A prior study in this journal, “Clinicians Are from Mars and Pathologists Are From Venus,” demonstrated that clinicians can erroneously interpret pathology reports up to 30% of the time. After noticing reporting heterogeneity in the setting of inflammatory bowel disease (IBD), we speculated that a standardized synoptic report could improve gastroenterologist comprehension.
To investigate the effect of a synoptic table on gastroenterologist comprehension of IBD pathology reports.
We recruited gastroenterology fellows and faculty to participate in this study. All participants were given 6 pathology reports and asked if the following were present: active inflammation, chronic inflammation, IBD, and dysplasia. Participants were also asked to rate their confidence. After a 6-week washout period, the same questionnaire was distributed with a synoptic report. We performed paired t-tests to compare the mean accuracy and confidence scores between the preintervention and postintervention responses.
A total of 39 physicians participated: 9 fellows and 30 faculty. Mean accuracy scores were higher after the intervention (0.81 versus 0.86; P < .001). Mean confidence was also higher after intervention, but this was not statistically significant (3.91 versus 3.98; P = .24).
The improvement in accuracy scores after intervention confirms that clinician comprehension improved with the synoptic table. A synoptic report may provide a standardized way of communicating diagnostic information to clinicians in the setting of IBD and potentially other inflammatory conditions.
No matter how much time a pathologist spends painstakingly detailing their findings in a report, the fact remains that their report does not directly help the patient. Instead, it informs the treating physician as to the patient's disease state and indirectly guides their management. As such, pathology reports are only as helpful as they are comprehended by the clinician.
Alarmingly, clinicians can misunderstand the content of pathology reports up to 30% of the time.1 This unsettling finding was first reported in this journal more than 20 years ago by Powsner et al1 in their whimsically titled article “Clinicians Are From Mars and Pathologists Are From Venus.” In their study, they gave trainee and attending physicians open book quizzes regarding the content of pathology reports testing their comprehension and the impact of a streamlined format on comprehension. Other studies have also noted significant self-reported gaps in pathologist-clinician communication2 or discrepancies between reported pathologist frozen section diagnoses and recorded diagnoses from operative reports.3,4
In our practices, we have noticed a wide diversity of phrases and terms used by different pathologists to sign out biopsies from inflammatory bowel disease (IBD) patients and wondered if this inconsistent phrasing could hinder comprehension. For example, some pathologists may concisely say, “Chronic active colitis,” whereas others may give a more descriptive and detailed diagnosis of “Active colitis with crypt abscesses, basal lymphocytosis, and crypt architectural distortion.” Given the potential shift to “histologic remission” as a treatment target,5 fully understanding IBD pathology reports is increasingly important for patient management.
We speculated that a standardized synoptic report, as is done with cancer reporting,6 used by all pathologists, could improve communication. To test this, we constructed a study similar to that by Powsner et al1 where gastroenterologists' comprehension of pathology reports without synoptic reports was compared to their comprehension of the same pathology reports with a synoptic report.
MATERIALS AND METHODS
This was a prospective study performed at 2 centers—an academic tertiary care referral center (UC Davis Health in Sacramento, California) and a Veterans Affairs hospital (VA Mather in Rancho Cordova, California). Adult and pediatric gastroenterology (GI) faculty were recruited to participate, as were adult GI fellows. There were no exclusion criteria.
All participants were given a questionnaire, either electronic or paper, with 5 questions (Figure 1) associated with 6 different sample pathology reports (Figure 2) asking the following questions: is active inflammation present, is chronic inflammation present, are the histologic findings representative of IBD, and is there evidence of dysplasia? Participants were also asked to rate their confidence in their answers on a 5-point Likert scale.
Sample pathology report. An example of 1 of the pathology reports. Six reports were constructed to represent the diversity of terminology encountered in practice (see supplemental digital content for additional reports).
Sample pathology report. An example of 1 of the pathology reports. Six reports were constructed to represent the diversity of terminology encountered in practice (see supplemental digital content for additional reports).
The 6 simulated pathology reports were designed by a gastrointestinal pathologist (KS) to reflect the variety of diagnostic terms that he has observed in practice. His intended answers were used as the gold standard for comparison. All 6 reports are included in the supplemental digital content at https://meridian.allenpress.com/aplm in the July 2024 table of contents. No other clinical information was provided.
We collected data on participant characteristics including career status (trainee or faculty), years in practice, additional training in IBD, and number of IBD patients seen per month.
After a 6-week washout period, the same questionnaire with the same sample reports was distributed, this time with a corresponding synoptic table summarizing the findings in a standardized format (Tables 1 and 2). A single synoptic report was included for each case after the diagnostic lines in a comment section summarizing the worst findings present in the biopsy series.
We performed paired t-tests to compare the mean accuracy and confidence scores between the preintervention and postintervention responses. We also performed subgroup analysis based on career status, as well as number of years in practice and average number of IBD patients seen per month using linear regression models. All statistical data treatments were performed with the R statistical programming environment (version 3.6.1, R core team, 2019). All data underlying this study are original and incorporated in this article.
RESULTS
A total of 39 physicians participated in our study: 9 fellows and 30 faculty. Faculty were in practice, defined as years after fellowship graduation, for an average of 11.3 years (range, 1–35 years; SD, 9.8 years) and saw an average of 16.3 patients with IBD per month (range, 0–100 patients; SD, 24.1 patients). Fellows saw an average of 7 patients with IBD per month (range, 0–16 patients; SD, 6.3 patients). Table 3 shows the accuracy and confidence scores for each question before and after the inclusion of the synoptic table. The accuracy rate for individual reports ranged from 62% to 97%. The lowest accuracy rates were seen in a report designed to show equivocal, mild chronic changes (62%, report 5) and a report designed to show acute, likely infectious, colitis (67%, report 3).
Accuracy and Confidence Scores for Each Report Before and After the Addition of the Synoptic Table
The average accuracy scores were higher overall in the postintervention group (0.81 versus 0.86; P < .001; Figure 3, A). Average confidence was also higher after intervention, but this was not statistically significant (3.91 versus 3.98; P = .24; Figure 3, B).
Comprehension questionnaire results. A, Comprehension accuracy without a synoptic report (“Pre,” blue) and with a synoptic report (“Post,” red). B, Comprehension confidence without a synoptic report (“Pre,” blue) and with a synoptic report (“Post,” red).
Comprehension questionnaire results. A, Comprehension accuracy without a synoptic report (“Pre,” blue) and with a synoptic report (“Post,” red). B, Comprehension confidence without a synoptic report (“Pre,” blue) and with a synoptic report (“Post,” red).
In subgroup analyses based on career status, fellow accuracy and confidence improved numerically in the postintervention group compared with the preintervention group (0.79 versus 0.81 and 3.44 versus 3.50, respectively), but this was not statistically significant (P = .42 and P = .28, respectively). Attending accuracy and confidence similarly improved in the postintervention group compared with the preintervention group (0.81 versus 0.88 and 4.04 versus 4.13, respectively). This was not statistically significant for confidence scores (P = .25), but was statistically significant for accuracy (P < .001).
In additional subgroup analyses using linear regression models, there was no clear linear relationship between accuracy (P = .65) or confidence scores (P = .87) and average years in practice. Similarly, there was no clear linear relationship between accuracy (P = .90) or confidence (P = .89) and the average number of IBD patients seen per month.
DISCUSSION
Communication gaps between pathologists and clinicians are a challenge that has been described by some as “a problem older than the hills,”7 but that has nevertheless been little studied and had few efforts made to mitigate them.1,8 Our study shows that the addition of a standardized synoptic report improved comprehension of pathology reports by gastroenterologists by 5%. Confidence scores were also higher in the postintervention group, although this was not statistically significant.
Reassuringly, our study showed a higher rate of baseline comprehension, 81%, compared with the 70% seen by Powsner et al,1 which further climbed to 86% with the addition of the synoptic report. This higher comprehension rate may reflect our subspecialty setting (in contrast, Powsner et al1 studied general surgery staff), the larger size of our study, and higher average years of experience among study participants, with most of our participants being seasoned attending physicians. Nevertheless, there is clearly room for improvement in both correctness and confidence, and it is vexing that comprehension does not approach 100%.
Generally, efforts to improve comprehension could focus on either report preparation or digestion. We chose to focus on trying to improve report comprehension by standardizing report preparation after noticing a bemusing diversity in the verbiage specifically used in IBD reports that we speculated could lead to inconsistent comprehension by gastroenterologists. Although standardizing biopsy “top line” diagnoses is one method that could be used to regulate reporting, knowing that some pathologists can be quite particular and possessive of their diagnostic lines, and that altering practicing physician behavior is sometimes like “herding cats,”9,10 we speculated that adding a supplementary table would face fewer barriers to implementation in the real world. Indeed, pathologists are very familiar with this format because analogous synoptic reports are widespread in the reporting of cancer.6
Although several indices for measuring histologic IBD activity have been proposed, none have been widely adopted and fully validated, and furthermore, there are no indices used for both Crohn disease and ulcerative colitis.11,12 So, we created a synoptic report for this study that incorporated elements from one of the most validated indices used in ulcerative colitis, the Robart Histopathologic Index,13 as well as other elements, such as architectural changes and dysplasia, that we thought needed to be reported consistently (Table 1).
Given the preliminary findings from this study, a simplified synoptic table has been introduced in our daily clinical practice with widespread support among both pathologists and gastroenterologists. Our “Colitis Synoptic Table,” as we call it, is included in any case where there is current colitis or a past history of colitis/IBD. A single synoptic report is included in a comment section for each case summarizing the worst findings present in the biopsy series. Our table has also been codified and streamlined into an electronic medical record fillable form that generally takes less than 20 seconds to complete.
Lucidly conveying the detailed findings in colitis and IBD is of increasing importance, with the growing evidence supporting a shift toward “histologic remission” as a treatment target.5 Increasingly, gastroenterologists need to consider (and therefore understand) the fine details of the histologic findings while deciding therapeutic interventions. Separately, when making an initial diagnosis of IBD, gastroenterologists are reassured by clearly knowing that there are histologic findings of chronic damage (such as a basal lymphoplasmacytosis and/or architectural changes) because this decreases the likelihood of an infectious colitis clinically mimicking IBD.
We believe that our study exposes a gap in the reporting of nonneoplastic surgical pathology and simultaneously raises a possible solution that heretofore has been largely restricted to cancer reporting. This could serve as a jumping-off point for the College of American Pathologists, or other advisory and/or subspeciality groups, to establish international standardized reporting of inflammatory cases to improve pathologist-clinician communication.
Interestingly, comprehension accuracy rates varied dramatically between the sample reports, with some reports having very high levels of comprehension (for example, report 4, with a 97% accuracy rate that improved to 98% with the synoptic report) and others having low levels of comprehension (for example, report 3, with a 67% accuracy rate that climbed to 71% after the inclusion of a synoptic report). This study was not designed to evaluate differences in diagnostic “top line” phrasing comprehension, but the 2 reports with the lowest comprehension were notably reports without straightforward active IBD, because 1 case was designed to be an active colitis of probable infectious etiology and the other was designed to show equivocal chronic changes without active colitis. The lower comprehension in these cases may be due to our participants having an IBD-biased “tunnel vision” in this setting and/or decreased comprehension of the histopathologic differential diagnosis of IBD. Future studies could delve into communication at this important fork in the diagnostic road of IBD versus non-IBD. It is possible that additional free text commentary or additional table fields could improve diagnosis at this important juncture.
Strengths of our study include its prospective design with no attrition of questionnaire responders on follow-up. The study was also designed and executed by practicing gastroenterologists in addition to a pathologist, which allowed for shared perspectives between specialists and increased clinical applicability. To our knowledge, no similar study has been conducted that evaluates gastroenterologist comprehension of IBD pathology reports.
The weaknesses of our study include its 2-center design and relatively small sample size, especially in the fellow subgroup. Furthermore, our study is specific to an academic setting with several gastroenterologists subspecializing in IBD as well as GI pathologists. Thus, it is possible that our methods cannot be easily and seamlessly extrapolated to community hospitals or nonacademic clinical practice settings.
In summary, increased standardization of pathology reporting with a synoptic table for IBD/colitis improves communication of diagnostic information to clinicians, allowing them to more easily “speak the same language” and hopefully provide better care for patients. If successful, this sort of synoptic tool could even be considered for use in other nonneoplastic specimens, where similar breakdowns in communication may occur.