’ hemepath counters pinging and their keyboards clicking away – and my energy would be renewed. I would read the reports churned out by these hemepath giants and be inspired by their greatness.

Two strikes

When it came time to start my practice, I was at a crossroads. What would my report look like? Of course it would be comprehensive in the sense that it would have all the essentials. But would it have something more? Would the contours of the malignant nuclei, the exact texture of the chromatin, or the shade of amphophilia in the cytoplasm be fondly described? Would every case, malignant and benign, usual and rare, all be given the same loving description – or not?

Two things helped guide my decision

The first was a call that I had received while still in training. It was my mother, calling from her home thousands of miles away. A physician herself, she had been having some oddball symptoms that necessitated a biopsy. “Beta [son],” she said, “you’re never really prepared to read the word carcinoma on your own report.” I had two parallel reactions: that of a pathologist, and that of a son. It was a uterine disease, so as a pathologist I wanted to know everything about the remaining endometrium. Was this a polyp? Any secretory changes? As her son, I needed to know whether or not she was okay. I was far away, and it was hard. So I asked her to read me the whole report. Apparently, there were two parts to the specimen – a polyp and an endometrial scraping. From what I could tell, they had put both the polyp and the endometrium in a single cassette, and now I didn’t know which part contained the carcinoma. There was no gross description saying what went where. No histologic grade was provided. Just “carcinoma.” Nothing further to go on.

I took a deep breath and considered the future. Should my mother come to the United States for a hysterectomy? How would we deal with insurance? But she was adamant that she wanted to have the surgery at home. I suggested she go to the hospital associated with my medical school, a prestigious institution with a fantastic pathology department. She did, and the surgery went well – except for one small hiccup: they didn’t find any carcinoma. Wait, what? Surely there’s a mistake. I didn’t trust this at all. I needed to see the report. Oddly enough, I would have been happier and more confident if they had found something and reported it; at least that way, I would have been sure that there was nothing left to hide.

And then I opened it: my mother’s pathology report, an innocuous-looking attachment in an e-mail. I started reading, ready to shred it to pieces. What did I find? The gross description was impeccable. The inking (or painting, as they called it) was perfectly described. Sectioning seemed to have been done adequately and correctly. They hadn’t found any tumor, so they had sampled the entire endometrium. Then I encountered a surprise: a detailed microscopic description. I wasn’t used to seeing a long microscopic description for a case that was ultimately called benign. But as I read the words, I could visualize the slide in front of me. Descriptions of glandular epithelia with benign nuclei, emphasis on pertinent negatives, such as the lack of mitoses or necrosis; a magical prose brush building a normal-looking stroma around the glands; some chronic inflammation for added effect; reassuring notes stating that multiple sections had been examined; even a small fibroid satisfyingly described with “interlacing fascicles of closely packed cells with elongated nuclei and abundant eosinophilic cytoplasm.”

As I finished reading this report, I truly felt that I didn’t need to see the slides. I was completely reassured – no exaggeration. The pathologist had taken the time to write a report that, to many, was a waste of time, but to this patient’s (pathologist) son, it meant the world. A secret language that relayed from one pathologist to another exactly what needed to be said.

Strike one.

Strike two occurred early on in my career at the scope with my residents. “How do you make sure you don’t miss dysplasia in a lineage, Dr. Mirza?” followed by, “How are you sure you have thoroughly evaluated the aspirate smear?” and a host of similar questions about the adequacy of a marrow review. At first, I wasn’t sure how to respond to these overwhelmed residents. Although the World Health Organization (WHO) classification for hematopoietic neoplasms sets out how to do the job perfectly, it is in itself an overwhelming read. When I thought about it, I realized that, as I review the slide, I write my microscopic description in my head. Every pathologist does it. As the scope moves, we look at patterns, architecture, features, outlines, contours, atypia, pleomorphism, changes, features, colors, textures…

As I look back on the early days of my career, that’s exactly what my hemepath mentors were doing – and teaching me to do. So now, I encourage my residents and fellows to write out microscopic descriptions. They don’t have to be very long. As pathologists, it is key to be able to express how you feel about cells (figuratively). Being able to say those things on paper goes a long way in aiding our ability as trainees. You only get your time in training once, so use it well. The microscopic description will go a long way.

As for practicing pathologists… I have learnt firsthand the beauty of the microscopic description. It truly is a secret language we can use to talk to other pathologists across the globe. It transcends regular conversation in ways that are difficult to explain in regular ol’ English. Of course, not every GI biopsy can have an extensive microscopic description, nor can the day’s seventeenth case of run of the mill myeloma, but there’s always something that can be said. When prudently used, pathologic descriptions still have a role to play – even in this crazy world of fast-paced diagnostics and relative value units.

Painting with words

The ability to translate what you see under the microscope into prose is the essence of a superlative pathologist – so it is no surprise that the microscopic description has been referred to as “painting with words.” As romantic as that sounds, let’s face it: there is a place and time for descriptive reports. Running a busy GI service with over 150 biopsies a day? Not all of your reports will be descriptive. More importantly, not every report should be; unnecessary descriptions run the very real risk of confusing the reader.

So when are such reports appropriate and efficient? Do all pathology reports demand a descriptive aspect? There are no guidelines on what to include, or on how to write microscopic descriptions in a way that can be easily interpreted by clinicians – and there are certainly none on when such reports should be written. Published data suggests that pathologists tend to use certain phrases to indicate specific levels of diagnostic certainty (1), but such usage is not standardized, and this sort of individuality can be the source of immense confusion (2). The streamlining of reports and the existence of synoptic reporting for tumors has come into existence for a reason! So, first and foremost, there are legal communicative aspects of a report – by way of the final diagnosis and synoptic reporting – that should be crystal clear. It also needs to be clarified that a pathology report does not require a microscopic description to be a complete legal document. That said, allow me to share my thoughts on some scenarios where I believe descriptive analysis may be of value.

1. The expert opinion.
   By far the easiest example of a useful descriptive report is that of a second opinion, wherein the case has been sent to an expert for their thoughts. The description (different from the diagnosis or final interpretation) serves as the expert’s explanation to the pathologist as to how the interpretation was made. One assumes that the need for an expert opinion arose in light of diagnostic ambiguity, and thus, clarification by way of a description is of utmost utility for the original pathologist or clinician.
2. Clarifying a contentious diagnosis.
   Along the same lines as above, some neoplasms or diagnoses don’t “read the book.” In such cases, descriptive reports explaining the specific features that led the pathologist to confidently arrive at a conclusion (despite ambiguous staining or morphologic features) are useful for other pathologists who may review follow-up biopsies or re-review the original material at a different institution. This information often has no place in the final diagnostic line – but that doesn’t make it any less vital.
3. Explaining suboptimal material.
   Often, a biopsy is negative for malignancy – so when the final diagnosis of a 10 cm, radiologically worrisome mass is “acute inflammation,” the descriptive report is the place to share with the reader that the submitted material may not be representative of the mass described in the patient’s history. The old adage of “clinical correlation is recommended” may actually have a role to play in these cases. The descriptive report can be a conduit to explain what the pathologist “feels” about the case without overstepping.
4. Intelligent extrapolation of data.
   Although I would never condone guessing of any kind in a report, the descriptive report can serve as the platform for extrapolation of histologic/cytologic findings in the context of an appropriate history – detailed morphologic assessment of a residual myelodysplastic syndrome, or the presence of only mature neuroblastoma. Such instances deserve recognition in the final diagnosis, but the details of what they look like belong in the descriptive report. For example, a description of findings could lead to the following: “Although no residual neoplasm is identified, the constellation of these findings are consistent with tumor bed.”
5. Catharsis.
   Sometimes, I have worked hard to figure out a case – and maybe I just want to talk about it in the microscopic description. It’s my report, so I will! There’s no harm, as long as I make sure to include only relevant information. On many occasions, I have seen pathology gurus make statements like, “This is a difficult case to characterize,” and the subsequent lines not only sum up their thoughts, but are also catharsis after days spent patiently working up the case.

This is by no means an exhaustive list of the appropriate times for a descriptive analysis on a pathology case – but, whatever your reasoning for such a report, they should never be either repetitive or confusing. There is no need to rehash what is already said in the final diagnosis; no one wants to read the same thing twice, and it gives us a bad rap. If anything, the descriptive report should clarify a diagnosis – not complicate it. A descriptive report should only be entertained if it facilitates clarity. To introduce differential diagnoses after determining a final answer, or to dilly-dally around non-committal morphologic features or stains, has never helped anyone.

Enduring value

I find that the best way to go about writing descriptive reports is to literally describe what you see. For cut sections (non-cytology), I find it helpful to start from the outside in. Does the lesion have a capsule? Is it a pseudo-capsule? Describe your cell(s) of interest and the pertinent background. Descriptions of nuclear and cytoplasmic features are basic, and commentary on special features such as specific “differentiation” or nuclear immaturity comes in handy. In some cases, starting with the lesion and working outward fits the case best. Are the cells discohesive but individually epithelioid? Do they have a hint of rhabdoid maturation or an intensely acidophilic nucleus? Offer the details of how unruly, vagabond cells break from the pack and infiltrate distant sites, disrespecting neighbors and causing mayhem on their journey. Often, the next paragraph goes through any immunophenotyping studies that were performed, and then a summation paragraph allows you to collect your thoughts and add anything you couldn’t say in the final line. Be careful not to say anything that is not true, don’t go out on a limb if you don’t need to, and always remember – these are legal reports and can always be held against you in a court of law. That does sound like a little bit of a buzzkill, but if you have no reason to mention something, or to derive a conclusion, please don’t!

By sharing with you some of the times when the microscopic description was important to me personally, I hope to underscore its value when appropriately executed. The stakeholders for this are not just other pathologists, but can include the patients and families themselves. In this age of “Googling” answers, with the abundant medical knowledge (correct or incorrect) at our patients’ fingertips, it may not be a bad idea to consider the descriptive report’s utility for informing patients – at least, those who want to know. And for archival purposes, some of these descriptions can help assist the eventual discovery of new morphologic correlations to different molecular alterations. As you can see, there are many good reasons to consider the descriptive report – but for me, they were most helpful when I was training. They helped me coordinate my skill and relayed to my mentors how I was progressing as a pathologist. I cannot stress enough the importance of these reports to my own trainees.

It’s true that we will not be able to convince everyone to read these reports – but not everyone has to. When written appropriately, the value of such reports remains within them. I cannot guarantee when their value will be realized – perhaps the next day by the patient; perhaps the next week by a different pathologist; or perhaps a century from now by a medical archivist – but this I can say with certainty: your effort will not go to waste.