pathology

flying cadeuciiThere’s a lot of talk about quality metrics, pay for performance, value-based care and penalties for poor outcomes.

In this regard, it’s useful to ask a basic question. What is quality? Or an even simpler question, who is the better physician?

Let’s consider two fictional radiologists: Dr. Singh and Dr. Jha.

Dr. Singh is a fast reader. Her turn-around time for reports averages 15 minutes. Her reports are brief with a paucity of differential diagnoses. The language in her reports is decisive and her reports contain very few disclaimers. She has a high specificity meaning that when she flags pathology it is very likely to be present.

The problem is her sensitivity. She is known to miss subtle features of pathology.

There’s another problem. Sometimes when reading her reports one isn’t reassured that she has looked at every organ. For example, her report of a CAT scan of the abdomen once stated that “there is no appendicitis. Normal CT.” The referring physician called her wondering if she had looked at the pancreas, since he was really worried about pancreatitis not appendicitis. Dr. Singh had, but had not bothered to enlist all normal organs in the report.

Dr. Jha is not as fast a reader as Dr. Singh. His turn-around time for reports averages 45 minutes. His reports are long and verbose. He meticulously lists all organs. For example, when reporting a CAT of the abdomen of a male, he routinely mentions that “there is no gross abnormalities in the seminal vesicles and prostate,” regardless of whether pathology is suspected or absence of pathology in those organs is of clinical relevance.

He presents long list of possibilities, explaining why he thinks a diagnosis is or is not. He rarely comes down on a specific diagnosis.

Dr. Jha almost never misses pathology. He picks up tiny lung cancers, subtle thyroid cancers and tiny bleeds in the brain. He has a very high sensitivity. This means that when he calls a study normal, and he very rarely does, you can be certain that the study is normal.

The problem with Dr. Jha is specificity. He often raises false alarms such as “questionable pneumonia,” “possible early appendicitis” and “subtle high density in the brain, small punctate hemorrhage not entirely excluded.”

In fact, his colleagues have jokingly named a scan that he recommends as “The Jha Scan Redemption.” These almost always turn out to be normal.

Which radiologist is of higher quality, Dr. Singh or Dr. Jha?

Continue reading “Who Is the Better Radiologist?”

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Cause of death on this 1937 death certificate? “Senile gangrene.”

I’ve always had nagging doubts about filling out death certificates.

An excellent article in the trade paper “American Medical News” by Carolyne Krupa explores the “inexactitude” of the custom.

As Krupa points out, doctors are never taught how to fill out the documents. She quotes Randy Hanzlick, MD, chief medical examiner for Fulton County, GA:

“Training is a big problem. There are very few medical schools that teach it,” he said. “For many physicians, the first time they see it is when they are doing their internship or residency and one of their patients dies. The nurse hands them a death certificate and says, ‘Fill this out.’ ”

That’s pretty much how it works. Though sometimes the person that comes calling with the death certificate is a hospital clerk. And she will make you fill out the form carefully, using only ‘allowable’ causes of death.

Of course, everyone dies from the same thing:lack of oxygen to the brain. But you can’t list that. Nor can you list common “jargon-y” favorites like “cardiopulmonary arrest,” “respiratory failure,” “sepsis,” or “multi-system organ failure.” All of which are true, but too inexact to be useful.

It’s intimidating to be the one to “pronounce” someone dead, and be the final arbiter of the cause. Isn’t that why we have medical examiners/pathologists?

We don’t autopsy patients much anymore, a trend that concerns many in the industry but doesn’t seem likely to change. That leaves interns and residents (at teaching hospitals) and community docs (in the real world) in charge of filling out these important statistical and historic documents.

Continue reading “Quantified Death”

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