Wednesday, May 4, 2016

Pathology in Rwanda: Synopsis of Synoptics

Isaac H. Solomon, MD, PhD
 Fellow in Infectious Disease and Molecular Microbiology at Brigham and Women's Hospital

Health and healthcare have changed tremendously in Rwanda over the last several decades, resulting in significant increases in life expectancy.  As the population ages, cancer is becoming an increasing problem.  In order to avoid over- or under-treating patients who present with a potential malignancy, a tissue-based diagnosis must be made by a pathologist.  Until 2012, only a few pathologists were available to serve the entire country of over 11 million people, and residency training required traveling to neighboring Tanzania or Kenya.  However, the first cohort of pathology residents in Rwanda will complete their training in the summer of 2017, considerably bolstering the ranks.

While training enough pathologists to do the work is a critical first step, additional improvements in patient care can be accomplished through improving communication between clinicians and pathologists, which is true in all settings around the globe.  Since the way in which pathologists communicate the most is through their written reports, inclusion of the most relevant information in a concise format is essential.  To this end, synoptic reports, reporting templates designed to present all the relevant findings of a case in a systematic fashion using standardized terminology, have been created by various pathology organizations.  Data from these reports can then be easily compiled and analyzed by epidemiologists and researchers to conduct population level studies.  Therefore, the primary goal of my project in Rwanda was to introduce synoptics to the current pathology trainees, starting with breast cancer and cervical cancer, in order to facilitate broader implementation. 

The residents as a group were very interested in the concept of synoptic reporting. I prepared a few lectures explaining all of the components in depth, and together we worked through several hypothetical examples of how to write the reports. We then reviewed several previously reported cases from BWH and Rwanda at the microscope.  During these activities, it became evident that some changes in grossing practices on behalf of the residents would be necessary to fully complete the reports, such as inking and additional sampling.  The residents, in turn, raised minor areas of concern regarding the additional level of detail required, significant increase in report length, and difficulty in assigning many of the histological features to "present” or “absent" options without equivocation.  By then end of the visit, it became evident that immediate adoption of synoptic reports in a drop-down menu format was unlikely to occur.  However, the residents were very enthusiastic about using the templates as a guide when preparing their reports in a narrative format to ensure completeness.  While there is still much work to be done, this was an excellent next step.

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