Introducing Dx Biases and too much information ... studies needed?

Perez-Ordonez, Bayardo Bayardo.Perez-Ordonez at UHN.CA
Tue Aug 13 23:42:44 UTC 2013

I am surgical pathologist with administrative responsabilities in a large medical centres in Canada. As general principle, the more information we have, the more accurate or helpful our reports will be. The information needed by a liver pathologist dealing with a core biopsy of a patient with acute liver failure are quite different from those needed by a head and neck pathologist dealing with biopsy of  a tongue mass.  Some information is useful, some might represent "red herrings" but knowing what is useful requires a combination of knowledge and experience which is hard to compress in a forum like this. Clinical information influences even how specimens are processed. We sample differently a resected femoral head fracture in a patient with no history of malignacy from a femoral head in a patient with radiologic evidence of a pathologic fracture. Far too often we even lack basic clinical information and diagnostic pathology is a poor and expensive screening procedure. More information is better! 
Bayardo Perez-Ordonez, MD   

----- Original Message -----
From: Lorri Zipperer [mailto:Lorri at ZPM1.COM]
Sent: Tuesday, August 13, 2013 07:16 PM
Subject: [IMPROVEDX] Introducing Dx Biases and too much information ... studies needed?

Forwarded by moderator

From: Robert Bell [mailto:rmsbell at] 
Sent: Tuesday, August 13, 2013 4:42 PM

Could it be that histologists and radiologists do not want too much
information for fear of a diagnostic bias being introduced?

After all one presumes accuracy is pretty good now. Would more information
improve or compromise accuracy? Studies needed?

Rob Bell

Sent from my iPad

On Aug 13, 2013, at 2:45 PM, James Oldham
<James.Oldham at SESIAHS.HEALTH.NSW.GOV.AU> wrote:

> Dear Mark
Great point. So we may need to define the diagnostic process between path
referral and path interpretation, which may be different for many common
path requests. (Is is just abnormal histology and imaging that presents this
too many alternatives problem?)
Clinical situation (differential would help) -> path request (how can it
> Great discussion
> Best wishes
> James
> James Oldham
> Chief Psychiatrist Mental Health Services ISLHN & Clinical Associate 
> Professor University of Wollongong

> -----Original Message-----
> From: Graber, Mark [mailto:Mark.Graber at VA.GOV]
> Sent: Wednesday, 14 August 2013 6:51 AM
> Subject: Re: [IMPROVEDX] Errors in Oncology Pathologies
> Thanks Jena for corroborating the value of Peggy's advice. I've heard very
similar comments from my Radiology colleagues, that supplying clinical
information improves their ability to make the right call.
> I'm worried though that this may sometimes bias the review and 'frame' the
case prematurely.  These kind of framing effects are SO common elsewhere, as
illustrated by the Rory Staunton case (His pediatrician communicated to the
ER that she was sending over a boy with gastroenteritis, and no surprise
that was the ER diagnosis too, missing his sepsis).  So if I send you a
lymph node saying 'Pt with weight loss, night sweats, lymphadenopathy,
suspected lymphoma', aren't you going to be biased towards a diagnosis of
lymphoma by that?
> Maybe the better way to frame this is to ask your advice:  How can
clinicians best provide clinical information WITHOUT inducing undue bias in
the subsequent pathologist's (or radiologist's) diagnosis?
> Mark
> Mark L Graber, MD FACP
> Senior Fellow, RTI International
> Professor Emeritus, SUNY Stony Brook School of Medicine Founder and 
> President, Society to Improve Diagnosis in Medicine
> Phone:   919 990-8497

Moderator: Lorri Zipperer Lorri at, Communication co-chair, Society for Improving Diagnosis in Medicine

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