Pathologists frequently mention “I consulted on this” or “I sent this case off to a consultant” or “We were consulted about…”. But what does it mean? It is frequently puzzling for clinicians or patients. Does that mean my tissue specimen went to another laboratory? Does that mean slides or images from my case were seen outside the institution? Who gets consulted? Who pays for this?
Many appropriate questions.
In most instances, and historically, representative sections from the biopsy or surgical specimen in the form of glass slides are transported to another pathologist. Or they are sent to another institution, for another opinion.
More recently through digital pathology, whole slide images from slides can be shared across pathologists and institutions, mitigating the need for additional slides to be made, stains to be performed, or delays or possible loss from sending patient material elsewhere.
Rarely does the specimen itself travel, but rather the histologic sections along with a gross description, or perhaps a gross photograph to assist with the consultation. Slides from a particular case, along with any pertinent clinical and radiographic information (ideally) are presented to the consultant for his/her opinion, much like the referring or primary pathologist would have available to him/her. This is sometimes easier said than done and requires preparation time by the referring pathologist. This is for both “internal” and “external” consults. It should be a common courtesy between referring and consulting pathologists.
Consultations are obtained for one of three primary reasons:
- The pathologist assigned the case has some doubts as to the best diagnosis after all attempts to classify the lesion.
- The department/institution has some disagreement about the appropriate diagnosis and sends the case to another pathologist to help decide the matter.
- The clinician requests a second opinion from another pathologist and/or the patient requests their slides be reviewed elsewhere, potentially where they may be seeking second or third opinions regarding their treatment options.
In the first two scenarios, the pathology department/group or hospital is responsible for the cost of the consultation. In the last scenario, a patient’s insurance may be typically billed by the consulting pathologist or referring institution for the cost of the clinician/patient-requested consult, much as it would be for a second clinical opinion.
There are a few caveats I think most pathologists ascribe to:
- Internal consultation should always be used in questionable cases.
- Pathologists should always be amenable to obtaining a consult at a clinician or patient request, even if the diagnosis is not in doubt. Pathologists should be able to choose the appropriate consultant.
- If a group of pathologists disagrees about the diagnosis, or if a consensus is unattainable, or doubt remains, external consultation should be sought. And in such cases, a single consultation should be obtained. This is where art meets science and is in some cases, more art than science. There are few issues as troublesome as dueling consultants about a particular case. Which brings me to –
- Pick a consultant, not an institution. While you cannot pick your neighbors, you can pick your consultant. Often times consults are sent to well-known academic institutions, arguably with a plethora of experts in their respective fields that have demonstrated expertise through service, publications and lectures, but those individuals may not be expert for your particular case. Picking your consultant should be based on reputation for timely, accurate service and prior experience, if possible, rather than the institution where they work. That being said, there are many instances of pathologists sending cases for consultation to places rather than people, because, in general, they receive timely service and feel as though an expert will review their case or multiple experts may review their case.
Finally, as a measure of good clinical business practices, consultants should be allowed to retain slides/images from any case they are consulted on (extramural consults) unless there are strong compelling reasons not to do so, which are hard to come by for digital images. Copies of the consultant report should be made available to the clinician/patient. This includes any and all reports, particularly so, if the consultant’s opinion is at odds with the referring pathologist(s) opinion.
If you liked this post from Dr. Keith Kaplan, subscribe to our blog to receive blog posts like these directly in your inbox.
