Dr. Thomas Wheeler entered the following blog (below) on Medscape about a week ago.  There is a simple solution to all of this that negates time, cost and risk for both referring and consulting pathologist/institution.  The answer of course in two words is digital pathology. Particularly with the ever increasing power of cloud computing.  Simply, the referring institution scans and uploads the slides, regardless of patient, physician or pathologist request for consultation or second opinion.  The referring pathologist uses the cloud to review the slides, render his or her report and complete the case.  This negates the need for referring hospital to package, send, check receipt of delivery and record receipt of slides upon return and account for any loss or damage upon return.  The consulting hospital is also spared the need to take receipt of case, inventory contents, accession and maintain slides in original number and condition.  Both sides are spared the cost and resources to maintain either send outs or consults.  A record of slide(s) reviewed is kept and data with regards to images reviewed can be maintained.  Perhaps most importantly, unlike the courier model, both the referring and consulting pathologist have a mechanism to look at the same slide(s) at the same time.

If the case requires additional immunohistochemical stains, these too may be done by referring hospital and later uploaded for review thus negating need to send tissue blocks and allowing referring hospital to capture the TC with potentially less delay than sending the block which would add another day on top of the time to do the stain(s).  This of course will not work depending on size and skill of referring laboratory but the model works the same when possible and requires courier if necessary. 

Lastly, cases of interest for potential further study or teaching are maintained where several participants can have access while maintaining access and patient privacy. No slides leave the originating department.

For reference labs this is common practice - that is hosting images for review by others.  It negates need to overnight slides when technical services are required and provides a shared image for both the reference lab and the client if discussion or repeat testing is needed.

More labs can and should do this on both ends of the slide consult model.  Why is this not more common?

Several reasons, among them -- cost of scanners, resources to scan and upload slides and maintain control and access, consultants reluctant to adopt digital pathology and/or referring pathologist reluctant to adopt, receiving pathologist may want to do his/her "own stains" and well-established processes in place that facilitate courier models in nearly every laboratory/hospital.  The first is really the still remaining barrier for some labs, the others are largely psychological and technical which requires a culture of change and degree of trust to allow for this kind of slide exchange.

Courtesy of Dr. Thomas Wheeler via Medscape:

Now more than ever, patients seek definitive treatment for cancer or other serious conditions at a major medical center, one different from the institution where the diagnosis is made.  This necessitates transfer of medical records, radiology reports and yes -- the pathology report and associated microscopic slides.  Typically, the slides are reviewed at the final institution where a pathology report on the referred slides is generated.  In most cases the original laboratory requests that the slides be returned along with a copy of the new pathology report.  Problems arise at this juncture.  The new institution may retain the slides or fail to return them in a timely fashion.

Case law is fairly clear that the original slides and blocks are the work product for the originating laboratory, a fact that can be construed to mean ownership.  Therefore, the original laboratory has the legal right to request/demand return of their slides.  After all, they are required to keep these slides for purposes of accreditation and by statute.

So why would the final institution want to keep the slides?  There are several reasons – teaching, clinical research, saving the expense of the return and medicolegal issues.  The first two are relatively straightforward, especially in institutions that have a pathology residency program and an active clinically-oriented research program.  The expense of returning the slides, even by standard mail, is not trivial when multiplied by hundreds or thousands of times over the course of a year.

The medicolegal issues may not be apparent but go something like this:  the pathologist making the last diagnosis on which the treatment decisions are made is ultimately the one who is legally liable in the case of misdiagnosis, regardless of the diagnosis of the original pathologist.  I remember distinctly a case in point.  An older woman had an enlarged neck node removed that the pathologist in the small town community diagnosed as metastatic papillary carcinoma of the thyroid.  The patient was referred to a large tertiary care medical center for additional surgery.  The pathologist at that academic institution “confirmed” a diagnosis of metastatic papillary carcinoma of the thyroid so the patient underwent a total thryoidectomy.  No cancer was found in the thyroid and it was determined subsequently that the women had an occult papillary serous carcinoma of the ovary.  Both pathologists were sued.  The jury found the academic pathologist to be negligent but did not hold the original pathologist responsible, even though both had made the same diagnosis.  The point is a matter of law – the academic pathologist’s action were the “proximate cause” to the patient’s injury.  It really didn’t matter what the original pathologist called it because the treatment plan was based only upon the last diagnosis rendered.  

Given the foregoing vignette, the pathologist at the final institution may feel that he/she should retain (rather than return) these slides, as he/she has now assumed all of the legal risk associated with the diagnosis.  If there is a problem with the patient’s subsequent diagnosis or clinical outcome the slides can easily be pulled and reviewed if they have been retained.  After all, the patient has left the primary institution and is now getting all the care related to this diagnosis at the new institution.  

Are your slides returned when requested?  Are they returned in a timely fashion?  Do you have a way to check off which cases have been returned v not so you can send reminders?  Do you prefer to send originals or recuts?