- What is a pathologist, and how is a pathologist involved in my care?
- When does a pathologist get involved in my medical care?
- How does a pathologist make a diagnosis?
- What kind of information is present in a pathology report?
- Why is the pathologist's diagnosis so important to my care?
- How long does it take for a pathologist to issue a report?
- Why did I get a bill from a pathologist who I never met?
- Is it possible to get a second opinion on a pathology diagnosis?
- Why would I consider allowing an autopsy?
Q: What is a pathologist, and how is a pathologist involved in my care?
A pathologist is a physician who has received several years of training beyond medical school in a pathology residency program in the study of human pathology, and who has demonstrated his/her diagnostic skills by passing rigorous examinations. A pathologist may practice one or more specialties and subspecialties, including surgical pathology, cytopatholgy, and clinical pathology (see below). The pathologist usually communicates directly with your doctor, and not usually with you, the patient. In some ways, the pathologist is the "doctor's doctor".
Pathology is the study of the structural and functional causes of human disease.
Pathologists use a variety of methods and their knowledge about human disease in order to provide a diagnosis (that is, to name the disease process and to provide information about the cause of the disease).
A surgical pathologist provides a diagnosis on samples of tissue obtained during surgery or from a biopsy obtained by a surgeon or other clinician. In addition, the surgical pathologist may be asked by the surgeon to provide a rapid diagnosis during surgery (by frozen section) to provide information that will be used to guide the next steps in surgery. The surgical pathologist uses a combination of tools to make the diagnosis, including microscopic examination, the use of special staining techniques, antibodies to detect specific cell or tissue markers, or molecular analysis of the tissue. A final pathology report of the diagnosis is provided to your doctor by the pathologist. The diagnosis may take a day to a week to complete, depending on the complexity of the case. (see below).
A cytopathologist is a pathologist who specializes in making a diagnosis based on the examination of individual cells obtained from tissue. The most common example is the Pap smear, which is used to detect early signs of cancer of the cervix. Cells can also be examined by using a syringe and needle to extract cells from a lump (for example, in the breast), and a diagnosis can be performed on these cells without having to actually remove (biopsy) a portion of the tissue.
A clinical pathologist is responsible for tests performed in the clinical laboratory, including studies performed on blood, urine, and other body fluids. The clinical pathologist may be called on to interpret the findings of clinical laboratory tests, and can provide guidance as to the tests that are needed to make a definite diagnosis.
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Q: When does a pathologist get involved in my medical care?
A pathologist is involved in your medical care anytime a specimen is submitted to either the clinical laboratory for tests, or a tissue specimen is taken by biopsy or needle aspiration for tissue or cell diagnosis.
In the clinical laboratory, the pathologist is responsible for ensuring the quality of the testing performed, and is called on for interpretation of tests and for advice to your doctor about ordering and interpreting tests. For example, on a routine blood test, abnormal cells my be detected by the automated instruments used to count and measure the cells in the blood, and these cells can be examined by the pathologist to determine their true nature.
Your surgeon may rely on the skills of the pathologist to provide a rapid diagnosis during your surgery using a frozen section to determine the diagnosis and whether any additional things need to be done during surgery in order to treat the disease. For example, a nodule in the lung may be shown to be due to an infection instead of cancer, and the operation can stop without any further removal of lung tissue.
Your surgeon or internist may request that a diagnosis be made on a sample taken by biopsy during your office or clinic visit. For example, a skin biopsy taken by your dermatologist because a mole has gotten larger will be seen by one of our pathologists specializing in skin diseases, and the diagnosis will be reported back to the dermatologist, who will use this information to guide treatment. A mole that has changed in size, shape and/or color must be carefully examined to make sure that the mole has not become malignant (cancerous). This diagnosis would require additional treatment so that a cure is possible.
The cytopathologist, in addition to performing a diagnosis on a Pap smear or aspiration cytology, may also be the physician who performs the needle aspiration procedure to obtain the diagnostic sample. For example, the cytologist may be called on to place a needle in a breast lump to suck out the cells into a syringe (aspiration biopsy), a fast a relatively painless way to determine whether the lump is due to cancer.
Last, the hospital pathologist is actively involved in the management of the hospital, and is involved with other physicians in ensuring the quality medical care meets our high standards.
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Q: How does a pathologist make a diagnosis?
The microscope is the main diagnostic tool used in surgical pathology and cytopathology. Thinly-sliced samples of tissue or cells are placed on rectangular sheets of glass measuring 3 x 1 inches ("glass slide"), and these tissues or cells are stained with various dyes to make the cells and tissue architecture visible and to bring out diagnostic features. By careful microscopic examination under various magnifications (from 40 to 1000 times enlargement), the structure of the tissues or cells can be evaluated for changes that indicate disease. It takes many years of experience to learn to distinguish normal cells and tissues from abnormal, and to identify the disease process correctly. In difficult cases, pathologists use a variety of more sophisticated tools to detect organisms, molecules or genes that may identify the disease process. For example, antibodies (proteins that bind to specific molecules) can be used to reveal the presence of a virus which is too small to be seen using the microscope. Certain cancers have abnormalities in their DNA which are specific to that type of cancer, and the pathologist can test for these abnormalities.
You can read a more detailed description of how a pathology diagnosis is made, by choosing one of the following links:
What happens after I have had a biopsy or surgery?
What happens to my Pap smear?
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Q: What kind of information is present in a pathology report?
A pathology report generally is one or more pages of text that should include the following information (may vary from place to place):
- Header: The name of the medical organization or pathology group issuing the report, with mailing address and telephone contact numbers
- Patient: The name of the patient, and other identifying information, such as Date of Birth, Medical Record Number (or Unit Number, or Encounter Number)
- Procedure Date: The date of the biopsy or surgery
- Received Date: The date the specimen was actually received by the laboratory
- Report Date: The date the report was finalized and released to the physician
- Physician: The name of the physician responsible for seeing the patient and who will receive the report
- Pathologists: The names of all pathologists responsible for the diagnosis
- Final Diagnosis: This part of the report contains the diagnosis, which may be the name of a disease, disease process, or tumor type (if present). The diagnosis section usually will include supplementary information, such as the severity or extent of the disease process and the results of special studies performed to arrive at the diagnosis
- Clinical Data: A small amount of clinical history which the physician provides to the pathologist to indicate the reasons for the procedure and a description of the procedure performed to obtained the tissue or cell sample
- Tissue submitted: Each specimen submitted to the pathologist is listed, as labeled by the physician (for example: "#1:Skin, right forearm; #2: Skin, left forearm)
- O.R. Consultation: The diagnosis performed by frozen section at the time of surgery, if this was done
- Gross Description: A detailed description of the specimen received by the pathologist (e.g., size, weight, color, dimensions, tumor size), as well as documentation of samples taken for microscopic examination
- Addendum: Additional comments that the pathologist may wish to add based on further review of the case
You should expect that a lot of the words used in the pathology report are difficult to understand without medical training, as the report is designed to communicate with the physician, and not directly with the patient. Your doctor should be able to explain to your satisfaction the meaning of any terms that you do not understand, and should be able to convey the overall meaning of the report and what effect it will have on your further evaluation or treatment.
Q: How long does it take for a pathologist to issue a report?
For a small biopsy (skin, colon, etc.,) the report is usually ready in less than 3 days. For a large specimen that needs to be fixed and sampled, it can take 4 - 5 days. Sometimes, pathologists have to order additional tests (antibody staining, cytogenetics, etc.,) to make an accurate diagnosis. Those additional testing can take additional time to complete.
For second opinion, if all the material is received, then a diagnosis can be rendered in 1 - 2 days. However, if the material needed for making a diagnosis sometimes is not readily available, it can take much longer for the material to be sent from the original hospital to BWH. Most of the delay in reporting is the result of delay in receiving all the material.
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Q: Why did I get a bill from a pathologist who I never met?
Even though you never met your pathologist, it was the pathologist who provided your doctor with the information based on laboratory tests or tissue samples that provide the diagnosis in your case. Not all illnesses require the services of a pathologist, but often the interpretation of a laboratory test or examination of a tissue specimen is necessary in order to arrive at the correct diagnosis. An accurate diagnosis is key to ensuring proper treatment.
The pathologist communicates directly with your doctor, who is responsible for your care. Armed with this information, you and your doctor will be able to make well-informed decisions about your treatment.
Often a pathologist's bill will show several charges. That is because there may have been several specimens submitted to the pathologist for diagnosis during your surgery or office visit, and each requires examination and diagnosis. The amount of the charge is determined in part also by the complexity of the case and the number of special studies that are needed to make the diagnosis, and we are required to charge only for those things that are proven to have been necessary for your diagnosis.
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Q: Is it possible to get a second opinion on a pathology diagnosis?
Making a diagnosis is not an exact science, and is highly dependent on the skill and experience of the pathologist. It is not unusual for pathologists to consult with one another in difficult cases. Making the correct diagnosis is critical to the treatment decisions that you and your doctor will make, especially if the diagnosis involves some kind of cancer. If you are going to another physician or hospital for treatment, it is strongly suggested that you have your pathology diagnosis reviewed by the pathologists associated with that practice site. Their agreement with the original diagnosis will give you additional peace of mind.
You have the right to request that your doctor seek another opinion regarding the pathology diagnosis. Your doctor will make the arrangements with the pathologists to have your diagnosis reviewed by an another pathologist. A pathologist will be selected based on his/her reputation and expertise in your disease.
If you are traveling to another hospital for consultation or for treatment, you should ask whether your diagnosis will be reviewed at that hospital, and whether your doctor will arrange to have your pathology materials sent there. It would be most useful to have this done before your visit so that the consulting doctor will have all of the information he/she needs when you arrive. At times, you will be asked to bring the materials yourself. This should not be a problem, as the glass slides usually can be carried in a small box, and should include the pathologist's report.
You may be seeking treatment or a second opinion at Brigham and Women's Hospital or Dana Farber Cancer Institute after receiving a diagnosis elsewhere. For information on how to send your pathology diagnostic materials to our department by mail, please see our referrals page.
If you are seeking treatment or a second opinion elsewhere, our department will mail your diagnostic materials (reports, glass slides, blocks) to the location specified by your referring clinician at his/her request. Alternatively, you may pick up your materials at the Department of Pathology Main office (see Map for directions). We suggest that you or your physician call our department in advance to avoid delays in receiving your case materials.
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Q: Why would I consider allowing an autopsy?
An autopsy, sometimes call a "post-mortem examination," is basically an operation performed on an individual shortly after death in order to perform a complete examination to determine the types of disease or diseases present and to determine the cause of death. In suspected criminal cases, this examination is required and is performed by a pathologist assigned by the state (the State Medical Examiner). In all other cases, the family of the deceased may be asked for permission for an autopsy, and can decide based on their own feelings and the reasons provided by the doctors for suggesting the autopsy. The autopsy will be performed by one of the hospital pathologists, and a complete report of all the findings will be provided to the patient's family through the patient's physician.
An autopsy is performed like an operation, and the deceased is treated with the utmost respect. In a complete autopsy, the entire body is examined and all internal organs are removed for study. The family may choose to limit the extent of the autopsy to obtain a sample from only a single body part. Regardless of the extent of the autopsy, the effects will not be visible if the body is to be placed on viewing.
The benefits of an autopsy include:
- The cause of death, which may have been uncertain, can be determined.
- Other medical conditions which may have affected the patient's health can be discovered, and may help explain the cause of death.
- The patient may be found to have a disease which may be inherited, and will alert family members to a disease which they may not yet be aware they have, and which can be treated.
- The doctors involved in caring for the patient will gain understanding which will help them to treat other patients with a similar disease or to gain additional knowledge which will lead to better treatments.
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