12 Jul 1996
The most dangerous weapon in pathology is a skin punch in the hands of a non-dermatologist.
Or so it seems to me. A few years ago, we began doing work for a regional reference lab, and I now know what it's like to be the Burger King of pathology ("Hold the history; hold the clinical description. Clueless doctors don't upset us. All we ask is that you let us print the bill your way!"). The source of the overwhelming proportion of reference lab work is divided between the female genital tract and the skin. Therefore, I have done skin pathology out the wazoo for a while now.
Skin pathology has always held a certain mystique for me, since it seemed like it had its own exclusive religious traditions. Bernard Ackerman's big inflammatory skin disease book actually looks like a hallowed family Bible up there on my shelf, especially now that it sports the patina of a decade and a half of fingerprints. The diagnosis of melanomas is something that is often best left to the College of Dermatocardinals, as mere village priests may not always be up for it, nor are the latters' decisions imbued with the stamp of infallibility held by the Holy CutaneoSee. Inflammatory skin lesions involve mumbled communications among members of a secret society of dermatologists and dermatology-trained dermatopathologists, and outsiders like us AP/CP grunts can only rarely be privy to the momentous decisions made within this cabal. In short, derm path can be very intimidating to us generalists.
But now, I am here to tell you, brothers and sisters, I have finally nosed my way into the sanctum dermatorum, muscled the seraphim aside, peeked into the Ark of the Integument, and have read the priestly tablets. Here's the deal:
Dermatologists believe that they are going with "the best" by sending their biopsies to dermatopathologists. In fact, the secret to much of skin pathology is similar to that of interpretation of kidney biopsies: the diagnostic features are more likely to be found on the requisition than on the slide. A competent dermatologist can usually narrow down the differential diagnosis to two or three items, none of which resembles the others histologically. Accordingly, a trained orangutan can make the final diagnosis at the 'scope. The dermatopathologist, being considerably more skilled than an orangutan, makes the correct diagnosis every time, and the dermatologist once again achieves his or her daily affirmation.
The non-dermatologist does not know that there are such things as dermatopathologists; therefore, he or she sends all skin biopsies to whatever lab is the cheapest or is on the patient's insurance. Moreover, the non-dermatologist is unable to develop a differential diagnosis any more focused than "lesion right arm." The shlimazopathologist at the reference lab gets the specimen (typically a superficial shave biopsy of an inflammatory lesion), and, after calling for the patient's age and sex, makes a diagnosis something like "lichenoid dermatitis, not nosologically specific." The non-dermatologist reads this report and, seeing as the diagnosis has more than five syllables, reflexively sends the patient to whatever dermatologist is covered by the patient's insurance. The dermatologist does a proper full-thickness punch biopsy and sends the specimen to the dermatopathologist with a two-item differential diagnosis and the next day gets back the slam-dunk diagnosis. "See, to get a correct diagnosis, you can't just send these skin biopsies to Slides 'R' Us. You've gotta send 'em to someone who knows what they're doing!"
Sheesh! We get no respect.
Actually, the most efficient use of resources would be for dermatologists to send their biopsies to general pathologists, while non-dermatologists should send their biopsies to dermatopathologists. That way, the expertise of one would compensate for the ignorance of the other!