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Issues in Dermatopathology
In the October 2005 issue of the Journal of American Academy of Dermatology, four esteemed dermatologists share their views on the issue of dermatologists interpreting skin biopsies performed upon their patients. Dr. Bernard Ackerman, director emeritus of the Ackerman Academy of Dermatopathology, leads the salvo with a strongly worded statement emphatically declaring that "self-referral of a professional (a dermatologist) to an amateur (a self-styled dermatopathologist) calls seriously into question the authenticity of professionalism."
Dr. Ackerman avers that the real motive for dermatologists reading their own slides is neither altruistic nor academic but to their own self-interests and financial gain.
The next three editorials, by Drs. Moy, Glogau, and Grant-Kels, rebut various points put forth by Dr. Ackerman. Each of their editorials make fascinating reading and propose equally valid points.
I truly believe that dermatologists are qualified to read out their own biopsy slides. My question to dermatologists is, Why would you want to do this?
I spend over 8 hours a day reading biopsies. I review over 20 journals a month (dermatology and pathology journals). At least two of these (American Journal of Dermatopathology and Journal of Cutaneous Pathology) are focused exclusively on dermatopathology. If I only read the clinical dermatology journals and these two latter journals, I would still miss a great deal of the dermatopathology literature. Look at the left hand column of this web page; I have listed the titles of articles with relevance to dermatopathology, all published during the past year in the American Journal of Surgical Pathology, a must-read journal for surgical and general pathologists. Even missing a few of these would leave me sorely lacking in dermatopathology knowledge...and this is only one journal title. As I perused my other pathology journals, I quickly counted over 40 titles of articles with similar relevance to dermatopathology, all published within this past year. This is one reason I use this forum as a means to keep my pathology and dermatology colleagues current on these key articles.
Every dermatologist must ask themselves whether they apply the same high standards to keeping up with dermatopathology as they do in keeping up with the latest therapeutic options for dermatologic conditions.
It is gratifying to read an article describing a new disease entity and then using that knowledge shortly thereafter to make the diagnosis. Such was the setting for an earlier case of Pigmented Paget's Disease of the Nipple which I first presented on this website. The article describing this unusual disease entity came out 3 weeks prior to my receiving a biopsy of this same condition. Even the pathologists who later reviewed this case at a tumor board at a major teaching university in Los Angeles were unfamiliar with the entity. I submit this example not to boast but rather to stress that I am continually humbled by the immense amount of information that must be digested by anyone practicing this craft.
I have worked with dermatologists who read their own slides, dermatologists who are both board-certified in dermatopathology and who are not. I also work with pathologists who see a high volume of skin biopsies and are not board certified in dermatopathology, and, of course, pathologists who are board-certified in dermatopathology. In all of these practice settings, I can confidently state that if these individuals see a large volume of dermatopathology and keep current with conferences and the dermatopathology literature, their diagnostic skills are excellent. The key is IF. The aforementioned individuals who are excellent do indeed keep current with their skills, an admirable and arduous task.
These same high standards must apply to every specialty in medicine. I bemoan the competition and turf battles that have arisen between pathologists and dermatologists and other specialists. Yet, this is the current state of our practice and adapt we must.
When you have reviewed these articles and discussion, please comment by email which I will post anonymously.
Submitted by Paul K. Shitabata, M.D.
I didnt realize how heated this topic was. Although very entertaining and dramatic, it was disappointing to see professionals in a common field throw such sharp daggers at each other. With colleagues like that who needs enemies. No wonder why physicians have a hard time sticking together. Dr. Ackerman painted such an ugly picture of dermatologists' intentions and it seems likely he caused more unrest than solve any issue with his article. I appreciated Dr. Richard Gordon Glogau's argument most since he gave credit to both the dermatologist and dermatopathologist and likened the relationship between them to that of a cardiologist and interventionalist in which more serious cases are reffered to higher level specialists. Your argument of "how do you know when you don't know", is a risk that dermatologist who read their own slides must have to take seriously and as you mentioned must mantain their level of competency by staying up to date in dermatopathology, especially within the realm of what they are willing to read themselves and not refer to a specialist. It's likely, though, that my opinions may change after a few years of training since my level in dermatology and especially dermatopathology is less than novice.
Thanks for posting Dr. Ackerman's letter and the three subsequent replies. I particularly liked your angle on this issue too. You should consider submitting your letter. I know some excellent dermatologists who don't read their own slides, and they agree with your statement completely. Why should they risk it, like you said. In fact, the dermatologists who do not read their own slides tend to insist that their cases are only read by dermatopathologists, and not regular pathologists. So I think this argument could apply to the many pathologists who are not board-certified in dermpath but who are reading skin biopsies everyday, like myself. Maybe regular pathologists should also not be reading skin biopsies! I think I am fairly competent in reading skin biopsies on my own, but I know I wouldn't do it if you were not around for me to show cases to on a regular basis. PS. Bernie Ackerman is the only person who can write like that and still be considered sane.
First Posted on October 21, 2005
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