- Email: [email protected]
Discordance in the diagnosis of melanoma
HUMAN PATHOLOGY
Volume 28, No. 4 (April 1997)
as separate entities, we hoped to mimic the true practice of consultation dermatopathology in melanocytic tumors. We agree with Dr Goldhahn that one can sometimes obtain a certain interpretation by carefully choosing one's consultant. However, does this verify (demonstrate the true answer) one's diagnosis, or simply show agreement? Who is correct if the consultant disagrees, as shown in this study? We also agree with Dr Goldhahn that we as pathologists and clinicians are less than perfect. In this study, we tried to quantify the degree of imperfection. EVAN R. FARMER,MD RENI~ GONIN, PHD MARK P. HANNA,MS Department of Dermatology and Medicine Section of Biostatistics Indiana University School of Medicine Indianapolis, IN
D i s c o r d a n c e in t h e Diagnosis of M e l a n o m a To the Editor:--We applaud your courageous editorial 1 expanding on the findings of the Farmer study2 which indicated disastrous discordance among expert pathologists in the critically important surgical pathology ultra-subspeciality of melanocytic neoplasms. Although it was shocking to see this substantiating information, we regret to say that we are not surprised. Among community-based pathologists, there is an old axiom that one should send a difficult case of any type to only one expert consultant because of the risk of receiving significantly differing opinions. Over the years, one becomes facile at selecting among consultants, utilizing a slight bias toward the expert opinion one wants to hear (some consultants are more malignant than others). Fortunately for patients, there is a huge difference between expertness and competence. Sadly, our legal system has yet to recognize this. By virtue of the extremely valuable direct interplay between local pathologists and the patient's physicians, the competent local pathologist is able to act closely with clinical physicians in the patient's best interest in all types of pathology and laboratory medicine cases. Of greater concern are managed care contracts that initially take specimens away from the local point of service and
send them to huge, distant commercial reference laboratories. Similarly, assuming that distant experts are truly superior in patient-specific performance, local clinicians are subject to the enticing marketing of distant subspecialized surgical pathology labs. This could remove an important check and balance that exists at the local point of service. Happily, in recent years (possibly related to the impact of computerization and the subsequent need for algorithmic criteria for diagnosis and management) many authorities have put forth serious efforts to help in-the-trenches practitioners perform more expertly and competently. The availability of information posted on ( a n d / o r discussed on) the Internet may help us even more. The Farmer study2 and subsequent editorial 1 are extremely important in that they forcefully puncture the notion in our society that the performance of medical experts is truly exemplary by comparison to nonexperts. We heartily agree with Dr Ackerman that surgical pathology is "100% subjective," and we extend further to state that almost no part of medicine is an exact science. If the experts can do no better than this degree of discordance, how can we generalists be legally held by both the public and professionals to a nearly perfect standard? Who defines the standards? While even our top experts struggle with the proper setting of standards, our legal system defines and redefines standards retrospectively on a case-by-case basis by way of the testimony of whatever expert witnesses are presented by plaintiff and defense. Is an expert witness a competent witness? Has the journal indirectly exposed, from a different angle, a huge problem within our legal system? In the final analysis, having our own limitations, we greatly appreciate our experts, whatever their h u m a n deficiencies may be. After all, we are only h u m a n (wishing that the legal system and its jurors could grasp this). ERWN B. SHAW, MD JOHN B. CARTER, MD Department of Pathology and Laboratory Medicine Lexington Medical Center West Columbia, SC 1. AckermanAB: Editorial,discordanceamongexpert pathologistsin diagnosis of melanocyticneoplasms.HUMPATHOL27:1115-1116.1996 2. FarmerER, GoninR, Hanna MP: Discordancein the histopathologic diagnosisof melanomaand melanocyticnevibetweenexpertpathologists.HUM PATHOL27:528-531,1996
BOOK REVIEW Cells, Tissues, and Disease: Principles of General Pathology. Guido Majno and IsabelleJoris. Blackwell Science, 974 pages, $75.00. This outstanding book fills a distinct void in the pathology literature. Not since the classics of Payling-Wright and Florey, first published more than three decades ago, has a comprehensive book of general pathology achieved broad acceptance. This is especially surprising given the remarkable advances in our understanding of basic disease processes that have occurred during these past 30 years. The time may have come with the publication of Cells, Tissues, and Disease: Principles of General Pathology by Guido Majno and Isabelle Joris. The apparent dearth of current comprehensive works concerned with general pathology is especially surprising given the remarkable advances in our understanding of basic disease processes that have occurred during the three-plus
514
decades since the first publication of the British texts referenced previously. But perhaps herein also lies the reason for the long hiatus. Few have the requisite experience, respect of their peers or infectious enthusiasm for the subject matter to undertake such a daunting task. Fortunately for all of us, Majno andJoris possess each of these attributes in abundance. Majno's entire investigative career has been devoted to enhancing our understanding of basic mechanisms of diseasecell injury-, inflammation, fibroplasia and neoplasia, andJoris has made important contributions to vascular biology and atherogenesis. Both authors have been recognized as exceptional educators for many, many years, most recently as members of the Department of Pathology at the University of Massachusetts Medical School. The book is divided into five parts and 34 chapters. Part 1 comprises seven chapters devoted to cellular pathology, and includes separate chapters on pathological calcification and
Volume 28, No. 4 (April 1997)
as separate entities, we hoped to mimic the true practice of consultation dermatopathology in melanocytic tumors. We agree with Dr Goldhahn that one can sometimes obtain a certain interpretation by carefully choosing one's consultant. However, does this verify (demonstrate the true answer) one's diagnosis, or simply show agreement? Who is correct if the consultant disagrees, as shown in this study? We also agree with Dr Goldhahn that we as pathologists and clinicians are less than perfect. In this study, we tried to quantify the degree of imperfection. EVAN R. FARMER,MD RENI~ GONIN, PHD MARK P. HANNA,MS Department of Dermatology and Medicine Section of Biostatistics Indiana University School of Medicine Indianapolis, IN
D i s c o r d a n c e in t h e Diagnosis of M e l a n o m a To the Editor:--We applaud your courageous editorial 1 expanding on the findings of the Farmer study2 which indicated disastrous discordance among expert pathologists in the critically important surgical pathology ultra-subspeciality of melanocytic neoplasms. Although it was shocking to see this substantiating information, we regret to say that we are not surprised. Among community-based pathologists, there is an old axiom that one should send a difficult case of any type to only one expert consultant because of the risk of receiving significantly differing opinions. Over the years, one becomes facile at selecting among consultants, utilizing a slight bias toward the expert opinion one wants to hear (some consultants are more malignant than others). Fortunately for patients, there is a huge difference between expertness and competence. Sadly, our legal system has yet to recognize this. By virtue of the extremely valuable direct interplay between local pathologists and the patient's physicians, the competent local pathologist is able to act closely with clinical physicians in the patient's best interest in all types of pathology and laboratory medicine cases. Of greater concern are managed care contracts that initially take specimens away from the local point of service and
send them to huge, distant commercial reference laboratories. Similarly, assuming that distant experts are truly superior in patient-specific performance, local clinicians are subject to the enticing marketing of distant subspecialized surgical pathology labs. This could remove an important check and balance that exists at the local point of service. Happily, in recent years (possibly related to the impact of computerization and the subsequent need for algorithmic criteria for diagnosis and management) many authorities have put forth serious efforts to help in-the-trenches practitioners perform more expertly and competently. The availability of information posted on ( a n d / o r discussed on) the Internet may help us even more. The Farmer study2 and subsequent editorial 1 are extremely important in that they forcefully puncture the notion in our society that the performance of medical experts is truly exemplary by comparison to nonexperts. We heartily agree with Dr Ackerman that surgical pathology is "100% subjective," and we extend further to state that almost no part of medicine is an exact science. If the experts can do no better than this degree of discordance, how can we generalists be legally held by both the public and professionals to a nearly perfect standard? Who defines the standards? While even our top experts struggle with the proper setting of standards, our legal system defines and redefines standards retrospectively on a case-by-case basis by way of the testimony of whatever expert witnesses are presented by plaintiff and defense. Is an expert witness a competent witness? Has the journal indirectly exposed, from a different angle, a huge problem within our legal system? In the final analysis, having our own limitations, we greatly appreciate our experts, whatever their h u m a n deficiencies may be. After all, we are only h u m a n (wishing that the legal system and its jurors could grasp this). ERWN B. SHAW, MD JOHN B. CARTER, MD Department of Pathology and Laboratory Medicine Lexington Medical Center West Columbia, SC 1. AckermanAB: Editorial,discordanceamongexpert pathologistsin diagnosis of melanocyticneoplasms.HUMPATHOL27:1115-1116.1996 2. FarmerER, GoninR, Hanna MP: Discordancein the histopathologic diagnosisof melanomaand melanocyticnevibetweenexpertpathologists.HUM PATHOL27:528-531,1996
BOOK REVIEW Cells, Tissues, and Disease: Principles of General Pathology. Guido Majno and IsabelleJoris. Blackwell Science, 974 pages, $75.00. This outstanding book fills a distinct void in the pathology literature. Not since the classics of Payling-Wright and Florey, first published more than three decades ago, has a comprehensive book of general pathology achieved broad acceptance. This is especially surprising given the remarkable advances in our understanding of basic disease processes that have occurred during these past 30 years. The time may have come with the publication of Cells, Tissues, and Disease: Principles of General Pathology by Guido Majno and Isabelle Joris. The apparent dearth of current comprehensive works concerned with general pathology is especially surprising given the remarkable advances in our understanding of basic disease processes that have occurred during the three-plus
514
decades since the first publication of the British texts referenced previously. But perhaps herein also lies the reason for the long hiatus. Few have the requisite experience, respect of their peers or infectious enthusiasm for the subject matter to undertake such a daunting task. Fortunately for all of us, Majno andJoris possess each of these attributes in abundance. Majno's entire investigative career has been devoted to enhancing our understanding of basic mechanisms of diseasecell injury-, inflammation, fibroplasia and neoplasia, andJoris has made important contributions to vascular biology and atherogenesis. Both authors have been recognized as exceptional educators for many, many years, most recently as members of the Department of Pathology at the University of Massachusetts Medical School. The book is divided into five parts and 34 chapters. Part 1 comprises seven chapters devoted to cellular pathology, and includes separate chapters on pathological calcification and