Material and Method: A survey has been prepared to cover all the aspects of consultation practice using the literature and referring to the current methods used in Turkey. The survey has been announced on the internet and 83 replies were collected.
Results: Multiple choice questions were evaluated in terms of percentages and open ended questions were grouped according to the answer contents. It was seen that problems could be grouped as follows: absence of written procedures covering each step, means of transport, reaching the consultant, payment, reporting and ethical issues. The absence of procedures and issues regarding the payment methods were the interfering factors for each step of consultation.
Conclusion: There are many problematic issues in consultation practice in pathology in Turkey. The basis of these problems is the absence of written regulations for procedural and payment methods. Regulations addressing these issues should be developed.
The consultation is a versatile process and has ethic, financial and legal dimensions in addition to its scientific dimension. Arrangements should be made so that any action will take all these dimensions into consideration. Regulating the consultation processes is now frequently recommended in developed countries and classic reference books (1- 4). However, there may be characteristics changing from country to country and even from time to time, especially for the areas with social dimensions.
In accordance with the laws in Turkey (Law on the Practice of Medicine and Medical Sciences, number 1219), providing an opinion on medical issues, arranging medical treatment and making a medical intervention are responsibilities of the physician. A physician requesting a consultation from a physician of another specialty is regulated by various legal arrangements regarding consultation in Turkey (Code of Medical Deontology, Patient Rights Regulations, Hospital Management Regulations, Code of Medical Ethics) but requesting a consultation from a physician of the same specialty is not regulated. Consultation in pathology is requesting the opinion of another physician from the same specialty. There is no legal or medical obstacle to requesting such an opinion. However, many problems occur in the application as such consultations are not regulated legally. Determination of the situation in Turkey and making arrangements according to internationally guides by taking the current situation of the country into account are therefore becoming more important.
As far as we know, some documents have been prepared by using internationally recognized sources but there has not been a study setting out the situation in Turkey. The main goal of this study was to determine the issues in the area of pathology consultation, to compare it with international methods and provide recommendations on methods unique to Turkey. Within this goal, the present situation will be put forth through a questionnaire prepared by taking the international methods into consideration.
Table I: Reasons for a consultation request
Table II: Documents requested for consultation, transportation methods and materials sent
Table III: The answers given to the survey questions
The answers given to the questions with options were numerically evaluated and the percentages were calculated according to the number of participants. In questions with more than one answer, the percentages were calculated according to the total number of participants. In questions only concerning consultant physicians, the percentages were calculated according to the answers given to these questions. In addition, the open-ended questions and comments written about the subject were grouped separately for each step of the process. We tried to group together similar opinions in these groups in sentences, keeping the original words as much as possible, and tried to express all the views. A quantitative evaluation could not be performed and only the content was investigated in this group evaluation.
The answers to the first two survey questions (What are the most important problems when you consult? and, what are the factors that you feel hinder you if you cannot consult?) were evaluated together and the answers given to open-ended questions were gathered in three groups as related to ‘’pathologists’’, ‘’the system’’ and ‘’the consultation procedure’’.
Pathologists: It was reported that that there was no systematic consultation process, so the personal relationships became important. One had to call first for a consultation and therefore needed spare time. It then took time to deliver it personally and this was not always possible. The thought of a delay in reporting and not meeting the standards of the other party also made requesting a consultation difficult.
The reported problems were: Absence of defined consultation centers and consultant physicians, not knowing which center has what kind of opportunities, not being able to select the consultant physician as desired, having communication difficulties with experienced pathologists and not being able to reach them easily, thinking about spending the time of the consultant and being uncomfortable by thinking that the consultant is not obliged, the consultant physician making one feel that he/ she is very busy or feeling that way, feeling embarrassed for not paying the consultant pathologist enough, the consultant physician not taking the case seriously enough because he/she was not getting paid, the consultant physician not giving enough attention to the case due to the intense work (or feeling that way), thinking that it is perceived as a chore which made one uncomfortable, thinking that it is taking away from the resident’s training time, worrying about “What will they think about me, I wonder if this question is too simple”, feeling inadequate from time to time, and feeling “I wish I had not consulted as at least I would not be disgraced”.
In addition, it was stated that there are frequently consultation opportunities and such a habit among faculty members in the same institution and that external consultation requirement was rare but a decrease in pathologists providing advice in intra-departmental consultations due to the increase in subspecialties, the absence of other pathologists in the region, the small number of experienced and senior faculty members working on specific subjects in small universities, not feeling free to make decisions, and not being able to make consultations without the consent of the department chief made consultations difficult.
It was reported that the consultant pathologists take all responsibility and try to examine every case sent to them so as not to offend anyone. It was therefore recommended that the consultant pathologists should be responsible for their diagnosis and should be paid. Criticism included consultations being avoided at some research hospitals, an effective diagnosis often not being provided for reasons such as ‘’bad processing, bad section, tissue spilled’’, problems with communication, implications to send paying patients, the consultants’ neglect, unfavorable attitudes and behaviors, ethical principles not being adequately followed when there was a diagnosis mismatch, and overly assertive behavior such as ‘’I said so, and this is how it is’’.
Not being able to reach the report of the outcome of the consultation, the consultation result arriving late, and not knowing the fate of the patient were the most frequently reported problems. In addition, the importance of making sure the definite diagnosis is provided by the original responsible person for the case was emphasized. The thought of getting a second opinion is thought to be not widely accepted among pathologists and it was said that this perception should change.
Not providing enough clinical and radiological information to the consultant physician, the lack of the desired paraffin block in the material sent for the consultation, lack of sufficient material making the consultation process difficult were also reported.
System: The lack of accepted standard procedures for sending a consultation and consultation pricing and payment rules were reported as the most important problems. Although there are limited rules such as making an official protocol with a higher institution for consultations, not being able to make an official consultation due to some research hospitals avoiding making a protocol and the lack of coordination between the patient and the consultation center were emphasized. The absence of a formal procedure regarding the delivery way and method due to shortage of transportation, staff and time, and trying to reach the consultant by sending the materials of the case by mail, courier, etc., also created difficulties. The institution or relatives of the patient not being supportive in this regard, the clinicians showing resistance to consultation and all courier costs being met by the pathologist from time to time were reported. Consultations abroad were avoided because of financial reasons.
It was reported that consultation fees are very low although consultation cases are more difficult than routine cases and require more responsibility and time, and that such risks would not be accepted and the necessary time spent when the proper payment was not made.
Pricing for immunohistochemical or other additional investigations were a problem during the consultation and the consultation center also encountered problems in cases that required advanced tests or when another polyclinic had to be involved for pricing additional procedures due to protocol-related issues.
Recommendations for a healthy system were specific consultation centers and/or consultants being created, standardization of material transportation, creating a billing method for the physician’s effort, material transfer and additional investigations, and developing a system where the case can be sent to the consultant physician and the official report received by mail without referring the patient.
Telepathology and internet-based systems were also recommended for report transmission and communication. The fees being covered by the consulting institution, and the consultant physician as well as the first evaluating physician being paid were among suggestions. However, there was concern that arrangements where the consulting institution was billed could have a deterrent effect. There were also participants who thought that choosing the consultant pathologist may contradict patient choice and legal cases.
Consultation Processes: The reasons for requesting a consultation are stated on Table 1. When the most consulted organs/systems were evaluated, the most common cases requiring consultation belonged to hematopathology, dermatopathology, neuropathology, and bone and soft tissue pathology. Table II presents the answers regarding the documents asked for during the consultation, the transportation method, the materials sent and the responsible persons.
Other questions: Those who stated that major errors in pathology diagnosis were acceptable to a certain extent emphasized that making mistakes is natural, and that everyone can make a mistake but the error rates have to be decreased by using quality development systems. Those who stated that major errors are not acceptable in the diagnosis emphasized that a zero error rate should be targeted. It was reported that collaborating with related physicians and clinics, providing the necessary technical infrastructure, and asking for a consultation when necessary could reduce these errors. It was also reported that minor errors should be reduced or completely eliminated with similar methods, differences can be decreased with standard reports where internationally accepted terminology also understood by clinicians and comprehensible language is used and that it can be undesirable to change wording only to be different.
Re-evaluation of the samples of patients presenting at another institution for treatment was accepted by the majority, but there were different opinions regarding which cases should be re-valuated. There are physicians who recommend re-evaluating all cases as well as those who recommend only re-evaluating the cases diagnosed with a malignant disorder are not consistent with the clinical findings, rare and require experience to interpret, have deficiencies in the first report, will be discussed in the clinicopathological council and have incomplete reports due to technical deficiencies, or where a re-evaluation is specifically requested by the physician. However, avoiding the wording which may cause loss of confidence in the pathologist performing the first evaluation by the patient, patient’s relative or clinician during this process is emphasized.
It is believed that the pathologist requesting the consultation is responsible for the adequacy of clinical information in consultations requested from a pathologist by another pathologist and that the clinician is responsible for the clinical information and the related deficiency in consultations requested by the clinician or patient’s relative. Reservations about the consultants being responsible as much as the physicians who perform the first examination are listed as lack of sufficient clinical information, and the macroscopic investigation, detection and follow-up procedures not being controlled by the consultant physician.
The general trend regarding the cases used in scientific research by consultant physicians is to have the name or permission of the pathologist who made the first diagnosis in case presentations. Some participants stated that the name of the first pathologist may not be included in cases where the diagnosis is changed by the consultant and that the consultant physician can use the case in case series or for original research.
Some participants stated that there may be losses and should be tolerated to a certain extent, and that they could not get their tissues back from some universities even if they persistently asked for them.
Another consultation method used frequently in Turkey is verbal notification by the consultant physician without issuing a formal report. In this case, those who write “Case consulted to Dr. X” in the report by the pathologist who requested the consultation say that they did it by taking permission, while those that do not approve it feel a second report should be written. Suggestions such as issuing reports separately for the non-formal inter-institutional consultations, specifying the consultant in the footnote, submitting the consultant pathologist’s report or the note attached, showing the final version of the report to the consultant and receiving approval, as well as not performing consultations using non-formal means were among the views.
For the section that summarizes the earlier diagnosis and inconsistencies if any in the consultation report, some believed that putting it in quality control documents was sufficient, some thought that this section should be sent by mail in particular to the pathologist who provides the consultation, while others believed such acts could act as a deterrent.
However, the results of the survey revealed that serious problems are experienced during the consultation. The basis of these problems is the lack of a formal or informal methodological regulation regarding the consultation requested from a physician in the same specialty. Although there are rules and regulations governing inter-specialty consultations, current regulations do not cover the special cases of the pathology discipline. There is no regulation, so everyone tries to request a consultation with his/her own method and this is usually with personal relationships. The consultant physician often provides the evaluation only by goodwill but does not get paid in this process. This causes the physician requesting the consultation to perceive the process as drudgery, and may stop or hinder the consultation as he/she believes he/she may be bothering the consultant or preventing him/her from completing regular work. Likewise, it is thought or perceived that the consultant who is not paid will not show enough interest in the case. In addition, changing conditions such as the lack of a pathologist able to respond to the consultation request in the area or in newly established universities, personal relationship problems or increased specialization even in institutions with a large number of pathologists make consultation difficult. Managers preventing consultations in some institutions is a striking problem. According to the Medical Deontology Regulation (Article 24, 26, 27) and Hospital Administration Regulations (Article 65), the consultation procedures should absolutely be written and the issues experienced during this process should be managed by the physicians in an executive position. The fee of immunohistochemical or other additional molecular genetic studies used during the consultation have also been reported as a major problem.
Another problem is sending the material to the consultant[6] and the communication during this process[7]. This process is most commonly performed by relatives of the patient but sometimes cannot be realized as they do not recognize the importance of consultation or are reluctant to send the material for consultation. In addition, the cost of sending through the mail and the lack of relevant regulation can be a problem.
These data show that the most important problems for Turkey regarding consultations are the fact they are not paid well and the lack of a determined method for consultation procedures and transport. Consultations are known to require much effort and time and more frequent additional complex methods than regular cases. A consultation is not a regular evaluation, and is performed by people with a high level of knowledge and experience. The institutional expenses during the consultation process should also be charged and paid for in addition to this scientific effort. Having regulations allowing choosing the consultant is another important matter.
As seen from examples in other countries, consultations are performed most commonly in cases with diagnostic problems and in cases requiring further examination such as immunohistochemistry and molecular genetics. Consultations are required in every field, but hematopathology, dermatopathology, neuropathology, and soft tissue and bone pathology are the areas that require consultation more frequently. These facts are worth taking into consideration for future regulations.
There are various opinions and approaches and no standard methods regarding what the consultation material consists of, which document should be received for the material given, and who should have the responsibility for sending complete information and material. Constituting standard procedures towards regulating the consultation processes will make the process easier and remove the obstacles preventing consultations. The most important of these issues is the subject of which institution will keep the blocks and preparations after the consultation. Creating an arrangement for this matter with regulations is quite important. At this stage, it would be best for pathologists to warn their patients not to keep the samples themselves and to leave them in a pathology laboratory (where the initial diagnosis / consultation / treatment is provided or other). A biopsy sample is best stored in the archives of a pathology laboratory as losses will occur otherwise.
The material must be sent using standard procedures, especially for inter-institutional consultations[1,2,6]. Representative slides, paraffin blocks, unstained preparations from the blocks that create additional costs for the institution or samples prepared from paraffin blocks for genetic studies, as well as a note indicating the purpose of the consultation, the patient’s clinical presentation, pathology report of this sample, previous pathology reports and samples related to this sample and the contact information should also be sent to the consultant physician[1,2]. The selected samples should absolutely be for the purpose of the consultation, and sending unnecessary samples that will not be used for the diagnosis should be avoided. The necessary measures should be taken against the breakage, distortion, meddling, and loss of these samples during transportation[6]. For example, a large number of specimens being put randomly into a bag or box without taking any measures may make these specimens impossible to evaluate. In the same way, samples received for consultation should be checked regarding the compliance of the numbers and codes on the previous report and the samples so as to confirm the patient’s identity[2].
Another important issue is the ethical problems during the consultation. Getting a second opinion has became an integral part of medical practice but it is reported that pathologists can still become uncomfortable when their diagnosis is questioned. In fact, a second evaluation and consultation in the institution is generally regarded as a patient right, and consultations are known to cause significant changes when used routinely in daily practice before planning treatment. In one study, re-evaluation when the treating institution was changed resulted in differences that could cause significant treatment differences in 5% of the cases. Cancer cases being reviewed by a second pathologist before they are approved is a consultation method for quality control purposes[2]. Taking a second opinion should be a part of the daily routine and should be accepted by everyone. One must not forget that a consultation is defined as a physician’s right in the Code of Professional Medical Ethics (Article 19).
Overly assertive and despising attitudes are another subject of complaint. These behaviors make the consultation difficult and can be very disturbing for pathologists. The ethical approach would be for consultants to feel empathy for the pathologist whose diagnosis is questionable. Another frequently mentioned issue is not being able to access the results of the consultation. Consultants who answered the survey commonly state that they hand over the results when requested by the pathologist but there are also those who reported the results only when they thought of a different diagnosis. Arrangements could be made to enable such communication by using electronic mail or internet-based methods.
Most believe that the outcome of the consultation should be registered even for inter-institutional consultations. However, there are different approaches regarding the consultant pathologist’s name being written on the report prepared by the sending pathologist. There are physicians who write the consultant pathologist’s name only if he/she approves, as well as those who do not write the name at all or who always write it. However, it should be considered as stated in the Medical Deontology Regulation (article 26) that the ideal is to record in writing each of the decisions reached in consultation, with the consent of the person who requested the consultation and the consultant.
The general trend regarding consultant physicians using the consulted case in scientific research is to have the name or permission of the pathologist who made the first diagnosis in case presentations while some participants stated that the name of the first pathologist may not be included in cases that the diagnosis is changed by the consultant and the consultant physician can use the case in case series or original research. The Federation of Pathology Societies and the Pathology Consultation Directive make similar recommendations[5].
In conclusion, regulations ensuring the consultant physician gets paid for consultations and defining original consultation processes that include every phase of the process and take the conditions in Turkey into account are required. Pathologists will then be able to send their cases for consultation without the concern of bothering others, and consultants will not lose their interest in these cases.
1) Association of Directors of Anatomic and Surgical Pathology. Consultations in surgical pathology. Am J Surg Pathol 1993, 17: 743–745. [ Özet ]
2) Slide review and consultation. In Rosai J. (Ed): Rosai and Ackerman's Surgical Pathology, 10th Ed., Elsevier, 2011, 1-23
3) ADASP position papers. In Rosai J. (Ed): Rosai and Ackerman's Surgical Pathology, 10th Ed., Elsevier, 2011, 2513-2522.
4) Consultation reports. In Lester SC (Ed): Manual of Surgical Pathology, 3rd Ed., Elsevier, 2010, 40-44
5) Patoloji Dernekleri Federasyonu, Patoloji Konsültasyon Yönergesi. Available from: http://www.turkpath.org.tr/files/turkpath6.pdf (Cited 2012 Aug 08)
6) Rosen PP. Special report: Perils, problems, and minimum requirements in shipping pathology slides. Am J Clin Pathol 1989, 91:348-354. [ Özet ]
7) Gutmaa EJ. Pathologists and patients: Can we talk? Mod Pathol 2003, 16:515-518. [ Özet ]
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