Pathology and laboratory medicine

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Re: Are pathologists to blame for H. pylori fiasco?

Dr. Dr. Brad H. brought up some very important and disturbing
questions regarding whether pathologists really give much
thought to what they are looking at every day.  H. pylori
was chosen as an example of something that was there for us
to see, but which went unheeded for decades until someone
made the connection between H pylori and gastritis.

Prostatitis may be another lesion that we see without
understanding.  Dr. Dr. Brad H. describes a friend of his with a
many year history of prostatitis, a rising PSA level and a
prostatectomy for what turned out to be a small focus of
cancer.  Are pathologists overlooking prostatitis just as we
overlooked H. pylori?  Are pathologists making adequate use
of the archived pathology tissue that must accumulate with
the many prostate biopsies performed each year?

It is very difficult for any pathologist to study a
biological problem that leads to some conclusion about the
causal relationship between an observed morphologic feature
and a particular disease process.  Just look at any
pathology journal.  You’ll see lots and lots of case
reports, reports of series of odd lesions, new morphologic
variants of old lesions, and studies of old lesions using
new laboratory techniques, but very few studies of basic
disease processes.  In two recent studies that came out of
our lab, we showed that most of the articles in the
pathology literature are unfunded works.  Furthermore, most
of the citations to articles in the pathology literature are
made to unfunded works.[refs]

Well designed studies that resolve questions of biologic
causality require time and money, two commodities in very
short supply.  There is ample literature showing that the
expectation of getting an investigator-initiated grant
is decreasing, the numbers of
young professionals receiving grants is decreasing, and
the expectation that Congress will be doing anything to
change this trend is decreasing.  Furthermore, University
Hospitals, once a santuary for unfunded researchers, are
no longer in a position to carry out unfunded research.
University Hospitals are competing for low-bid managed care
contracts and there is very little slack for research that
extends from clinical observations. It is my general
observation that many academic centers are looking for ways
of decreasing their staffs.  They know that hiring a
pathologist with the hope that the pathologist will bring in
more than his/her salary in grant money is a long-shot these
days.  It is my feeling (correct me if I am wrong) that
Academic centers are trying to get maximal service work out
of their staff (by reducing staff size) and that research
pursuits are falling more or less into the realm of a diversion
or hobby.  Regarding the current crop of pathology
residents, there seem to be very few who are interested in
issues of experimental design, statistics, critical review
of research articles related to disease causality … maybe
they’ve seen the writing on the wall.

Regarding the role of prostatitis in elevated PSA’s and
prostatic carcinogenesis, our lab recently published several
articles on the high PSA issue.  In one of our
submissions, we noted that we were seeing some very high PSA
levels in patients with negative prostate biopsies.  We
tried to list the non-cancer causes of elevated PSA and
included prostatitis and prostatic infarction (a not
uncommon sequela of prostatic hyperplasia).  The reviewer
objected, saying that we had not provided any experimental
evidence to show that these conditions resulted in elevated
PSA.  The paper was rejected, and it took us about a year to
get it accepted elsewhere (and another year to see our papers in
print). [refs] My point is, reviewers can be very harsh when it
comes to casual observations, and unless the investigator is
ready and willing to go all the way to experimentally satisfy
the objections of reviewers, it can be  very difficult to use
journal publicatons as a forum for any kind of speculation.

Dr. Dr. Brad H. also made reference to how well pathologists use the
vast amount of tissue received in their laboratories.  This
issue is near and dear to my heart.  For several years, Dr.
Bill Moore and myself have been crusading for the use of
pooled surgical pathology and autopsy databases that could
be used for epidemiologic studies, as well as studies
related to disease processes.[refs]  Each record
would consist of a case identifier (encrypted to hide
patient identification), demographics (age, gender, race),
and encoded diagnoses (SNOMED or ICD).  As it stands now,
pathologists don’t have access to anyone’s pathology data
other than their own, and many pathologists don’t have much
access to their own data (because they do a bad job at
SNOMED coding, or their search software is bad, or their
LIS just doesn’t support database studies).  So yes, many
thousands of prostate biopsies are performed in this
country, but each pathologist’s access to all those biopsies
is very limited.

Finally, regarding the pathologist’s seemingly perfunctory
remark about Dr. Dr. Brad H.’s friend’s prostatitis,
(in the surgical pathology report)  the pathologist
is seldom given the full history of the patient who comes to
prostectomy.  The pathologist must fulfill his main task of
documenting cancer and providing a description of the extent
of disease.  Unless the surgeon conveyed an interest in
prostatis, it would be unlikely that the pathologist would
make much of an issue about inflammation.  However, since
only a small focus of cancer was found in the prostatectomy
specimen, it would seem prudent to review the original
biopsy.  Granulomatous prostatitis can mimic cancer.

In conclusion, are pathologists now in a position to make
new, clinically useful observations based on observations
on tissue samples received in the course of their practice?
Mmmmmmm, maybe not.  But at least pathologists today have a
forum for observations (half-baked or otherwise)…. THE
INTERNET.  Nothing stops anyone from writing a Newsgroup
letter asking for corroboration or input from pathologists
and other health professionals.  Even if the feedback isn’t
always constructive, it is always fast.



Moore GW,  Berman JJ.  Automatic SNOMED Coding.
Journal of the American Medical Informatics Association
(JAMIA), Symposium Supplement 1994 and the Proceedings
of the 18th Annual  Symposium for Computer Appllications
in Medicine (SCAMC),  pp 225-229, 1994.

Berman JJ, Moore GW, O’Neill T, Liebelt A,
Saffiotti U. Registry of Experimental Cancers of the
National Cancer Institute: a database resource for
cancer research.  American Journal of Pathology
142:351-352, 1993.

Borkowski A, Berman JJ, Moore GW.  Unfunded
pathology research: its frequency and success in
the scientific literature. Modern Pathology
5:577-579, 1992.  This article was abstracted in
the Yearbook of Pathology and Clinical Pathology,
1994, eds. WA Gardner, Jr., BD Bennett, JB Cousar,
AJ Garvin, GF Worsham, Mosby, St. Louis, p 5, 1994.

Moore GW, Berman JJ.  Automatic versus manual
SNOMED coding: quantitating the differences.  Am J
Clin Pathol 101:253-256, 1994

Berman JJ, Moore GW, Alonsozana ELC, Mamo GF.
Elevated prostate specific antigen and the negative
prostate biopsy.  Southern Medical Journal,
87:290-291, 1994

Berman JJ, Borkowski A, Rachocka H, Moore GW.
The impact of unfunded research in pathology,
surgery and medicine. Southern Medical Journal
88:295-299, 1995

Berman JJ, Alonsazana, Brown L, Moore GW.
PSA screening for prostate cancer: lack of reduction
in Gleason scores. Modern Pathology 7:487-489, 1994

Berman JJ, Moore GW, Donnelly WH, Massey JK,
Craig B. A SNOMED analysis of three years’
accessioned cases of (40,124) of a surgical pathology
department: implications for pathology-based
demographic studies.  Journal of the American
Medical Informatics Association (JAMIA), Symposium
Supplement 1994 and the Proceedings of the 18th
Annual  Symposium for Computer Appllications in
Medicine (SCAMC),  pp 188-192, 1994
2:34-36, 1994

Berman JJ, Moore GW.  SNOMED-Encoded surgical pathology
databases: a tool for epidemiologic investigation. In press,


Anderson V, Lubowsky J, Cobham A, Greco MA,
Moore GW, Berman JJ.  Multi-institutional pediatric
AIDS autopsy database using natural language retrieval.
Mod Pathol 5:143A, 1993.

Moore GW, Hutchins GM, Berman JJ. Object oriented
programming system for autopsy retrieval.  Modern Pathol
5:100A, 1992 and Lab Invest 66:100A, 1992.

Borkowski A, Berman JJ, Moore GW.  Unfunded pathology
research: its frequency and success in the scientific
literature. Modern Pathol 5:100A, 1992 and Lab Invest
66:100A, 1992.

Moore GW, Hutchins GM, Berman JJ.  Object-oriented
retrieval system for the Johns Hopkins autopsy database.
MedInfo 92, Lun KC, Degoulet P, Piemme TW, Rienhoff, eds.
Elsevier, Amstedam, 1992, p 1613.

Berman JJ, Moore GW, Alonsozana ELC, Mamo GF.  Elevated
prostate specific antigen and the negative prostate biopsy.
Modern Pathol 6:56A, Jan., 1993

Berman JJ, Borkowski A, Moore GW. (letter appearing
under correspondence title Unfunded research? I am Shocked,
Shocked!) JAMA July 7, 270:44-45, 1993

Berman JJ, Borkowski A, Moore GW. Correspondence
re: T.J. Flotte.  Research by Pathologists in the United
States: analysis of publications.  Mod Pathol 6:484, 1993.
Modern Pathol 7:887-888, 1994.

Berman JJ, Borkowski A., Rachocka H., Moore G.W.
Unfunded research by pathologists, internists and surgeons.
Modern Pathology 7:69A (inclusive), 1994

Berman JJ, Moore G.W., Alonsozana E.L.C., Brown L.A.
Prostate specific antigen screening for prostate cancer:
no drop in Gleason scores.  Modern Pathology 7:162A
(inclusive), 1994

Berman JJ,  Moore GW.  PSA screening for prostate
cancer: lack of reduction in Gleason scores. (Letter)
Lancet 343:728-729, 1994

Berman JJ,  Moore GW,  Donnelly WH,  Massey, JK,
Craig B.  SNOMED Analysis of 40,124 Surgical Pathology
Cases.  Am J Clin Pathol 102:539-540, 1994

Berman JJ,

posted by admin in Uncategorized and have Comment (1)

One Response to “Re: Are pathologists to blame for H. pylori fiasco?”

  1. admin says:

    This is in response to J.J. Berman’s post, which was in response to Brad
    H.’s post (chic… on the role of pathologists in
    discovering new pathogenetic mechanisms, especially failure thereof in
    H. pylori and potential thereof in prostatitis.
    (I would have liked this to be a thread under Dr. Berman’s post, but
    don’t know how to do that; I’m using Netscape 1.1N, if anyone can
    enlighten me.)

    Dr. Berman said what I was thinking of saying in response to Brad H.’s
    post, and in a much more informed way than I could have.  I look forward
    to reading some of the articles in his reference list.

    I agree that path departments in academic medical centers are being
    pushed to do more service work with less and less people (not just
    pathologists), and there is little time, and less resources, available
    to do (unfunded) exploratory research of questions such as those raised
    in Brad H.’s post. This seems sad to me, and is a narrowing of the role
    of pathologists in medicine.  I don’t have an answer, though, other than
    that academic medical centers must be subsidized for their training and
    research role.  The alternative, to be funded to do research, seems more
    and more difficult to do and still actively practice medicine; so I will
    probably do the former and not the latter.

    Regarding the pooling of pathology databases, this certainly would be a
    good thing, and not conceptually difficult (though perhaps some
    questions regarding protecting patients’ rights to privacy) – probably
    the majority of larger groups use a computer system and so
    machine-readable report text should be available; even if it is not
    SNOMED-coded, either coding could be automatically done or one could
    resort to full-text searches.  But without tissue banks, slide review,
    or other patient data, how much could one learn?

    Peter Wang, M.D., Ph.D.
    MRC Centre for Protein Engineering,
    Hills Road, Cambridge, CB2 2QH, England

    Tel (01223) 402100  (international calls +44-1223-402100)
        (01223) 402104  (direct number)
    Fax (01223) 402140