Policy
Policy
Subject:
Provision of second opinions with particular reference to
morphological examination
Approval Date: March 1999, Revised 11 October 1999, Revised March 2001,
Revised March 2007, November 2013, October 2016, November
2017
Review Date:
November 2021
Review By:
Anatomical Pathology AC, Cytopathology AC
Number: 2/1999
Key Issues
1. Introduction
The growing complexity of modern medical practice, particularly sub-specialisation, has
increased the frequency and widened the circumstances under which second and
subsequent opinions may be requested on a variety of pathological specimens, but
particularly those which involve evaluation of cell or tissue morphology. Most of what
follows is directed predominantly towards histopathology and cytopathology but the
principles may apply in any area of pathology testing where material is examined
morphologically, eg. blood and bone marrow films. The College has separate Guidelines
for Provisions of Second Opinions in Forensic Pathology
Coinciding with this increased demand for referral for second and subsequent opinion is
increased privacy requirements for personal health information. Accordingly, when
material is provided for a second opinion, care must be exercised to ensure there is no
breach of statutory and common-law privacy principles (see RCPA Guideline: Managing
Privacy Information in Laboratories
Of particular note, pathologists should at all times put the interests of patients first when
other opinions are requested and should not unreasonably refuse to provide material to
allow a second opinion as this may cause harm to patients. This includes pathology
providers who are in direct commercial competition with each other. All pathologists
involved in the second opinion process should behave in a professional and ethical
manner towards peers, clinical colleagues and patients, acknowledging that second
opinions frequently involve additional clinical information and diagnostic refinement rather
than discordance of opinion and should not trigger unintended consequences such as
referral inducements, commercial advantage, punitive actions etc.
2. Definitions
To assist with understanding this document, a few definitions are provided for terms that
are used frequently in subsequent sections:
“(pathological) material”
This is any specimen or part of a specimen of
human tissue or cells in a form suitable for
examination by any pathology test. It includes but is
not limited to: unfixed, fixed or embedded tissue,
stained or unstained tissue sections and smears or
films of blood or normal or abnormal body fluids.
“pathologist of record”
The pathologist responsible for the initial report on
the material in question. In some situations, this
pathologist may be the person who initially
performed the examination and wrote the original
report. In others, however, it may be a designated
pathologist on whose behalf the test was done by a
non-pathologist member of staff or Department or
Pathology Service Director under whose authority
the report was issued. The latter are likely to
become involved when a second opinion is
requested on material stored for a period of time,
long after the original reporting pathologist has left
the practice.
“effective control of
pathological material”
This is exercised by the medical practitioner who at
the time the request is made for a second opinion,
exercises administrative control over the stored
material. Usually this will be a Department or Service
Head (including a Managing Partner). The term is
used to avoid involvement in the complex issue of
“ownership” of pathological material.
“pathologist of referral”
The pathologist responsible for provision of the
second opinion in question. Implicit in this concept is
that the pathologist of referral would personally
provide that opinion unless the request is clearly
made to a pathologist in his or her capacity as a
Department or Service Head.
3. Policy
Statements
This section contains a series of separate, but related statements that deal with some
specific common “scenarios” in which second and subsequent opinions may be requested
and with some specific issues that are common to more than one of these scenarios.
3.1
Second Opinions requested by the “pathologist of record”
3.1.1. This statement deals only with the situation where:
a)
the second opinion is requested formally; and
b)
the pathologist of referral is a member of a pathology practice
different from that of the pathologist of record.
Showing a slide to a colleague “out of interest” is not regarded as seeking
a second opinion in the context of this statement. Arrangements for
second opinions within a practice also are not covered by this statement
but should be addressed by an appropriate internal practice policy.
3.1.2. Requests for second opinions should either be made in writing or
confirmed in writing after a verbal request (this includes communication by
facsimile or e-mail).
2
3.1.3. The request should include all relevant clinical and other information
known to the pathologist of record in a professional capacity. It may
however be useful to “package” this information in such a way that the
pathologist of referral has the option of considering the material “blind” in
the first instance and considering the clinical information afterwards.
3.1.4. The nature and origin of the material submitted for second opinion should
be clearly evident. In particular, slides should be identified either as
“recuts” or the “originals” which have been examined by the pathologist of
record.
3.1.5. The pathologist of referral should attempt to fulfil the request only if he or
she has the expertise and resources to do so.
3.1.6. In the circumstances covered by this statement, a pathologist is not under
any obligation to act as a pathologist of referral unless required to do so
under some form of contract. Any refusal of a referral should however be
timely and courteous but no justification is necessary.
3.1.7. The second opinion should be issued in writing. It may be in the format of
either a letter or of a standard report from the pathologist of the referring
practice.
As a rule it should include:
the clinical information provided, or at least a summary of relevant
issues;
a description of the material submitted on which the report is based;
any description of relevant microscopic appearances;
the conclusion including diagnosis and/or differential diagnosis and any
comments; and
the results of any additional testing performed in the course of the
review (eg additional IHC stains or molecular studies).
3.1.8. On receipt of the second opinion by the pathologist of record, this should
be provided to the original requesting practitioner intact with full attribution
to the pathologist of referral. If an extract is made, this should be quoted
verbatim and attributed to the pathologist of referral.
3.1.9. Any component of the report by the pathologist of record should ensure
that his/her findings or comments are clearly and unambiguously
distinguished from those of the pathologist of referral.
(NOTE: In context of this scenario, patient consent is implied provided that
the referral by the pathologist of record is in good faith and in the course of
normal professional practice).
3.2
Second opinions requested by a third party who is a medical practitioner
currently involved in the medical care of the patient from whom the
pathological material was originally obtained.
3.2.1. This statement deals only with the situation where the request is from an
institution or medical practice different from the one to which the material
was originally submitted. Arrangements between departments or units
within the same institution are for them to determine internally however it is
recommend that second opinions be appropriately recorded in the patient
record.
3
3.2.2. In these circumstances, the request to provide material for a second
opinion should be made to the pathologist of record provided that person is
still a member of the practice which is in effective control of the material. If
not, the request should be directed to some other medical practitioner who
is in the control of the material, usually a department or service head.
3.2.3. Unless mutually agreed otherwise, any such requests should be in writing
or confirmed in writing. Before acceding to the request, the person
responsible for the material should be satisfied, of its
bona-fides. In the
absence of a written consent form, some information should be supplied to
substantiate that this request is for the purpose of patient care.
3.2.4. The request should clearly identify the pathologist to whom the material is
to be sent and who will be responsible for the second opinion.
3.2.5. Provided the issues in 3.2.3. and 3.2.4. are adequately addressed,
provision of material for this purpose should not be unreasonably withheld.
3.2.6. Unless agreed otherwise, the material requested under these
circumstances should be accompanied by:
a)
A copy of the original report issued by or on behalf of the
pathologist of record;
b)
A covering letter to indicate whether the material submitted is that
on which this original report was based or if it consists of recut
sections. It is also advisable to indicate whether or not some or all
of the material is to be returned. It would however be unacceptable
for the pathologist of referral to retain material contrary to the
expressed wishes of the person providing it, once all examination
was completed. It is accepted practice that all material is returned
unless the original laboratory specifically indicates it is not
necessary, or the pathologist of referral makes specific request to
keep a representative slide and this is agreed to.
3.2.7. The second opinion should be issued in writing. It may be in the format of
either a letter or of a standard report from the pathologist of referral’s
practice.
As a rule it should include:
the clinical information provided or at least a summary of relevant
issues;
a description of the material submitted on which the report is based;
any description of relevant microscopic appearances;
the conclusion including diagnosis and/or differential diagnosis and any
comments; and
the results of any additional testing performed in the course of the
review (eg additional IHC stains or molecular studies).
3.2.8. This report should be provided to:
the medical practitioner requesting the review;
any other person who is entitled to receive such reports in the institution
in question, eg. Medical Record Administrator;
as a courtesy, the pathologist of record or other person who had
provided the material; and,
4
in some instances, to the patient.
3.2.9. Any such report received by the pathologist referred to in the preceding
paragraph shall not be used other than for clinical management of the
patient without the agreement of the pathologist of referral.
3.2.10. If there is a genuine difference of opinion between the pathologist of
referral and the original opinion of the pathologist of record, a reasonable
attempt should be made to notify the pathologist of record. If the
pathologist concerned is no longer at the practice providing the material,
the pathologist currently in charge should be notified. That person will in
turn then have to determine whether it is a matter which requires them to
contact the pathologist of record.
3.2.11. If there is a revision to the original diagnosis based on a genuine
difference of opinion between the pathologist of referral and the original
pathologist of record and/or if additional testing is performed in the course
of the review (eg additional IHC stains or molecular studies), the original
pathologist of record should ensure they are appended to the original
report.
3.2.12. It is unacceptable conduct for a pathologist of referral to artificially
exaggerate a difference of opinion from that of the pathologist of record by
use without explanation of alternative, but equivalent terminology, or to
otherwise make any statements which could be perceived as enhancing
personal prestige or “cultivating” referrals.
3.2.13. If the pathologist of referral in turn intends to seek a further opinion on the
material, eg. from an overseas expert, this should be notified as soon as
practicable to the person providing the material for the referral.
Please note that there may other permutations to this scenario of a second and
subsequent opinion.
For example:
Clinician A sends a specimen to Pathologist B.
The patient then goes for a second clinical opinion to Clinician C who asks that another
pathologist, Pathologist D, review a new specimen. The specimen may be the same type
of sample or different tissue (for example a fine needle aspirate or biopsy).
There has been an initial diagnosis of malignancy with a subsequent diagnosis of benign
lesion.
As clinicians have no ownership of patients and the patient has agreed to see Clinician C,
who as is often the case refers the material to a pathologist at Clinician C’s institution,
Pathologist D has an obligation to provide a report to the requesting Clinician.
If it is apparent that the diagnosis is different, the same approach outlines in this section
should be adopted in relation to obtaining the specimen for review from Pathologist B.
In addition, it is professional courtesy for Pathologist D and Clinician C to notify
Pathologist B and Clinician A of a variation in the diagnosis.
3.3
Review of material requested for purposes of education or quality assurance
5
3.3.1. When the material is provided for this purpose, the issue of the patient
consent requires consideration.
3.3.1.1. If
the
patient
is
currently an inpatient or outpatient at the institution where
the educational or quality activity is taking place; and the
purpose is a review of past lesions to compare with current
pathology; and at least some persons present at the
educational or quality activity are involved with the case, it
could be accepted that the presentation, while of an
educational or quality assurance nature, has a component
of discussion of current patient care, so consent might be
considered to be implied.
3.3.1.2
If the patient is not a patient currently receiving active
medical management where the educational or quality
activity is taking place, but; is a person with pathology,
educational or quality activity interest,
consent may not be needed provided that the
material and any accompanying documentation is
irreversibly de-identified.
3.3.1.3.
If neither of the above apply, patient consent may be
required. If in doubt, advice should be sought from the
relevant institutional Ethics Committee.
3.3.2. Material used for this educational purpose should be properly attributed
during the presentation to the pathologist of record and the practice from
which it has originated.
3.3.3. For many educational purposes, it may be sufficient to do no more than
present the findings and conclusions of the pathologist of record without
modification. If, however, in addition to presenting the original findings,
there is a review of the material with production of a second opinion, the
process set out in 3.2 above should apply.
3.3.4. Unless agreed otherwise, once the educational activity has ended, the
entire material should be returned to the pathologist of record as soon as
possible.
3.4
Review of material requested for purposes of research
3.4.1. Again the issue of patient consent requires consideration. This should be
provided in writing unless the request is accompanied by documentation in
relation to the project from the relevant Institutional Human Research
Ethics Committee(s) indicating that this is not required. This may require
the material to be de-identified. Provided this issue is resolved and the
project is
bona-fide research, co-operation should not be unreasonably
withheld.
3.4.2. The material should be used only for the purpose specified in the original
request. A further request must be made if additional studies are to be
made together with evidence of approval of the change to the project by
the Institutional Human Research Ethics Committee.
6
3.4.3. In the event that a researcher wishes to provide a second opinion, the
process of 3.2 must be followed with an approach to the pathologist of
record being made before this is done.
3.4.4. Unless agreed otherwise, any residual material should be returned when
the research is complete.
3.4.5. Unless the pathologist of record and/or the laboratory concerned is a
participant in the research, an offer should be made by the researchers to
cover any costs incurred in providing the material.
3.5
Review of material requested for medico-legal, commercial, insurance or
employment purposes
3.5.1. Unless covered by a
subpoena, or some other legally enforceable
instrument of power (see 3.6), the written consent of the patient must be
supplied before complying with the request. Once supplied however, it is
suggested that any refusal to comply with the request should occur only
following legal advice.
3.5.2. With requests of this type, the pathologist of record usually has no
entitlement to a copy of the report of the pathologist of referral however the
pathologist of referral should clarify the legal status of the report and their
own medico-legal status with respect to the case with their medical
indemnifier.
3.5.3. When the material is no longer required for the purpose for which it was
requested, it should be returned as soon as possible.
3.5.4. All reasonable costs associated with compliance should, as a rule, be met
by, or on behalf of, the person making the request.
3.6
Review of material required under a subpoena, warrant or some other legally
enforceable instrument
3.6.1. The demand must be in writing and the pathologist of record or other
named person or any other person with authority to respond must satisfy
themselves that is in order.
3.6.2. Such valid requirements must be complied within the manner and time
limits specified. If however, the person who is required to respond has
concerns about the validity or appropriateness of the demand, advice
should be sought from the legal advisor to the pathology practice. This is
particularly relevant if the demand is to produce a range of material and
documents apparently more extensive than would seem to be necessary
for the intended purpose (sometimes referred to as a “fishing expedition”).
Application to the court concerned may result in some limits being placed
on the scope of this demand.
3.6.3. The material should be returned to the practice providing the information
as soon as possible as once it is no longer required.
3.6.4. In a civil case, reasonable expenses to cover costs of compliance should
be paid by the person or organisation making this demand. In some
jurisdictions, and for some services, there may be a set scale of fees and
charges. In criminal cases, material and documents may have to be
produced without any costs being paid, eg. in response to a search
warrant.
7
3.7
Request by a patient for reports and material
3.7.1. The purpose of the request must be established clearly. An interview with
the patient may be necessary in order to ensure the patient understands
the possible implications for future testing if material is no longer available.
3.7.2. If this request has arisen because the patient is travelling overseas or
interstate and has a continuing medical condition, it would be reasonable
to provide the patient with a copy of each relevant report in an envelope to
be given to any attending medical practitioner.
3.7.3. It would be inadvisable to provide the patient with any actual material,
particularly if this is of an irreplaceable nature, but contact details should
be provided so that it could be forwarded to any pathologist of referral who
may in future become involved in this patient’s case.
3.7.4. In the event of a patient’s insistence that all material be provided, the
problem should be resolved in accordance with the policy of the practice.
Legal advice may be necessary.
3.8 “Irreplaceable
Material”
There are some types of pathological material where the quantity containing the
medically significant changes is small, eg. a slide of a single level of one block of
tissue, a tissue block which has been almost cut through or a single abnormal
cytology smear.
When such material is requested for review in any of these situations set out
above, it is recommended that:
3.8.1. All reasonable options for the pathologist of referral to review the
irreplaceable specimen in the laboratory that currently controls the
specimen should be examined.
3.8.2. If there are no such options, the material must be transported to the
requesting laboratory by a secure method, eg. courier, taxi or registered
mail.
3.8.3. If the material relates to a clinical or medico-legal issue of critical
importance, a detailed photographic or electronic record may be advisable
before it is dispatched.
3.8.4. It would be advisable to notify the laboratory or pathologist of referral of its
dispatch including date, time and identity of the carrier and any relevant
invoice or waybill number. Receipt should be notified to the laboratory that
has dispatched the material.
3.8.5. When examination has been completed at the referring laboratory, the
material should be returned by the same, or equivalent, secure method.
3.8.6. The requesting laboratory or persons for whom they are acting should bear
the full costs of transport to and from the referring laboratory unless agreed
otherwise.
3.9
Australian Medical Benefits Schedule Items for Morphological Second Opinion
8
3.9.1 There are two items in the Australian MBS schedule (72858 & 72859) to fund the
provision of morphological second opinions.
3.9.2 The items are available to be used in two different scenarios:
(i)
a pathologist of record requests a second opinion on a difficult case from
an expert referral pathologist, or
(ii)
a non-pathologist clinician requests a second opinion in a case where
some doubt exists regarding the diagnosis in order to facilitate appropriate
care of the patient
3.9.3 The two items (72858: non-complex <30 mins opinion and 72859: complex >30 mins
opinion) are restricted to services covered by histology items, non-gynaecological
cytology items and bone marrow items, where the second opinion is provided by a referral
pathologist located in a different laboratory (APL) to the pathologist of record. The item
descriptors also require that a full written report is provided.
3.9.4 Additional investigations (such as further IHC tests) may be requested and funded in
addition to the second opinion item, and the specimen referred fee (73940) may recoup
some of the administrative and handling costs (at least for the referring laboratory).
3.9.5 The items are not intended to provide funding for intra-departmental/intra-institutional
case review, quality assurance activities or mandatory/routine review of all cases referred
to treatment centres. Simple presentation of non-controversial referred cases at Multi
Disciplinary Team meetings are expected to be funded only under Multi Disciplinary Team
meeting items 871 & 872.
3.9.6 In order to limit inappropriate utilisation of the items, in both scenarios, current MBS
descriptors require that the pathologist of record and the requesting clinician must agree
that a second opinion is reasonably necessary for diagnostic purposes for further clinical
management of the patient.
3.9.7 In scenario (i), this means that the pathologist of record needs to obtain sign-off from the
requesting clinician.
3.9.8 In scenario (ii), this means that the pathologist of record has to agree with the requesting
clinician to refer the case for second opinion in the interests of optimal patient care. This
does not necessarily imply that the original pathologist of record’s report is inconclusive or
wrong, but recognises that the requester may have access to other information which
leads them to seek confirmation/clarification of the diagnostic findings before proceeding
with definitive treatment.
In this scenario:
The request for material to be sent for second opinion clearly comes from the
treating clinician, who should attest that the second opinion is required for optimal
patient management
The request should clearly indicate the referral pathologist to whom the material
should be sent for second opinion
The request should include an acknowledgement by the pathologist of record that
by releasing the case they agree with provision of a second opinion being
reasonably necessary in the interests of appropriate patient management. This
acknowledged position should not be unreasonably withheld.
The request should include appropriate patient demographic details and Medicare
assignment information.
3.9.9 If there is more than one pathologist of record (eg multiple specimens from different
laboratories) permission should be obtained from each.
9
3.9.10 Professional collegiality is required to make these items workable, both on the part of the
pathologist of record, and by the referral pathologist, who may be in possession of
additional/follow-up information not available to the pathologist of record.
Attachment A provides an example of a form that could be used requiring a second
opinion for scenario (ii) above.
3.10
Charges by the pathologist of referral for providing second opinions when the MBS
Item is not available
When a pathologist is requested to provide a second opinion on pathological
material from a pathology practice different from the one by which they are either
employed or otherwise engaged, a charge may be made by or on behalf of the
referral pathologist should the MBS item not be available to them for the service.
In rendering any such charge, the following should apply:
3.10.1. The likelihood of such a charge being made should be advised before any
work is undertaken in providing the second opinion and, in general,
practices should publish their scale of charges. If charges are to be
directed to the patient, they should be advised of charges and consent to
payment be obtained prior to the work being undertaken.
3.10.2. The charge should have regard for the substantial professional component
involved in provision of many second opinions.
3.10.3. Responsibility for ensuring payment of any charge shall lie with the person
or organisation initiating the request for the second opinion and, where
appropriate, assurances in respect of payment may be sought before any
review is done. In the event that it is intended that the charge for such
review is to be paid by the patient concerned, and not by or on behalf of
the clinician, an employing institution or other third party, the clinician,
should obtain the patient’s informed consent and advise the pathologist of
referral accordingly in writing.
3.10.4. Any revenue accruing from provision of second opinions shall be treated in
the same way as revenue for any other professional services provided by
the referral pathologist.
3.10.5. Pathologists and pathology practices should have an unrestricted right to
waive any such charge. The College would expect the proprietor of a
pathology practice to heed the advice of the pathologist providing the
second opinion that the charge be waived.
3.11
Charges by or on behalf of the pathology practice to recover costs involved
in providing second opinions which it has not requested when the MBS Item
is not available
3.11.1. Where the material is provided other than in accordance with a statutory
duty or a contract for which no charge can be made, it would be
reasonable for the pathology practice concerned to recover any significant
costs.
3.11.2. Any such charge should be notified promptly to the requestor before the
material is provided.
10
3.11.3. The charge should be sufficient only to recoup costs necessarily incurred
in responding to the request or in accordance with any applicable
published scale of fees.
4. Conclusion While the statements in this document may cover many of the situations encountered in current
practice it is unlikely that they will deal with every eventuality.
As a general guiding principle, however, any action should be judged on whether it has as its
principle objective of safeguarding the interests of the patient concerned. In addition, any actions
with a potential to be controversial should be documented by adequate contemporaneous notes.
In addition, in the event of difficulties, advice should be sought as appropriate from professional
colleagues in the practice concerned, Office Bearers of this College, any relevant Institutional
Ethics Committee and if necessary, legal advisers of the practice.
Attachment A is found on the following page:
11
REQUEST FOR A SECOND OPINION ON HISTOPATHOLOGY OR CYTOPATHOLOGY
PATIENT DETAILS or PATIENT LABEL
ORIGINAL LABORATORY DETAILS
NAME:
ORIGINAL PATHOLOGY LABORATORY:
DOB: DD/MM/YYYY UR NO:
ADDRESS:
REF/ACCESSION NO:
DATE OF COLLECTION: DD/MM/YYYY
.
MEDICARE NO:
.
A Medicare Rebate is available for a second
opinion on histopathology and cytopathology
samples where both the original pathologist and
CLINICAL INFORMATION/REASON FOR
specialist involved in the care of the patient are in
REQUEST
agreement that a second opinion is reasonably
required for confirmation of diagnosis and
management planning.
By releasing this case material for review, the
initial pathologist agrees the above criteria are
met.
PATIENT ASSIGNMENT OF MEDICARE REBATE
MEDICARE AGREEMENT
(Section 20A of the Health Insurance Act 1973)
I offer to assign my right to benefits to the approved pathology
practitioner who will render the requested pathology service(s)
SELF DETERMINED ☐
and any eligible pathologist determinable service(s) established
as necessary by the practitioner.
REFERRING CLINICIAN
SIGNATURE:
NAME:
DATE: DD/MM/YYYY
PROVIDER NO:
PRACTITIONER USE ONLY:
Reason patient cannot sign:
I confirm that I am involved in the care of this
patient and request a second opinion for
confirmation of diagnosis and treatment planning.
State the patient’s status at the time of this request
SIGNATURE:
DATE: DD/MM/YYYY
PLEASE SEND A COPY OF THIS FORM TO THE
REFERRAL LABORATORY WITH A COPY OF
THE PATHOLOGY REPORT, PLUS:
REFERRAL LABORATORY DETAILS
Stained Slides
REFERRAL LABORATORY:
A representative block (which will be
returned) in case additional IHC is required
(or 10 unstained sections on positively
charged slides)
ADDRESS:
A COPY OF THE 2ND OPINION WILL BE
PROVIDED TO BOTH THE REQUESTING
CLINICIAN AND ORIGINAL PATHOLOGIST.
CASE MATERIALS WILL BE PROMPTLY
If an opinion is required from a specific
RETURNED TO THE ORIGINAL LABORATORY.
pathologist, please nominate:
DETAILS OF MATERIAL PROVIDED:
[if unavailable the case will be referred to another
appropriate pathologist in the practice]
12
