A visit to any district general hospital pathology department in the UK will reveal the same issues - an excessive burden of work, a shortage of staff and of facilities. Although my local trust serves a population of 220,000 with a single cardiologist and diabetologist, the recruitment of a fourth histopathologist has long been a priority.
What work will this new specialist do? Pathology, like other support services such as radiology, is demand led.
But referrals to pathology do not appear to have equal weighting. For a director of women and children's health, apart from the relatively small number of malignant cases the most important pathological issue is an autopsy in the event of unexplained foetal or neonatal death.
This has been acknowledged in the Confidential Enquiry into Stillbirths and Deaths in Infancy, and guidelines for these were set out in 1993 by the Royal College of Pathologists.
Even where permission is not given for the full post mortem, a limited autopsy can provide valuable information with which to counsel the bereaved couple.
Both types of post mortem are becoming increasingly difficult to obtain, not only in the district general hospital but also regionally. The reasons given is pressure of work and the time required for even a small number of these examinations. Requests for prioritisation are met with 'tell that to your colleagues in other specialties'.
Are there ways in which we could ease the burden on hospital pathology services? As a house officer I recall my consultant making a visible examination of specimens such as endometrial (womb lining) biopsies or uteri removed, for example, to cure heavy periods. Only selected samples were sent to the laboratory. During the 1970s, pathological services burgeoned and it became 'routine' to send such samples together with, for example, tonsils from children for histological examination.
I decided to look at only two surgical interventions for overtly benign disease, suspected appendicitis and fibroids, treated at the Kent and Sussex Weald trust. In the two years to December 1999 this involved 916 operations.
The surgical specimens were collected in theatre, transported, fixed, sectioned, stained, examined and reported. The results indicated that 911 cases fulfilled the appropriate benign criteria - fibroids, normal or inflamed appendix. Five cases, or 0. 52 per cent of the total, revealed different pathologies. Four appendices contained a carcinoid and one uterus a sarcoma.
The management of the cases was interesting. The house officer's discharge letter remarked on a normal appendix in one case, appendicitis in two and only in the fourth was carcinoid noted and as a result the patient brought back to the follow-up surgical clinic. At this point the consultant discharged the patient, describing the carcinoid as 'of no clinical significance'. The sarcoma patient was seen by the gynaecologist at a six-week follow-up and discharged from hospital care. There seems no reason to quest ion the clinical correctness of these management plans since carcinoid of the appendix seldom, if ever, metastasises, while the only proven treatment of uterine sarcoma is surgical - usually hysterectomy with or without removal of the ovaries since radiotherapy or chemotherapy is ineffective.
The need for defensive medicine should be acknowledged, and this is manifest, for example, in the current pathological examination of a breast lump specimen. Whereas three histological sections might have been satisfactory 10 years ago, 20 may now regularly be inspected before a firm diagnosis is given. We have the tools to reverse some of the inexorable trend to over investigation.
Simple clinical audit systems are efficient in the secondary care sector and, as in the cases of appendicectomy and hysterectomy, where there is no clinical suspicion of malignancy there is the potential to empower clinicians so that they no longer 'routinely' send their samples for analysis. This would allow valuable pathology time to be freed up for more relevant investigations into suspected malignancy or unexplained perinatal death.
REFERENCES
1 Confidential Enquiry into Stillbirths and Deaths in Infancy. Sixth Annual Report. Maternal and Child Health Research Consortium. London, May 1999.
2 Guidelines for Post Mortem Reports. The Royal College of Pathologists. London. August 1993.
3 Muir's Textbook of Pathology (13th edition). MacSween, RNM, Whaley K (eds). Page 1027. London: Edward Arnold, 1992.
4 Practical Gynaecologic Oncology (2nd edition) Berek JS, Hacker NF (eds). Page 1094. Williams & Wilkins, 1994.
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