Using a pencil in the laboratory? Absolutely verboten. If you write down something in the lab, make sure it’s in indelible ink, magic marker, or perhaps blood. Something, anything, that can’t be erased.

Does a tech need to make a change in what they see on an instrument printout? Our accreditation regulations (courtesy of the College of American Pathologists) are pretty strict:

Original (erroneous) entries must be visible (ie, erasures and correction fluid or tape are unacceptable) or accessible (eg, audit trail for electronic records).Corrected data, including the identity of the person changing the record and when the record was changed, must be accessible to audit.

In layman’s terms, that means carefully drawing a line through your mistake, initialing, and then dating your correction.

So what am I doing wearing pencil after pencil down to its nub? I am making sure I am the best pathologist I can be.

Through this part of my career, looking at multitudes of prostate biopsies, I have developed, inaugurated, and continuously improved a printed, unofficial worksheet that I use for every prostate case. At the top of each sheet our laboratory information system prints the patient’s name, age, medical record number, and pathology case number. I then search the medical record and add in relevant clinical history, such as previous biopsy findings, PSA values, and results from imaging studies.

The sheet then contains a row for every biopsy location. After looking at each slide I can quickly pencil in whether I think the biopsy is benign or malignant, what the Gleason Grade is, the extent of tumor, and any special studies I want to perform. It is really a very efficient way for me to work.

And I do it in pencil. Why? Because diagnostic pathology is not all ink–it is an art as well as a science. Cancer cells don’t actually have a big “C” on them under the microscope. Malignant changes can be striking, but they can also be subtle, and first impressions can sometimes be misleading.

Sometimes looking at the 7th core in a patient’s biopsy series can affect how I view what I saw on the 3rd biopsy. Sometimes special stains are going to nudge me to call a biopsy malignant that I had originally noodled in as “atypical.” Sometimes viewing a core the next morning will clarify my thinking, or a word from my associates will lead me in a better direction. When any of those things happen I grab my worksheet and out comes my pencil, eraser end first. And I mark down my new, improved, diagnosis.

Eventually, the worksheets get turned into our administrative team, entered into a digital pathology report, and following my electronic signature, become very official. Corrections can still be made, but only through a very regimented procedure, with documentation of every step. No more pencils, no more erasers.

But rest assured, the next morning I will be at the sharpener, getting my favorite diagnostic tool ready for another busy day.

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