The Rubber-Band Pathologist and How to Avoid Becoming One
What’s a Rubber-band Pathologist?
Being a rubber-band pathologist is something many pathologists can probably relate to. During the first few weeks as a wide-eyed, new-in-practice pathologist, I noticed a pattern in my diagnoses. If I showed a challenging case to someone who thought the diagnosis was more benign than I thought, I saw subsequent cases with a more benign eye. Later, a case would come up where someone suggested a more malignant diagnosis than mine and this would push my “malignometer” back toward the malignant side again. Cases that followed would all look a little bit more malignant. Just like the rubber-bands all over my desk, I felt like I was stretching in and out, back and forth between benign and malignant. A rubber-band pathologist stretches in and out, back and forth between two decision points. This isn’t always between benign vs. malignant but it can be on any number of scales used in pathology (i.e. degree of inflammation, percent positive cells). Within a few degrees, we all vary from time to time, even from slide to slide. Just in case you’re wondering, there is a distinction between rubberbanding and intraobserver variability. Rubberbanding is more about what’s going on inside your head and not what ends up in the report. In short, you don’t get into trouble with the law for being a rubber-band pathologist. What gets you in trouble is when you “stretch” too far.
The Trouble with Rubber-bands
There are risks associated with being a rubber-band pathologist. You might get “snapped” if you stretch too far. Always overcalling compared to your colleagues because you don’t want to miss a diagnosis may lead to false positives, and vice versa. During training I once heard that we pushed our diagnoses towards the malignant side because if the case was reviewed by a prestigious institution with a reputation for overcalling cases, we would look like we missed the diagnosis. I’ve heard this similar scenario among residents, fellows, and even practicing pathologists when they send consultations for expert review. Is the fear of being upstaged by the experts making us too aggressive? We also risk losing the trust (and business) of the physicians we serve if we bounce around too much. Being consistent will help build stronger relationships with physicians and surgeons. In today’s competitive environment, being inconsistent also means risking losing business to other laboratories. The problem isn’t just when you start practicing pathology. In fact, it’s practically part of every day life as a resident or fellow. Let’s bring in another “pathspective” on this subject and see what residents thinks.
The Resident Pathspective
G. Eli Morey, Chair, Residents Forum Executive Committee, CAP
During my first year of residency, I had a daily hour-long scope session with a seasoned pathologist, someone who seemed excellent at pretty much everything you could throw at him. He was devoted to teaching, and he had determined that the most valuable thing he could do was mold our fledgling diagnostic minds by teaching us to rely on criteria. We were quizzed mercilessly on “triads,” groups of three features that would largely define an entity. Perhaps the most important thing he taught us was his own mantra: “If I do not have all of these, I do not call it.” What I’ve tried to do in residency is to rely on criteria I’ve been taught, and to bounce around less by taking feedback “with a grain of salt.” This year, during my cytology rotation I attempted to visualize this effect to achieve a sort of diagnostic mindfulness. I created a spreadsheet where I plotted how each diagnosis differed from that of my attending. What I saw was an improvement over time!
It is our duty then, at the very least, to be predictable to our clinicians or those we work with. I believe the main value of a residency is to develop that predictability.
I learned that my criteria were not necessarily wrong, but I was not applying the appropriate weight to certain criteria. I also was reminded that clinical features (age, gender, lesion location) can play an incredibly important role in how we make a call, and bearing these in mind can attenuate our malignometer. In addition, I found my diagnostic meter was more aligned with some pathologists compared with others. Until computational image analysis is implemented, there will continue to be subjectivity in pathologic diagnosis. It is our duty then, at the very least, to be predictable to our clinicians or those we work with. I believe the main value of a residency is to develop that predictability.
How to Avoid Becoming a Rubber-band Pathologist
Here are a few ways to find your center and lose your stretch:
- Follow Standard Criteria: Not sure if your aspirate is adequately cellular? Follow current criteria. Are those villi blunted? Follow criteria. Did the consultation come back with something unexpected? Start praying there’s standard criteria. Joking aside, if you’re not sure about a case, be judicious about following current criteria and you’ll sleep better at night. A great resource is the aptly named Stanford Surgical Pathology Criteria. WHO Classification for lymphoid neoplasms and AJCC also come to mind when looking for solid criteria.
- Ask this one question: If this was from a family member, what would I call it?
- Experience: While this tendency to shift back and forth doesn’t ever really go away, time and experience will definitely help increase your precision. Just keep at it.
- Take a Break: If you’ve been looking at a case for awhile and you mind keeps bouncing around, set the case aside and work on something else. Coming back with a fresh set of eyes may just cure those “rubber band blues.”
Something to “Stretch” Your Mind Around
Next time you wrap that rubber-band around a tray, signaling you a done with a case, take half a second to think: Am I rubber-band pathologist? Let me know what being a rubber-band pathologist means to you in the comment section below! Is there a lot of stretch in your “malignometer”?