COMMENTARY
Same Specimen, Different Diagnoses: Suprahistologic Elements in Observer Variability Robert M. Genta, MD, FACG*wz
Abstract: External influences, referred to as suprahistologic elements, may modulate pathologists’ interpretation of morphologic findings. These elements can be divided into those that are loosely evidence based and exert a desirable influence on the diagnosis and those that arise from emotional, sometimes irrational perceptions not rooted in objective evidence. The latter, together with individual experience and competence, may lie at the core of the notorious interobserver and intraobserver variability. Key Words: histopathology, diagnosis, evidence-based practice
(Adv Anat Pathol 2014;21:188–190)
U
ndeterred by the bloody revolution that was ravaging Czarist Russia, Prince Nikolai Trubetzkoy, a linguist recently graduated from Moscow University, continued to work on his theory that more than words influenced the meaning of verbal communication. In a crowded Moscow theater, Trubetzkoy had an actor hidden behind a curtain repeat the words (pronounced “seevodnya vyecheram” and translated as “today in the evening” or, more colloquially, “this evening”), each time using a different intonation, cadence, speed, and voice volume. The audience, instructed to record how they perceived the message, was able to discriminate 42 different meanings of the phrase. A whispered question was interpreted as an intimate invitation, whereas a staccatocadenced loud question implied refusal and mockery; a rising tone meant surprise (“are you really are inviting me out this evening?”), and a clipped falling tone was taken as an order. Prince Trubetzkoy, who went on to found the Prague School of linguistics where he taught until his premature death during the Nazi invasion of Czechoslovakia, called the external factors that modulated the meaning of words “supralinguistic elements.”1 This term was later expanded to include not only intonation, but also hand gestures, body movements, facial expressions, and generally any nonverbal feature that can affect the meaning of a message. Supralinguistic elements are not limited to oral communication. The now ubiquitous texting employs nonverbal signs to convey meanings that the letters on the device monitor could not express, ranging from the simple use of capital letters to indicate shouting to the more elaborate codes for indicating facetiousness (LOL) or an
From the *Miraca Research Institute, Miraca Life Sciences, Irving; wDepartments of Pathology and Medicine, Veterans Affairs North Texas Health Care System; and zThe University of Texas Southwestern Medical Center, Dallas, TX. The author has no funding or conflicts of interest to disclose. Reprints: Robert M. Genta, MD, FACG, Miraca Research Institute, Miraca Life Sciences, 6655 North MacArthur Blvd, Irving, TX 75039 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
188 | www.anatomicpathology.com
ellipsis (y) to convey perplexity or an unfinished thought, and to the creative use of punctuation to depict happy :), sad :(, crying :00 (, or mocking :p faces. Warning: if you are not a texter you need to tilt your head 90 degrees to the left to see these symbols as faces. Some of these conventions have found their way to other, unexpected fields. Recently, the US Navy has discontinued its traditional use of all capital letters in their official communications because texting-sensitized young recruits perceived it as shouting.2 Similarly acting external influences, which I will call suprahistologic elements, modulate the histopathologic interpretation of slides. Pathologists are akin to the Moscow audience: instead of words, we see images on slides; instead of intonations, we receive or generate elements that may profoundly modify our interpretation of the morphologic findings. These elements can be divided into 2 broad categories: those that are loosely evidence based and exert a desirable influence on our diagnoses, and those that arise from emotional, sometimes irrational perceptions not rooted in objective evidence. I shall refer to the latter as the emotional elements and submit that, together with individual experience and competence, they are at the core of the notorious interobserver and intraobserver variability. Table 1 summarizes the evidence-based suprahistologic elements, further divided into 2 major categories, demographic and clinical. Several of these elements act synergistically to modify our approach to a case and the diagnosis we ultimately make. We use sex to include or exclude certain differential diagnoses: if the patient is a woman, a prostate primary is not a consideration when evaluating a bone metastasis of unknown origin. Age, ethnicity, and epidemiologic data are often used together to narrow the differential diagnoses of rare or unfamiliar lesions. Even before seeing the specimen, one would expect a nasopharyngeal mass to be an angiofibroma in a 10-yearold European boy and a lymphoepithelioid carcinoma in a 50-year-old Chinese man.3 The clinical history provided is one of the major determinants in our diagnostic approach, and we use that in concert with demographic and epidemiologic elements to reach the interpretation that best fits the clinical picture that we either get or extrapolate from data provided to us by clinicians. When evaluating the esophageal biopsies of a 15-year-old boy with dysphagia we struggle to find that 15th eosinophil that will seal the diagnosis of eosinophilic esophagitis; if the same specimens come from a 50-year-old man with erosive esophagitis, one would be satisfied with a cursory assessment of the eosinophil infiltrate before declaring it reflux esophagitis.4,5 Aware of the risks of neglecting a patient’s personal and clinical background, we make a deliberate use of objective suprahistologic elements, sometimes privately applauding ourselves for having been able to put together clinical and pathologic findings into a perfectly fitting Adv Anat Pathol
Volume 21, Number 3, May 2014
Adv Anat Pathol
Volume 21, Number 3, May 2014
Suprahistologic Elements
TABLE 1. Evidence-based Suprahistologic Elements—Demographic and Clinical Evidence that may Play a Useful Role in the Interpretation of the Morphologic Findings of a Pathology Specimen
Demographics
Clinical
Age Sex Ethnicity Epidemiology
Patient’s personal history Family history Clinical findings (physical examination, endoscopy) Imaging (x-rays, magnetic resonance imaging, positron emission tomography scans)
diagnosis. Often, however, we are not aware that emotional, irrational, subjective influences creep into our assessment and diagnosis of all but the most trivial cases. Table 2 lists several circumstances in which elements unrelated to the available clinical and morphologic data affect a pathologist’s approach to a case. A desire to influence management is probably the most common suprahistologic element that creeps into the formulation of a diagnosis. A colonic adenoma contains a focus of highgrade dysplasia well removed from the resected stalk, which is free of dysplasia. A pathologist who believes (or knows from experience) that surgeons will interpret a diagnosis of high-grade dysplasia as a license to resect, might be tempted to leave any mention of this finding out of the report to protect the patient from a needless procedure. In a contrasting direction, an adenocarcinoma arising in a polyp looks like it could have invaded into the stalk and deeper, but the pathologist can only find tumor at 1.5 mm from the resection margin, a setting that would not require further intervention. Convinced that the patient is best served by surgery, the pathologists will try to find a way to make that distance measure
Same Specimen, Different Diagnoses: Suprahistologic Elements in Observer Variability Robert M. Genta, MD, FACG*wz
Abstract: External influences, referred to as suprahistologic elements, may modulate pathologists’ interpretation of morphologic findings. These elements can be divided into those that are loosely evidence based and exert a desirable influence on the diagnosis and those that arise from emotional, sometimes irrational perceptions not rooted in objective evidence. The latter, together with individual experience and competence, may lie at the core of the notorious interobserver and intraobserver variability. Key Words: histopathology, diagnosis, evidence-based practice
(Adv Anat Pathol 2014;21:188–190)
U
ndeterred by the bloody revolution that was ravaging Czarist Russia, Prince Nikolai Trubetzkoy, a linguist recently graduated from Moscow University, continued to work on his theory that more than words influenced the meaning of verbal communication. In a crowded Moscow theater, Trubetzkoy had an actor hidden behind a curtain repeat the words (pronounced “seevodnya vyecheram” and translated as “today in the evening” or, more colloquially, “this evening”), each time using a different intonation, cadence, speed, and voice volume. The audience, instructed to record how they perceived the message, was able to discriminate 42 different meanings of the phrase. A whispered question was interpreted as an intimate invitation, whereas a staccatocadenced loud question implied refusal and mockery; a rising tone meant surprise (“are you really are inviting me out this evening?”), and a clipped falling tone was taken as an order. Prince Trubetzkoy, who went on to found the Prague School of linguistics where he taught until his premature death during the Nazi invasion of Czechoslovakia, called the external factors that modulated the meaning of words “supralinguistic elements.”1 This term was later expanded to include not only intonation, but also hand gestures, body movements, facial expressions, and generally any nonverbal feature that can affect the meaning of a message. Supralinguistic elements are not limited to oral communication. The now ubiquitous texting employs nonverbal signs to convey meanings that the letters on the device monitor could not express, ranging from the simple use of capital letters to indicate shouting to the more elaborate codes for indicating facetiousness (LOL) or an
From the *Miraca Research Institute, Miraca Life Sciences, Irving; wDepartments of Pathology and Medicine, Veterans Affairs North Texas Health Care System; and zThe University of Texas Southwestern Medical Center, Dallas, TX. The author has no funding or conflicts of interest to disclose. Reprints: Robert M. Genta, MD, FACG, Miraca Research Institute, Miraca Life Sciences, 6655 North MacArthur Blvd, Irving, TX 75039 (e-mail: [email protected]). Copyright r 2014 by Lippincott Williams & Wilkins
188 | www.anatomicpathology.com
ellipsis (y) to convey perplexity or an unfinished thought, and to the creative use of punctuation to depict happy :), sad :(, crying :00 (, or mocking :p faces. Warning: if you are not a texter you need to tilt your head 90 degrees to the left to see these symbols as faces. Some of these conventions have found their way to other, unexpected fields. Recently, the US Navy has discontinued its traditional use of all capital letters in their official communications because texting-sensitized young recruits perceived it as shouting.2 Similarly acting external influences, which I will call suprahistologic elements, modulate the histopathologic interpretation of slides. Pathologists are akin to the Moscow audience: instead of words, we see images on slides; instead of intonations, we receive or generate elements that may profoundly modify our interpretation of the morphologic findings. These elements can be divided into 2 broad categories: those that are loosely evidence based and exert a desirable influence on our diagnoses, and those that arise from emotional, sometimes irrational perceptions not rooted in objective evidence. I shall refer to the latter as the emotional elements and submit that, together with individual experience and competence, they are at the core of the notorious interobserver and intraobserver variability. Table 1 summarizes the evidence-based suprahistologic elements, further divided into 2 major categories, demographic and clinical. Several of these elements act synergistically to modify our approach to a case and the diagnosis we ultimately make. We use sex to include or exclude certain differential diagnoses: if the patient is a woman, a prostate primary is not a consideration when evaluating a bone metastasis of unknown origin. Age, ethnicity, and epidemiologic data are often used together to narrow the differential diagnoses of rare or unfamiliar lesions. Even before seeing the specimen, one would expect a nasopharyngeal mass to be an angiofibroma in a 10-yearold European boy and a lymphoepithelioid carcinoma in a 50-year-old Chinese man.3 The clinical history provided is one of the major determinants in our diagnostic approach, and we use that in concert with demographic and epidemiologic elements to reach the interpretation that best fits the clinical picture that we either get or extrapolate from data provided to us by clinicians. When evaluating the esophageal biopsies of a 15-year-old boy with dysphagia we struggle to find that 15th eosinophil that will seal the diagnosis of eosinophilic esophagitis; if the same specimens come from a 50-year-old man with erosive esophagitis, one would be satisfied with a cursory assessment of the eosinophil infiltrate before declaring it reflux esophagitis.4,5 Aware of the risks of neglecting a patient’s personal and clinical background, we make a deliberate use of objective suprahistologic elements, sometimes privately applauding ourselves for having been able to put together clinical and pathologic findings into a perfectly fitting Adv Anat Pathol
Volume 21, Number 3, May 2014
Adv Anat Pathol
Volume 21, Number 3, May 2014
Suprahistologic Elements
TABLE 1. Evidence-based Suprahistologic Elements—Demographic and Clinical Evidence that may Play a Useful Role in the Interpretation of the Morphologic Findings of a Pathology Specimen
Demographics
Clinical
Age Sex Ethnicity Epidemiology
Patient’s personal history Family history Clinical findings (physical examination, endoscopy) Imaging (x-rays, magnetic resonance imaging, positron emission tomography scans)
diagnosis. Often, however, we are not aware that emotional, irrational, subjective influences creep into our assessment and diagnosis of all but the most trivial cases. Table 2 lists several circumstances in which elements unrelated to the available clinical and morphologic data affect a pathologist’s approach to a case. A desire to influence management is probably the most common suprahistologic element that creeps into the formulation of a diagnosis. A colonic adenoma contains a focus of highgrade dysplasia well removed from the resected stalk, which is free of dysplasia. A pathologist who believes (or knows from experience) that surgeons will interpret a diagnosis of high-grade dysplasia as a license to resect, might be tempted to leave any mention of this finding out of the report to protect the patient from a needless procedure. In a contrasting direction, an adenocarcinoma arising in a polyp looks like it could have invaded into the stalk and deeper, but the pathologist can only find tumor at 1.5 mm from the resection margin, a setting that would not require further intervention. Convinced that the patient is best served by surgery, the pathologists will try to find a way to make that distance measure
