Wednesday, June 22, 2011

Gross Room Survival Guide Part 5. Dictating gross description

Probably not worth a separate section, you might say. However, a well dictated gross description goes a long way. It keeps your attending happy. It keeps the transcriptionists happy. It saves you time by not having to go over it with a red pen, redictate it the next day, or explain to your attending what exactly you meant by “tan to pink, red-brown, slightly yellowish, gray tissue”. It saves you an embarrassment at multidisciplinary conferences. It may mean a great deal should there be litigation.

A good dictation should be concise, clear, accurate, but without unnecessary details. Any pathologist 20 years from now should be able to pick up your description, read it and picture the specimen in their head. Be systematic. Go from outside in and from top to bottom (or the other way around, but be consistent). Do not overdo negative findings, but rather concentrate on positive ones. Keep it professional and be grammatically correct.

Templates versus no templates. Our institution utilizes templates for gross description. The idea is to make gross descriptions consistent and to save time typing reports. Templates are good for standard specimens like placentas or non-neoplastic colectomies. However, I do find them difficult to use with any more or less complex or non-standard specimens. It is a personal choice whether to use them or not. If you decide to use templates try to memorize the more common ones so you don’t have to look for the greasy bloody paper template every time.

Dictating as you gross saves enormous amounts of time. For the first month or two, until you become dab hand with dictating gross, you may find it easier to write down all the measurements and then dictate the description after you are done grossing. However, you really should try to move to dictating “as you go”, the sooner the better. It is doable for most specimens, even Whipple resections and composite neck dissections, as long as you think about the specimen for a minute beforehand and plan the way you are going to dissect and dictate it.

Do not dictate unnecessary details of no diagnostic value. Bundle lymph nodes together. Is there really any advantage in saying “A1: two possible lymph nodes, both of them bisected, one inked in black and the other one in blue” versus “A1: two lymph nodes”? They do look like lymph nodes grossly, why do you call them “possible”? You are going to see four pieces of lymphoid tissue under the scope, two of them with a rim of black and two with a rim of blue. You do the math…

No comments:

Post a Comment