SAN FRANCISCO As director of the University of Colorado Hospital's dermatopathology services, Dr. James Fitzpatrick manages the handling of 70,000 skin specimens each year, with about 3,000 of those being pediatric specimens.
Those numbers posed a problem for Dr. Fitzpatrick, whose staff (including him) at the Aurora, Colo., hospital numbered only four dermatopathologists, the equivalent of 2.6 full-time employees, none of whom were trained specifically to handle pediatric cases. They got little quality support from the general pathologists, he said.
"General pathologists as a rule are not very good at dermatopathology, particularly in pediatric dermatopathology," he said at a meeting of the Society for Pediatric Dermatology. "There are a lot of glaring omissions" in their reports.
What he needed, he decided, was a pediatric dermatopathologist who also could help with the adult dermatopathology workload.
Dr. Fiztpatrick made his case to the chair of the university's dermatology department and to the Children's Hospital in Aurora, and managed to get funding from the Children's Hospital for a pediatric dermatology fellow to learn dermatopathology from him and his staff.
Some physicians criticized the plan, claiming that anyone could do pediatric dermatopathology.
Dr. Fitzpatrick disagreed: "There are a lot of issues that are unique to pediatric dermatopathology."
For example, there was one skin specimen from a 2-year-old that looked exactly like Sweet's syndrome on histology. Clinically, however, the child had osteomyelitis and anemia, two of the clinical features of genetic Majeed syndrome. Further confusing the diagnosis was the fact that Majeed syndrome, like Sweet's syndrome, can cause fever.
"What's the likelihood of your general pathologist or adult dermatopathologist, like me, getting it right? You really need someone with the proper background" to put the clinical and histologic picture together to make the right diagnosis, he said.
The ideal background for pediatric dermatopathology probably should include knowledge of pediatrics and of genetic syndromes, Dr. Fitzpatrick suggested. Training a dermatology resident or pediatric dermatology fellow to become a dermatopathologist probably makes more sense than trying to teach pediatrics to a dermatopathologist or a pathologist, who lacks clinical expertise.
The department chair wanted to know how the position would pay for itself.
"It's actually an easy sell, because you make more money in dermatopathology than you do seeing a bunch of kids" in clinic as a dermatology fellow, he noted.
The plan has worked out beautifully, Dr. Fitzpatrick said.
Dr. Lori Prok, who is the new pediatric dermatopathologist, works in an office right next to his. "When a clinician calls up and says, 'I have a 3-year-old,' I say, 'Hold on a second.'" He can then transfer the call to Dr. Prok for better care.
Those who were resistant at first to the idea of a pediatric dermatopathologist have since come around. "Now, if Lori's gone for 2 days, they hold everything until she gets back," Dr. Fitzpatrick said. Every other week, a case conference brings Dr. Prok together with pathologists, dermatopathologists, and pediatric dermatologists from several departments.
Dr. Fitzpatrick and Dr. Prok have expanded her role since she started to fill another voidresearch in pediatric dermatopathology.
She is involved in multiple research projects dealing with Spitz nevi, the role of Polyomavirus in Langerhans cell histiocytosis, and varicella zoster virus, to name a few.
Pediatric dermatopathology is a niche whose time has come, but so far it has been discovered by only a few physicians, said Dr. Fitzpatrick. If you search the Internet for pediatric dermatopathologists, you'll find a grand total of two, one of whom is Dr. Prok, he noted.