At First Glance,Descriptive reports are time-consuming and often go unread—yet even so, they hold value, as physicians, patients, families, and even lawyers can refer back to them later. Not every case requires a descriptive report, but they can be used for clarification, explanation, inference, or even catharsis. Even if not immediately referenced, descriptive reports retain their worth—someday, their creation will be rewarded.
Both my wife and I work at two tertiary-care academic centers in Chicago—she is a pulmonary critical care physician, and I am a pathologist. Since our institutions are close, it’s common for patients to transfer between them. At that time, I was still in residency. One evening, while having dinner together, she mentioned seeing my name on a pathology report, which thrilled me immensely.
To protect patient privacy, we couldn’t discuss many details, but I was eager to know which patient it was and what type of tumor. Unfortunately, she told me it was an autopsy report I had issued—the patient had been transferred from her hospital to mine after passing away. It was as if I were the chief prosecutor, and her team had received a courtesy report.
I was very proud of my autopsy report because I always put extra effort into autopsy pathology work, like a diligent archaeologist piecing together each puzzle with hidden clues. I felt my report was well-summarized and hoped to hear some praise for my professional skills from her, but I was disappointed!
“You guys didn’t find the cause of death?” she said, stuffing salad into her mouth.“But I’m sure I mentioned something in the descriptive part of the report,” I insisted.
“Oh, I just read the report summary,” she mumbled with a mouthful of food.“No one reads the full report—you know that, right?””
“Of… of course!” I said against my will. “What about that report I wrote?” I wished she had violated HIPAA so I could report her.“I shredded it.”“Just like my hopes and dreams,” I muttered.
I had an epiphany, albeit a bit exaggerated. My wife has seen all kinds of patients in the ICU—bleeding, strokes… My summary points in the microscopic descriptions were worthless to her, but surely those descriptions mattered to my pathology colleagues… right?
Later, I continued striving and became a hematopathology fellow. That year, I delved deeper into pathology, an area I had known little about before. Sitting at the microscope, learning from masters was an extraordinary experience—and an inspiring one. It made me want to be the best pathologist so I could show them that nurturing me was worthwhile. Our reports back then were long—averaging three pages, each a work of art. Pathologists from across the country would send us very difficult cases they thought were undiagnosable; my mentors would unravel these mysteries, send back detailed reports, revealing the secrets of the cases in microscopic descriptions.
Did others appreciate these reports? If it was a definitive diagnosis, some praised them, but for descriptive reports, few did. Every now and then, we’d encounter pathologists from other hospitals—they’d jokingly tease us about the length of our reports. “Who has time to read them?” “No one reads them.” “What’s the use of the description?” “Don’t say too much!” “The more you say, the more lawyers will use your wording!” “I prefer shorter reports over longer ones…” Clinicians weren’t much better. They’d tell me, “No one reads these things, Kamran,” “I don’t even know where the diagnosis is,” or even, “Why don’t you just say ‘correlate clinically’ and be done with it?” These remarks were heartbreaking blows to what I considered a labor of love, poured from my heart.
I admit writing pathology reports can be exhausting. It’s busy work, and by the end of countless reports in a day, I’m drained. But when my HP is running low, I pause and listen. From the open doors of my colleagues’ offices, I can hear the mentors’ cell counters clicking, their keyboard taps echoing—and my spirit reignites. I read the reports written by these hematopathology giants and draw inspiration from their greatness.
Two things helped me decide.
When I started my formal practice, I was at a crossroads. What would my reports look like? Of course, they would be comprehensive, containing all necessary information. But could they have more? Would the contours of malignant nuclei, the exact texture of chromatin, or the shading in the cytoplasm be meticulously described? Could every case, whether malignant or benign, common or rare, be given the same loving description—or not?
The first was a phone call I received during my residency, from my mother, calling from our hometown thousands of miles away.It was, first and foremost, a uterine issue.She is also a doctor and had been experiencing some strange symptoms, leading to a pathological biopsy. On the phone, my mother subtly said, “Beta (my nickname), my pathology report came back malignant.” At that moment, two reactions surged within me: the pathologist’s reaction and the son’s reaction. As a pathologist,I took a deep breath, considering the future. Should my mother come to the U.S. for a hysterectomy? How would we handle insurance? But she insisted on having the surgery in our hometown. I suggested she go to my medical school’s affiliated hospital, a prestigious institution with an excellent pathology department. She did as I said, and the surgery went smoothly—except for one small problem: they found no cancer. Wait, what? Something must be wrong. I couldn’t believe it; I needed to see the pathology report. I had a strange feeling that if they had found and reported cancer in my mother’s hysterectomy specimen, I would have been happier and more confident; at least then, I could be sure there was nothing undiscovered to worry about.I wanted to know everything about the remaining endometrium. Was it a polyp? What were the secretion changes? As her son, I wanted to know if she was okay. But I was too far away and couldn’t easily leave, so I asked her to read me the entire report. Apparently, the specimen had two parts—a polyp and an endometrial curettage. As far as I could tell, they had placed both my mother’s polyp and endometrium in one specimen cassette, and now I had no idea which part had cancer. A vague description, no site specified, no histological grade provided. Just “carcinoma,” nothing more to go on.
Then I opened my mother’s pathology report—an apparently innocuous attachment in an email. I started reading, ready to tear it to shreds. Guess what I found? The gross description was impeccable. Inked margins were perfectly described, and sampling seemed adequate and correctly done. They found no tumor, so they had entirely submitted the entire endometrium. Then I encountered a surprise: detailed microscopic descriptions. For a case ultimately called benign, I wasn’t used to seeing lengthy microscopic descriptions. But as I read the words, I could visualize the pathology slide before me. Descriptions of glandular epithelium with benign nuclei, emphasizing relevant differential points like lack of mitoses or necrosis; a magical prose-style depiction of normal stroma around glands; sprinkled with some chronic inflammation for effect; reassuring statements about multiple sections examined; even a small leiomyoma was satisfyingly described as “tightly packed interlacing bundles of cells with elongated nuclei and abundant eosinophilic cytoplasm.”
When I finished reading the report, I truly felt I didn’t need to see my mother’s pathology slides. I was completely reassured—literally. The pathologist took the time to write a report that, to many, might seem a waste of time, but to this patient’s son (also a pathologist), it meant the world. A secret language passed from one pathologist to another, almost telepathic.
The second thing happened early in my career, during my residency. “How do you ensure you don’t miss dysplasia in the hematopoietic lineage, Dr. Mirza?” followed by, “How do you ensure you’ve thoroughly evaluated this bone marrow aspirate smear?” and many similar questions about the adequacy of bone marrow examinations. At first, I didn’t know how to respond to these intimidating residents. Although the WHO classification of hematopoietic tumors outlines how to do this perfectly, it’s itself an intimidating read. When I thought about it, I realized that while reviewing pathology slides, I could write my own microscopic descriptions in my mind. Every pathologist does this. As the field of view moves, we look at patterns, structures, features, contours, atypia, pleomorphism, variations, characteristics, colors, textures…
When I look back on my early career, this is exactly what my hematopathology mentors were doing—and teaching me to do. So now, I encourage my residents and fellows to write microscopic descriptions. They don’t have to be long. As pathologists, being able to express your feelings about cells (figuratively) is key. Being able to articulate these words on paper greatly helps our abilities as trainees. You only have one training period, so make the most of it. Microscopic descriptions will go a long way.
As for practicing pathologists… I’ve personally experienced the beauty of microscopic descriptions. It truly is a secret language we can use to communicate with other pathologists worldwide. It transcends ordinary conversation in ways that are hard to explain in plain English. Of course, not every gastrointestinal biopsy specimen can have extensive microscopic descriptions, nor can the 17th case of the day, a typical myeloma, but there’s always something that can be said microscopically. If used judiciously, pathological descriptions can still play a role—even in this fast-paced, crazy world.
The ability to translate what you see under the microscope into prose is the essence of the highest-level pathologists—hence, it’s no surprise that microscopic descriptions are called “painting with words.” While it sounds romantic, let’s face it: descriptive reports have their time and place. More than 150 GI biopsy cases a day? Not all reports are descriptive. More importantly, not every report should be descriptive; unnecessary descriptions can confuse the reader.
So when is it appropriate and effective to include descriptions in a report? Do all pathology reports need descriptions? There are no guidelines on what to include or how to write microscopic descriptions in a way clinicians can easily interpret—certainly no guidelines on when such reports are needed. Published data show that pathologists tend to use certain phrases to indicate specific levels of diagnostic certainty, but this usage isn’t standardized, and such personalization can be a source of great confusion. There’s a reason for report brevity and the existence of synoptic reports! Therefore, first, the legal communication aspect of the report—through the final diagnosis and synoptic report—should be crystal clear. It also needs to be clarified that a pathology report does not need microscopic descriptions to be a complete legal document. That said, allow me to share my thoughts on some situations where descriptive analysis might be valuable.
1. Expert Consultation Opinions.
So far, the simplest example of a useful descriptive report is a consultation opinion, where a case has been sent to an expert for their input. The description (distinct from the diagnosis or final interpretation) serves as the expert’s explanation to the pathologist on how to interpret the findings. If expert opinion is needed due to diagnostic uncertainty, clarification through description is most useful for the primary pathologist or clinician.
2. Clarifying a Controversial Diagnosis.
Similar to the above, certain tumors or diagnoses don’t play out exactly as written in textbooks. In such cases, a descriptive report explaining the specific clues that led the pathologist to confidently conclude (even if stains or morphological features are ambiguous) is useful for other pathologists who may review subsequent biopsies or re-examine the original material. This information often isn’t in the final diagnosis—but that doesn’t diminish its importance.
3. Explaining Minor Components.
Often, if a biopsy result isn’t malignant—for example, when the final diagnosis for a 10 cm, radiologically concerning mass is “acute inflammation”—a descriptive report can inform the reader that the submitted specimen may not represent the entire lesion. The old adage “correlate clinically” might actually serve a purpose here. Descriptive reports can be a channel to explain the pathologist’s “subjective feel” for the case without overstepping.
4. Intelligent Speculation on Data.
While I absolutely do not tolerate any speculation in reports, descriptive reports can serve as a platform for inferring histological/cytological findings in the appropriate clinical context—detailed morphological assessment of residual myelodysplastic syndrome, or the presence of only mature neuroblastoma components. These instances deserve acknowledgment in the final diagnosis, but the details of their appearance belong in the descriptive report. For example, description of findings might lead to: “Although no residual tumor is identified, the distribution of these findings is consistent with a tumor bed.”
Sometimes, I’ve put a lot of thought into a case—maybe I just want to talk about it in the microscopic description. It’s my report, so I will! As long as I ensure only relevant information is included, there’s no harm. On many occasions, I’ve seen certain pathology masters include statements like “This is a difficult case to describe,” which not only summarize their thoughts but also serve as catharsis after days of patiently working on the case.
This is by no means an exhaustive list of times for descriptive analysis of cases—but whatever your reason for such reports, they shouldn’t be repetitive or confusing. There’s no need to repeat what’s already said in the final diagnosis; no one wants to say the same thing twice, and it leaves a bad impression. If included, descriptive reports should clarify the diagnosis—not complicate it. Descriptive reports should only be accepted if they aid clarity. Introducing differential diagnoses after the final answer or dwelling on ambiguous morphological features or stain markers is redundant.
I find the best way to write descriptive reports is to literally describe what you see. For tissue sections (non-cytology), I find it helpful to start from the outside in. Does the lesion have a capsule? Is it a pseudocapsule? Describe the cells of interest and the surrounding context. Descriptions of nuclear and cytoplasmic features are fundamental; comments on special features like “differentiation” or nuclear immaturity come in handy. In some cases, describing from the inside out works too. Are the cells cohesive, or are they free-floating and epithelioid? Do they have clues of rhabdoid differentiation or strongly eosinophilic nuclei? Details on how free-floating cells detach from nests and infiltrate distantly, ignoring barriers and causing havoc in their spread. It’s common to list all immunohistochemical markers performed in a second paragraph after the description, then allow a summary paragraph to conclude your thoughts, with a final line noting anything you haven’t mentioned. Be careful not to say anything untrue, don’t take risks if you don’t need to, and always remember—these are legal reports and can always be used against you in court. It does sound a bit alarmist, but if you have no reason to mention something or jump to a conclusion, don’t write it blindly!
By sharing my insights on why microscopic descriptions are personally important to me, I hope to emphasize their value when appropriately executed. The stakeholders here aren’t just other pathologists but also patients and families themselves. In this era of “Baidu search” answers, where our patients have abundant medical knowledge (correct or incorrect) at their fingertips, considering the utility of descriptive reports in informing patients might not be a bad idea—at least for those who want to know. For archival purposes, some of these descriptions help eventually correlate different molecular changes with new disease morphologies. As you can see, there are many good reasons to consider whether to include descriptive reports—but for me, they were most helpful during my training. They helped me coordinate my skills and communicate my progress as a pathologist to my mentors. I cannot overemphasize the importance of these reports to my own trainees.
Indeed, we can’t convince everyone to read these reports—but not everyone has to. If well-written, the value of such reports remains within them. I can’t guarantee when their value will be realized—perhaps the next day when the patient receives the report; perhaps next week when another pathologist reads it; or perhaps a century later by a medical archivist—but I can say with certainty: your efforts will not be in vain.
Translator of this article: Wang Xiaolu, Yichang Central Hospital
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