I Might Have Some Bad News: Disclosing Preliminary Pathology Results

Abstract

Cytopathology is a subspecialty of pathology in which pathologists frequently interact directly with patients. Often this interaction is in the context of fine needle aspiration (FNA) procedures performed at the bedside by the cytopathologist or by another clinician with the cytopathologist present. Patient requests for preliminary results in such settings raise fundamental questions about professional scope of practice and communication of uncertainty that apply not merely to pathologists but to all clinicians. In certain settings, cytopathologists may share preliminary diagnostic impressions directly with patients. Essential to these conversations is the need to articulate potential uncertainty about both the diagnosis and next steps. In addition, the involvement and notification of the referring physician is obligatory, both for care coordination and to ensure that patients receive a consistent message. CaseDr. H is a cytopathologist who performs and interprets fine needle aspirations (FNAs) of suspicious lesions, typically at a patient's bedside. Often, a radiologist obtains the sample with the help of radiologic image guidance, and the cytopathologist examines a portion of the sample in the form of Diff-Quik ® -stained smears under a microscope during the rapid onsite evaluation (ROSE), used primarily to assess whether a sample is adequate. This procedure can offer the opportunity to disclose a preliminary diagnosis. The remainder of the sample is subsequently processed by the lab after the conclusion of the procedure. A diagnosis is not given until the sample is processed by the cytopathology laboratory and all the slides are evaluated under the microscope. If necessary, additional tests are ordered on this final sample prior to diagnosis. One morning, Dr. H is attending his patient, Mr. Smith, a man with a history of melanoma who presented with a new soft tissue lesion in his abdomen. Mr. Smith's oncologist has consulted radiology for an ultrasound-guided