Urgent Breast-Related Consults Seen by Acute Care Surgery at a Safety Net Hospital.

BACKGROUND: Classically, urgent breast consults are seen by Breast Surgery or Surgical Oncology (BS/SO). At our safety net hospital, Acute Care Surgery (ACS) performs all urgent surgical consultations, including initial assessment of breast consults with coordinated BS/SO follow-up. The objective was to determine safety of ACS initial assessment of acute breast pathology. METHODS: All urgent breast-related consultations were included (2016-2019). Demographics, consult indications, and investigations/interventions were captured. Outcomes were compared between patients assessed by ACS versus both ACS and BS/SO at presentation. RESULTS: 234 patients met study criteria, with median age 39 years. Patients were primarily Hispanic (82%) women (96%). Most were not seen by BS/SO at presentation (69%), although BS/SO assessment was more frequent among patients ultimately diagnosed with cancer (8% vs 1%, P = .012). No patient had delay >90 days to core biopsy from presentation. Outcomes including time to cancer diagnosis (14 vs 8 days, P = .143) and outpatient BS/SO assessment (16 vs 13 days, P = .528); loss to follow-up (25% vs 21%, P = .414); and ED recidivism (24% vs 18%, P = .274) were comparable between patients seen by ACS versus ACS/BS/SO at index presentation. CONCLUSION: Urgent breast consults at our safety net hospital typically underwent initial assessment by ACS with outpatient evaluation by BS/SO. Time to follow-up and cancer diagnosis, loss to follow-up, and ED recidivism were similar after index presentation assessment by ACS versus ACS and BS/SO. In a resource-limited environment, urgent breast consults can be safely managed in the acute setting by ACS with coordinated outpatient BS/SO follow-up.

Molecular and Cytogenetic Education in Hematopathology Fellowship.

OBJECTIVES: Given the increased complexity of molecular and cytogenetic testing (MOL-CG), the Society for Hematopathology Education Committee (SH-EC) was interested in determining what the current expectations are for MOL-CG education in hematopathology (HP) fellowship training. METHODS: The SH-EC sent a questionnaire to HP fellowship program directors (HP-PDs) covering MOL-CG training curricula, test menus, faculty background, teaching, and sign-out roles. These findings were explored via a panel-based discussion at the 2018 SH-EC meeting for HP-PDs. RESULTS: HP fellows are expected to understand basic principles, nomenclature, and indications for and limitations of testing. Interpretation of common assays is within that scope, but not necessarily proficiency in technical troubleshooting of testing or analysis of complex raw data. CONCLUSIONS: The consensus was that HP fellows should understand the components of MOL-CG testing necessary to incorporate those results into an accurate, clinically relevant, and integrated HP report.

Assessment of Malpractice Claims Associated With Acute Compartment Syndrome.

BACKGROUND: Because acute compartment syndrome is one of the few limb-threatening and life-threatening orthopaedic conditions and is difficult to diagnose, it is a frequent source of litigation. Understanding the factors that lead to plaintiff verdicts and higher indemnity payments may improve patient care by identifying common pitfalls. METHODS: The VerdictSearch legal claims database was queried for the term "compartment syndrome." After 46 cases were excluded for missing information or irrelevancy, 139 cases were reviewed. The effects of plaintiff demographics, mechanism of injury, and complications were assessed. RESULTS: Of 139 cases, 37 (27%) were settled, 69 (50%) resulted in a defendant ruling, and 33 (24%) resulted in a plaintiff ruling. Juries were more likely to rule in favor of juvenile plaintiffs than adult patients (P = 0.002) and female plaintiffs than male plaintiffs (P = 0.008), but indemnity payments were not affected by the age or sex of the plaintiff. Plaintiffs who experienced acute compartment syndrome as a complication of surgery were more likely to win their suit and receive higher awards (P < 0.05), compared with those in whom the condition developed as a result of trauma. Amputation or delay in diagnosis or treatment did not affect plaintiff verdicts or awards. CONCLUSION: Defendants were more likely to lose a lawsuit concerning the management of acute compartment syndrome if the patient was a woman or child or if acute compartment syndrome developed as a complication of a surgical procedure.

Revenue Generation and Plastic Surgery Training Programs: 1-Year Evaluation of a Plastic Surgery Consultation Service.

BACKGROUND: In academic institutions, residents make substantial contributions to clinical productivity. However, billing cannot be generated unless there is direct attending physician supervision of these services. The purpose of this study was to quantify clinical services provided by residents at a large academic medical center. METHODS: The authors performed a review of all consultations to the plastic surgery service between January 1 and December 31, 2014. Documentation was reviewed and hypothetical billing for services was generated using American Medical Association Current Procedural Terminology and evaluation and management codes. RESULTS: A total of 2367 consultations were reviewed during the 1-year study period. Residents provided services under indirect supervision for the majority of consultations [n = 1940 (81.9 percent)]. If these services had been billed, evaluation and management would have resulted in 6970 physician work relative value units. More than half of the encounters (52.0 percent) involved at least one procedure, resulting in an additional 3316 work relative value units from 1339 Current Procedural Terminology codes. Using a conservative estimate (2014 Medicare reimbursement rates), charges from these services would total $368,496. CONCLUSIONS: The plastic surgery consultation service is a potential source of uncaptured revenue for training programs using indirect supervision of residents. Greater than 10,000 work relative value units could have been generated from resident clinical services, which is considerably more than the national average productivity of a full-time, academic plastic surgeon. Capturing a portion of this revenue stream could improve the fiscal balance of training programs and improve the cost-effective use of resident productivity.

Does Taking the Fellowship In-Service Hematopathology Examination and Performance Relate to Success on the American Board of Pathology Hematology Examination?

OBJECTIVES: The biannual Fellow In-Service Hematopathology Examination (FISHE) assesses knowledge in five content areas. We examined the relationship between taking the FISHE and performance on it with outcomes on the first attempted American Board of Pathology Hematology subspecialty certifying examination (ABP-HE). METHODS: The pass rate between the ABP-HE candidates who took the spring FISHE and those who did not were compared. The likelihood of fellows passing the ABP-HE based on their percentiles on the FISHE was also assessed. RESULTS: ABP-HE candidates who took the spring FISHE had a higher pass rate (96.4%) than those who did not (76.1%, P < .001). Spring FISHE performance, including total percentile and percentiles in four of five FISHE content areas, was only a weak predictor of passing the ABP-HE. CONCLUSIONS: Candidates who take the spring FISHE do better on the ABP-HE than those who do not. Most fellows passed the first attempted ABP-HE regardless of FISHE performance. Whether this is due to fellows making use of the FISHE as a self-evaluation tool to help identify and then correct their knowledge deficiencies remains to be determined.