Building Consensus

by Stacey E. Mills, MD

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A few months back I wrote about the pluses and substantial minuses associated with going to subspecialty or modified subspeciality signout in surgical pathology. If you missed that one, dig back through the blog postings and check it out.(I would point you to the exact posting with a link, but then you might miss scanning all of the other great posts!) One of the several driving forces behind subspecialty signout is the clinicians’ desire to have a trusted expert review their cases. Another is realistic pathologist concerns regarding keeping up with all of the changes in the broad and ever expanding field of surgical pathology.

I won’t review the problems associated with subspecialty signout, especially in smaller or medium-sized academic practices, but I would like to briefly discuss what I think is an excellent way to address many of the pressures on surgical pathologists to subspecialize, without actually subspecializing and thus avoiding the associated problems; the institution of a daily consensus conference.

Although we utilize this in a medium-sized academic department, it can work equally well in a multi-person private pathology practice. Here’s how it works for us. All available faculty and residents gather around a multiheaded scope with a projection screen at 3:00 in the afternoon. Faculty members sit around the multiheads and residents take any available additional multihead seats or view the cases on the monitor. Faculty on service present the day’s problematic or highly interesting cases to the group, with the associated resident providing background history. The presenting faculty member will give his or her thinking about the case and a brief discussion will then take place about the validity of the diagnosis, alternate possibilities, additional studies needed, etc. Each case takes 5 minutes or less and the entire conference typically lasts 30 minutes or less. If more time is required for an individual case, the case is brought back with additional studies or concerned faculty may elect to view the case in more detail on their own scope.

The end point of the case should be a diagnosis that the group can unanimously support. Teaching points are often emphasized to the residents, particularly once diagnostic agreement is reached, but the focus is on making this a working conference directed towards optimizing patient care. Every case presented at the conference has a note attached to the diagnosis that, “This case was reviewed at the daily surgical pathology consensus conference and the group agreed with the diagnosis.” Of course, a consensus diagnosis may not be a specific diagnosis as in many problematic cases a specific diagnosis cannot be rendered.

The advantages of this conference are many. To list just a few:

Although resident/fellow teaching is not the primary function of the conference, it is an excellent venue to further residents’ education, particularly with regard to real time approaches to problematic cases.

The conference helps refine and unify (as much as is possible) the department’s diagnostic criteria for a variety of problematic areas. For example, all Barrett’s esophagus cases with any suspicion of dysplasia are reviewed at the conference. This gives the rest of the faculty a chance to hone their dysplasia criteria to closely match those of the departmental GI gurus.

The conference is the perfect forum for discussing the clinical implications of what may seem to pathologists to be minor differences in terminology. As with many institutions, we have a large number of interdepartmental specialty conferences and the pathology faculty member who attends each of these conferences has first hand knowledge, which can be shared with the group, of the current clinical thinking regarding the diagnosis -> therapy paradigm.

The conference provides more than a little medicolegal support by flagging the case as problematic and indicating that it was reviewed by a group of faculty who agreed with the diagnosis. It’s hard to argue that standard of care has been violated when a group of half a dozen or more pathologists has agreed with the diagnosis.

The conference is a genuinely enjoyable experience giving everyone the chance to see interesting and challenging cases, swap stories about their day, etc. Try it…. you’ll like it.


(originally posted on the Pathology Network by Stacey E. Mills, MD, here: )

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