Tips for Communicating with Your Dermatopathologist

 

Tips for Communicating with Your Dermatopathologist
By Randie Kim, MD

This month, we will be discussing the requisition form as the primary form of communication between clinicians and dermatopathologists. The requisition form accompanies a biopsy specimen and ideally contains a specific clinical question for histopathologic interpretation, which is then sent back to the clinician to help guide management. Believe it or not, on average, 20 different handoffs can occur throughout the skin biopsy process (1).

What information is typically included on a requisition form? In a survey of 145 surveyed dermatologists (2), three elements were rated as “important” for the requisition form and included biopsy site location, size, and the clinical impression. In contrast, dermatopathologists identified 10 clinical elements that they felt were critical for the requisition form. These included age of the patient, any prior diagnoses, location, duration, morphology, clinical impression, any pertinent clinical diagnoses, the inclusion of photographs, and if it was a melanocytic process, any ABCDE criteria and whether it was a partial or complete sampling (3).

Already, we see a disconnect between what the clinician feels is important and necessary vs. the dermatopathologist. And there is some truth to that disconnect. When assessing dermatologists’ beliefs about the requisition form (2), almost 1/3 of respondents agreed or somewhat agreed with the statement “I am reluctant to add clinical information because I do not want to bias the dermatopathologist.” Similarly, 1/3 of respondents agreed or somewhat agreed with the statement “Pathologists should make a diagnosis without clinical information.”  

So, what if we viewed the requisition form as a transition of care document instead - similar to the handoff that you might give to night float or when you go off service. Are there measurable outcomes such as time to diagnosis, the need for additional tissue sections or stains, and rates of re-excision or re-biopsy that are directly related to the quality of the requisition form?

In a study examining 249 requisition forms (3), the authors found that for inflammatory disorders, 36% of cases underwent additional stains, 23% required additional sections, and 36% of cases took longer than 2 days to diagnosis if the requisition form contained 3 or more pieces of clinical information. Anything less than that, 81% of these cases required stains, 56% needed additional sections, and 87% of them took longer than 2 days to diagnose.

Another element that can cause confusion is the use of vague terminology. Examples include “neoplasm of uncertain behavior”, “lesion”, and “rule out.” In practice settings where pathologists did not have access to the electronic health record, just the term “rule out” led to more tissue sections, more stains, and ultimately, a longer turnaround time (4). Therefore, the quality of the requisition form can have a direct impact on healthcare utilization, patient safety, and patient satisfaction.

How can we improve the quality of the clinical information of the requisition form without making it overly burdensome for the clinician? Some have suggested the 5 “Ds” - description, demographics, duration, diameter, and diagnosis (5). For melanocytic lesions, there are 3 elements that dermatopathologists felt to be important, and that is the size, whether there was a history of trauma or prior biopsy, or if it was a partial or complete sampling (6). And if you really had to pick just one element, then the lesion diameter or size is the most critical. These are simple things that can greatly improve the quality of the requisition form.

Ultimately, your dermatopathologist is on your clinical care team and is there to help you put the pieces of the puzzle together. Help us help you!

 

References:

1.      Watson AJ, Redbord K, Taylor JS, Shippy A, Kostecki J, Swerlick R. Medical error in dermatology practice: development of a classification system to drive priority setting in patient safety efforts. J Am Acad Dermatol. 2013 May;68(5):729-37. doi: 10.1016/j.jaad.2012.10.058. Epub 2013 Jan 27. PMID: 23360864.

2.      Chismar LA, Umanoff N, Murphy B, Viola KV, Amin B. The dermatopathology requisition form: attitudes and practices of dermatologists. J Am Acad Dermatol. 2015 Feb;72(2):353-5. doi: 10.1016/j.jaad.2014.10.021. PMID: 25592344.

3.      Romano RC, Novotny PJ, Sloan JA, Comfere NI. Measures of Completeness and Accuracy of Clinical Information in Skin Biopsy Requisition Forms: An Analysis of 249 Cases. Am J Clin Pathol. 2016 Dec;146(6):727-735. doi: 10.1093/ajcp/aqw186. Epub 2016 Dec 27. PMID: 28028116.

4.      Abdou Y, Lohse C, Comfere NI. Use of the term "rule out" in requisition forms may cause diagnostic delays in dermatopathology practice. Int J Dermatol. 2017 Jan;56(1):86-91. doi: 10.1111/ijd.13403. Epub 2016 Oct 25. PMID: 27778322.

5.      Boyd AS, Neldner KH. How to submit a specimen for cutaneous pathology analysis. Using the '5 D's' to get the most from biopsies. Arch Fam Med. 1997 Jan-Feb;6(1):64-6. doi: 10.1001/archfami.6.1.64. PMID: 9003173.

6.      Waller JM, Zedek DC. How informative are dermatopathology requisition forms completed by dermatologists? A review of the clinical information provided for 100 consecutive melanocytic lesions. J Am Acad Dermatol. 2010 Feb;62(2):257-61. doi: 10.1016/j.jaad.2009.06.049. Epub 2009 Dec 5. PMID: 19962786.