Report writing within Histopathology training

Histopathologists produce reports that communicate the diagnosis to the clinicians. 

A good report is clear, concise, and clinically relevant. 

The text of the report communicates how the diagnosis was made:

a) to other pathologists reviewing your case – identify the key observations  - specific features present (or absent) - that lead to your diagnosis and exclude alternatives. Where there is a differential, your deductions that eliminate alternatives, or make them less likely (like mathematics, ‘show your workings’).  Even if the other pathologist doesn’t agree, they can see how you reached your diagnosis.

b) to the clinician - a clear statement of diagnosis, or differential diagnoses, on which the clinician bases further investigation/treatment.

Trainees learn to recognise most pathological processes/entities in the first 2 years of training.  Pathologists develop their reporting style over decades. 

Good report writing is central to histopathology training. 

It feels to trainees that different consultants in different specialties like to do things in different ways.  It’s risky to draft a report – it will probably be edited, or crossed out, uncomfortable for trainee (and consultant?) – better to wait and discuss the case first.  However, this leads to delay in practicing the important skill of report writing.

It would help to have a joint understanding of what is expected when trainees draft reports. 

My suggestions are:

Define stages of report writing

Trainees will move through stages 1-5 during their training – and will be at different stages for straightforward v. complex cases.  Try to move on to the next stage for as many cases as you can. Learn to handle straightforward cases quickly and efficiently – these are not ‘boring dross’ but are good for practicing on, and are a fact of life in all histopathology departments.  Because of the tertiary work and sub-specialisation in Leeds, there will always be some cases that are mainly handled by consultants, but they will be happy to share the experience with enthusiastic trainees.  

Stage 1. Trainee looks at slides, lists key features, discusses case with consultant, consultant writes report, trainee reviews slides and report and understands why it’s been written as it has. 

Stage 2. Trainee looks at slides, drafts microscopy report by hand, and discusses it with consultant, edits, and gets the report typed. (The secretaries need you to dictate, in this order: the clinical details, macroscopic description, microscopic description, ‘bottom line’ diagnosis and SNOMED codes ).  The printed draft report may be further discussed and edited with the consultant and then authorised.

Stage 3. Trainee brings case to consultant for checking with the report already typed on computer, and if discussion/editing likely, with a printed copy of the report.  They edit it together and sign out.  (Trainees can retain the edited paper copy of interesting cases in their portfolio).

Stage 4. Towards independent reporting (currently GI, skin, cytology) – for the cases in stage 3 where they would be confident to send the report out independently, the trainee writes the number and diagnosis on their independent evaluation list These are signed off on the list by the consultant at the time of authorisation.

Stage 5.  Trainee reports cases independently – refers to consultant when uncertain, or for cases on the list that require a consultant supervisor (see appendix).

How much detail in the report?

For trainees in year 1-2,

For trainees year 2-5,

  • Straightforward, common conditions where the diagnosis is clear – aim for concise reports including only key descriptors of tissue type and essential diagnostic features.
  • Unusual cases and cases where there is a differential diagnosis – read about the diagnosis, include key diagnostic features present and absent that lead to your diagnosis and eliminate differentials.  Describe them in a way that gives another pathologist/clinician insight into your thought processes.
  • Ensure that your report includes clinically necessary features – e.g. items in datasets for cancer resections, and for biopsies answer the question (written or implied) in the clinicians mind when they ordered this procedure.

Practicalities:

Cases are assigned to Consultant on booking in, trainee name added at cut-up or  according to rota.

Who types the reports?

The secretary to the consultant whose name is on the case, even for those reports done independently by trainees.  I.e. for skin cases, the consultant supervising that day’s cases; for other work, the secretary working for your supervising consultant. When the secretary is away, put your work in the tray near Jas’s desk in the office.

Typing – secretaries prioritise

  1. urgent cases
  2. trainee reports
  3. consultant non-urgent reports

As soon as your reports are typed, check through and correct typographical errors, and forward them to the consultant’s list for authorizing, (or authorize your own, as appropriate).

How to be a good dictator

Being able to produce good audiotapes that are easy to type makes life easier for everyone – work is done more quickly with less stress.  This is an important skill for trainees – if secretaries have trouble understanding our dictation, it is not their fault.

Here are some tips:

  • Make notes of the key points of the report before you start dictating.  For reports that are not straight forward, compose them in longhand first, so that you can consider order of information in paragraphs etc.
  • Speak slowly and clearly, hold the Dictaphone close to your mouth, and spell out unfamiliar words.
  • Don’t make long tapes – start a new one once more than half way through, and put with cards in a new clear holder.  For digital dictation –start a new file for each case.
  • Keep cards in order of dictation.
  • Dictate clearly:
    • Name, histology number
    • Clinical information (with endoscopist for GI biopsies)
    • Macro description (full text, not cut-up abbreviations)
    • Micro report
    • Final diagnosis/bottom line
    • SNOMED code – as words or numbers.

Your tapes are typed by the secretary of the consultant supervising the work, if she is away, put the work in the typing tray.

If possible, speak to the secretary when you bring a tape for typing, to indicate its urgency.  She will type it before non-urgent consultant’s work.

She will return the request cards to you after typing – check and correct them, make sure your name is the ‘P’ principle pathologists, and then give to the consultant for authorizing (or authorize independent work yourself).

Finally – always be pleasant and courteous.  Secretaries have generally been here a lot longer than trainees, and they know the system and are doing their best.  The occasional box of chocolates in appreciation of their efforts may go down well.

Some brief comments on writing biopsy reports - Richard Bishop 2004

 

Structureof Bx reports

 

1 Description -  First write a paragraph or so describing the relevent features (see below)

2 Interpretation -  Then write a summary sentence or paragraph indicating the conclusions that you have made based on the findings you have described

Add any other relevent information eg min data set/other tests awaited etc

1 Description-

Hit them in the eye with the key features– don’t save the best bits until last

Include other pertinent positive findings

Also need to include pertinent negative findings (link with clinical info/your knowledge/ data sets)

Make note of and use economical pathological descriptive words

Eg Lichenoid, the formed elements of blood, tumour diathesis

Main abnormalities

Cover the main structures if relevant remembering all the easy to forget areas (eg vessels in lung, Giardia in duodenum)

2 Interpretation -

Finally write a summary sentence if it is a short simple case

Eg “this is a dermatofibroma which is clear of the margins” (could be the whole report of course!)

If any discussion of diagnosis/ clinicopath correlation/ areas of uncertainty exist then it is useful to write a paragraph with summary/ comment/ conclusions

Narrow down as far as you are able to BUT NO FURTHER!! (no one knows everything and overconfidence can be dangerous)

Egs This is a bland dermal spindle cell lesion which is clear of the margins.  OR

This is a cytologically malignant epithelioid tumour within a lymph node the exact nature of which is not clear with routine histological stains.

Then give realistic differentials if you have some

….. And the bit you don’t say in so many words is “but I haven’t a clue beyond that what it is”

Then some things to enable you to reach or get closer to the answer:

•Look at gross specimen

•More blocks

•More levels

•More stains

•Another opinion

•Look up literature

Expressing degrees of certainty (or could that be doubt?)

 

When you are sure be sure

Eg   This is condition X                          or

These are the features of condition X

(the latter may be more for clinicopathological diagnoses)

If there is a degree of doubt decide where in spectrum features lie between diagnoses. eg benign vs malignant

Explain why you think this in the report

Eg While features a/b/c favour/are seen in/can be seen in Condition X, features d/e/f are seen in this biopsy and these favour/suggest/are suspicious of condition Y