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Using the microscope as a crystal ball.


Robledo F. Rocha

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Like any other pathologist, I often receive specimens without adequate clinical information on request form. As a consequence, my mobile phone has been a working tool as essential as my microscope.

A few days ago I phoned up to a first-year dermatology resident just to ask about the withhold information concerning a worrisome melanocytic lesion. While I was waiting for her answer, I was thinking of how to explain to a neophyte, as kindly and didactically as I can be, that, in dermatopathology, detailed clinical information is equivalent to the gross description, bearing in mind that even some experienced dermatologists fail in the same way.

“I was unaware that you expected all those information to be provided for me”, she sincerely admitted. “Once I referred to you a specimen without any clinical information and you not only diagnosed erosive mucosal lichen planus, but also you indicated that patient might got hepatitis C virus infection. Your hypothesis was subsequently confirmed and thereafter I came to believe you use the microscope as a crystal ball!”

Then I spent a bit more time trying to persuade her that pathologists do not have extrasensory perception. Most importantly of all, the required information was transmitted at last.

Did I have success on my attempt? Did she learn the necessity of adequate clinical information on request form? I will only find out for sure on the next occasion she refer a specimen to me. At least I was successful at preventing serious complications of hepatitis C virus infection, like cirrhosis and hepatocellular carcinoma.

It doesn’t matter how many times the hypothesis won’t be subsequently confirmed, but the patients who will benefit from it. Including, in a final note of the report, possible associations, even though questionable or infrequent ones, may help diagnosing, for example, unsuspected diabetes mellitus in a case of generalized granuloma annulare or occult gastric adenocarcinoma in a case of acanthosis nigricans. As if the microscope had been used as a crystal ball.


REFERENCES

1) Kwittken J. Clinical dermatology: an exercise in gross dermatopathology. Ariz Med. 1985;42:404-406.

2) 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;62:257–261.

3) Bull AD, Cross SS, James DS, et al. Do pathologists have extrasensory perception? BMJ. 1991;303:1604–1605.

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Dr. Richard Carr

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Superb!! It is great when one of our suggestions actually comes true - like the Muir Torre etc. I do worry sometimes though that because your clinical colleagues know you are so good they forget that you are also only human. I always try to re-iterate to them I may be right [u][b]most[/b][/u] of the time but please do question any diagnosis that does not fit clinically as I might have been having a bad day or even heaven forbid been looking at the wroing slide!
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