In 1988 the Department of Health (DOH) recognized the cytology screener grade of laboratory staff. Cytology screeners have a 2 year training period after which they must sit a ‘competence examination’. the British Society for Clinical Cytology offers an examination to meet the DOH specification. It consists of a written paper, a practical screening test, a spot test and a short viva voce. the screening test is paramount and candidates who miss a dyskaryotic smear cannot be successful. In the first 3 years there have been 22 examinations, 294 candidates and a pass rate of 76%. the majority of candidates were Cytology Screeners of 2–3 years experience but significant numbers of Medical Laboratory Scientific Officers (MLSOs) and senior MLSOs also chose to sit the examination.

As part of a programme of assessment of the 'Sterotix' localisation device, aspiration cytology was carried out on 50 patients with 52 impalpable, mammographically detected breast lesions using the stereotaxic guidance device. This was followed by an open localisation biopsy of the area for confirmation. In 12 patients (23%) the aspirations failed to yield sufficient material for diagnosis. This was frequently due to the poorly cellular nature or very small size of the lesions. Of the remaining 40 patients, 15 were regarded as having both mammographically and cytologically benign changes which were confirmed histologically; they could thus have been spared diagnostic surgery. Ten patients had a diagnosis of malignancy with both investigations, and could have had planned investigation and subsequent definitive surgery. Of the remainder, 14 lesions had a report of malignancy or suspicion of it with either technique and these patients would have come to conventional localisation biopsy. Only one patient was found to have a malignancy, who had cytologically benign and mammographically 'probably benign' disease: this was an invasive lobular carcinoma with a dominant in-situ component and may well have been an incidental finding on biopsy.

HistopathologyVolume 13, Issue 4 p. 465-467 Primary pulmonary lymphoma: a case diagnosed by bronchial cytology and immunocytochemistry D. R. GOULDESBROUGH, Corresponding Author D. R. GOULDESBROUGH Department of Pathology, University of Edinburgh Medical School, Edinburgh, ScotlandAddress for correspondence: Dr D. R. Gouldesbrough, Department of Pathology, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, Scotland.Search for more papers by this authorE. McGOOGAN, E. McGOOGAN Department of Pathology, University of Edinburgh Medical School, Edinburgh, ScotlandSearch for more papers by this author D. R. GOULDESBROUGH, Corresponding Author D. R. GOULDESBROUGH Department of Pathology, University of Edinburgh Medical School, Edinburgh, ScotlandAddress for correspondence: Dr D. R. Gouldesbrough, Department of Pathology, University of Edinburgh Medical School, Teviot Place, Edinburgh EH8 9AG, Scotland.Search for more papers by this authorE. McGOOGAN, E. McGOOGAN Department of Pathology, University of Edinburgh Medical School, Edinburgh, ScotlandSearch for more papers by this author First published: October 1988 https://doi.org/10.1111/j.1365-2559.1988.tb02064.xCitations: 4AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Citing Literature Volume13, Issue4October 1988Pages 465-467 RelatedInformation

or accepted by clinicians. Some certainly give the autopsy a very low rating, as witness some of the responses to a questionnaire[3] circulated by Dr Cameron and I to clinical consultants in the South Lothian District. Dr Cameron[2] quotes several adverse opinions, to which I add one more: 'I discourage the request of a PM except in those cases where the diagnosis is uncertain'. To ascertain whether these attitudes are justified, or whether the hospital autopsy, in addition to improving the accuracy of death certification and mortality statistics, has a role in refining clinical diagnostic expertise, it was necessary to obtain relevant facts and figures. For this purpose, we conducted a prospective review of 1,152 consecutive routine hospital autopsies[4]. These did not include any Fiscal, neonatal or paediatric cases. The clinical data were recorded and authenticated by a senior clinician before autopsy. Comparison of clinical and autopsy diagnoses showed that, with an autopsy rate of 25 per cent, autopsy failed to confirm 39 per cent of main clinical diagnoses, and also failed to confirm 66 per cent of other conditions considered to have contributed to death. We tried to relate the frequency of confirmation to the clinician's confidence in his diagnosis; in 47 per cent of cases the diagnoses were certified as 'fairly certain'; 'uncertainty' was expressed in only 16 per cent. We found that, even when clinicians were reasonably confident of their diagnoses, their main diagnoses were not confirmed in 25 per cent of cases (Table 1).

A further analysis of 1152 hospital autopsies provides data on inaccuracies of specific diagnoses; there are many examples of overdiagnosis and underdiagnosis. All were encountered in a routine hospital autopsy service and their frequency confirms the importance of the hospital autopsy in medical audit. A knowledge of the misdiagnoses which recur frequently could provide guidance in the selection of cases for autopsy.

Comparison of certified clinical diagnoses with autopsy findings showed that, while the major cause of death was confirmed in 61 per cent. of cases, many diagnoses--both major and contributory--were wrong; many clinical diagnoses were either disproved or relegated to a less important role, and many autopsy findings had not apparently been anticipated. Accuracy was particularly poor in some clinical categories: notably cerebrovascular disease and infections. In these, the diagnosis was more often wrong than right. Thus, death certificates are unreliable as a source of diagnostic data. The clinician's confidence in his major diagnosis bore a fairly close relationship to the frequency of its confirmation. Nevertheless, even when certified as "fairly certain", the major diagnosis was wrong in about one-quarter of these cases. An attempt was made to assess the significance of incorrect diagnoses; one half of these might be clinically significant. Diagnostic accuracy did not improve with the time spent in hospital, and it bore an inverse relationship to the patient's age.

An attempt to obtain necropsies on all deaths from a selected group of clinical units resulted in a necropsy rate of 65% (compared with a normal of 30% in these units). The effect of increasing the necropsy rate was to produce a higher rate of confirmation of clinical diagnoses; nevertheless, 15% of main diagnoses and 42% of causes of death were not confirmed. A large proportion of these were deemed by clinicians in consultations with pathologists to be clinically significant. Of main diagnoses considered certain, 10% were not confirmed. The proportion of diagnostic discrepancies was virtually identical in two groups--those in which the clinicial believed he would normally have requested necropsy, and those in which he would not. Thus clinical confidence in the diagnosis is not an adequate assurance of its accuracy. Although in this survey necropsy was requested on almost all cases, permission was refused in many which may be attributed either to resistance by relatives or to an inadequate approach by the medical staff. The proportion of permissions secured by individual units varied from 50% to 92%. This indicates that the nature of the approach to relatives is the more important factor. As present practices do not adequately allow for the detection of a wide range of misdiagnoses and missed diagnoses it is proposed that a "partial audit" would provide a valuable yardstick; clinicians would be asked to obtain permission for necropsy on an agreed proportion (say, 20%) of deaths over and above those cases in which they are particularly interested and would normally request a necropsy.

An enquiry into the attitudes of clinical consultants to autopsies was conducted by questionnaire. Responses indicate that most of the consultants accept that the autopsy is important in hospital practice and in teaching. There are, however, marked differences of view on the reasons for doing autopsies, and on the results of autopsies (e.g. in altering diagnoses or revealing unsuspected pathology), differences which influence the frequency with which autopsies are requested. Some clinicians believe that increasing resistance by relatives to granting permission contributes to the falling rate, but this is a minority view. Clinicians also vary in their reactions to the falling rate, some regarding it as worrying while others are not concerned.

Examination of mortality statistic for Scottish hospitals showed that from 1961 to 1974 necropsy rates fell by almost 0-6% a year; by 1974, the rate over the whole country was 23% of hospital deaths. The fall resulted from a reduction in the number of necropsies and a coincident rise in the number of number of deaths in hospital. The necropsy rate fell with increasing age, was rather lower for women than men, and was lower for some diseases than others. There were considerable inaccuracies in the figures from which these trands were drawn, and these were in turn due to inaccurate recording of clinical and necropsy data. Examination of necropsy returns from the Scottish teaching hospital departments showed that, while a similar fall in necropsy rates was seen in some, there was no consistent pattern.