A picture (in the microscope) is worth a thousand words

Many of us (especially the old-timers) went into hematology with the realization that this was a unique opportunity to correlate “bedside medicine” with the picture portrayed in the microscope. Not many other subspecialties of medicine permit the chance to evaluate a patient by history and physical examination, look in the microscope, and quickly offer an assessment or a diagnosis. The picture (microscope) and the picture (patient's clinical problem) viewed simultaneously could not be equaled in other specialties; for example, the endocrinologist awaits the postal service delivery of the hormone levels, the rheumatologist requires the results of antibody testing, and the pulmonologist needs the culture results or biopsy.

In this issue of Blood, we are reminded again about the fundamental need for information that is provided by the microscope. An assessment has been made of telehematology for use in remote areas of the globe. Luethi and colleagues (page 486) investigated the accuracy and potential problems of transmitting digital images of peripheral blood and bone marrows by electronic mail or by real-time conference methods. Not unexpectedly, e-mail–transmitted image interpretations are very dependent on the skills of the laboratory personnel who prepare them (quality of the stains, areas of slides that are photographed, number of images that are transmitted, etc). Although acceptable, especially for use in remote areas, these methods are much improved by real-time teleconferencing. The efforts of the authors are to be applauded and further development should be encouraged. The reasons are obvious: the clinical hematologist requires the correlation of clinical and microscopic material, the physician in a remote area need not wait extended time for information retrieval, and the patient needs a diagnosis with reasonable speed and accuracy for prompt transport, if necessary, to adequate facilities.

This paper should alert us to a similar need in our local areas, most of which are not in underdeveloped countries or in geographically distant sites. Unfortunately, the picture from the microscope has grown distant from patient evaluation for other reasons. Blood counts are performed by machines that make judgments as to whether a smear should be reviewed by human eyes. Insurance contracts often insist that blood counts and bone marrow evaluations be performed by reference laboratories that may be remote from the clinical location. Errors in judgment made by the staff at reference laboratories or misinterpretations by treating clinicians who read transmitted reports have already been reported. In addition, modern hematology contributes to a shift in emphasis from microscopic assessments (peripheral smears and bone marrow) to flow cytometry, chromosomal analyses, and molecular diagnostic testing. However, the flow cytometry report that is diagnosed as acute promyelocytic leukemia on a patient with leukocytosis and blasts is not valid until the microscopic picture affirms the diagnosis. The patient with thrombocytopenia need not have an expensive laboratory and radiologic investigation if the history, physical examination, and a microscopic picture show platelet clumping or reveal large platelets associated with polymorphonuclear leukocytes that contain Dohle bodies.

Teleconferencing and telehematology are indeed needed greatly in remote areas. However, this paper reminds us that the value of the microscope and of telehematology should enter, if it has not done so already, into many of our current locations. Hematologists must remain as the connector between “bedside medicine” and the laboratory. The picture of clinical findings and the picture from the microscopic are worth a thousand words.