To the Editor.—I read with considerable interest the paper by Gibson et al1 on the communication of certainty in surgical pathology reports. In this study, the authors performed a survey of pathologists (practicing and in training) and clinicians (practicing, in training, and allied health professionals). This is an interesting study with intriguing results.
The authors duly acknowledge that performing multi-institutional surveys without considering institutional structures provides confusing results. Limiting the survey to physicians participating in multidisciplinary tumor boards is biased and not inclusive. Also, including pathology residents (who are not independently responsible for generating final pathology reports), medical students, and allied health professionals (who may lack proper knowledge or experience and are not independently responsible for decision making) may confound the results. I acknowledge the non-staff clinicians' role in misunderstanding pathology reports by presenting their interpretation of pathology reports to the staff clinicians and by reflecting their opinion in patients' records.
In a regional survey, 17 pathologists and 225 clinicians (practicing in academic and private practices, and fellows) were queried.2 Eighteen modifying phrases (MPs) were included, and an alternative of “no modifying phrase” was added to distinguish presence of MPs in reports. The participants assigned a certainty range to each MP, and clinicians were asked if they offered definite treatment when confronting MPs. The pathologists used MPs in roughly 3000 pathology reports (out of 30 000 annual reports, about 10%) and preferred “suspicious for,” “cannot exclude,” “consistent with,” “suggestive of,” “favor,” and “diagnostic of.” There was discordance between pathologists and clinicians in interpretation of diagnostic of (P = .002), in keeping with (P < .001), likely (P < .001), suspicious for (P = .003), suggestive of (P < .001), and probably (P < .001). The discordance was irrespective of participants' subspecialty or experience. Pathologists and clinicians with >5 years of experience had higher awareness of the potential miscommunication and regularly contacted each other directly. Clinicians dealing with tumors also relied on tumor boards for clarification of ambiguity. It was concluded that pathologists should refrain from using controversial MPs. When an MP is necessary, adding explanatory comments on the reason of uncertainty is important, although only an estimated 30% of clinicians pay attention to the comments in pathology reports.
One troubling issue raised by Gibson et al1 is that only 50% of staff pathologists felt very comfortable writing pathology reports. It is unclear if this is due to uncertainty in diagnosis or medical-legal concerns. The authors state that excessive administration of MPs as defensive medicine practice is detrimental to the quality of reports and decreases the trust in the pathology team. There is a need for education of pathology trainees on report preparation skills.
In an effort to standardize reporting of certainty, we introduced a standard scheme for reporting certainty in pathology reports (SSRC-Path) to be added to the biopsy reports containing uncertainty. The final report will contain MPs, SSRC-Path score, and a SSRC-Path table (Table). This resembles the organic radiology report system (ie, breast imaging reporting and data system), and can improve communication of pathologic findings.
