Errors in Oncology Pathologies

Michael.H.Kanter at KP.ORG Michael.H.Kanter at KP.ORG
Wed Aug 14 05:02:53 UTC 2013


I am a pathologist who has practiced for over 20 years.  I think that 
there is a big difference between improving diagnosis and decreasing 
diagnostic errors that is not often talked about.  A pathologist will 
almost never make an error if he/she hedges their diagnosis with words 
like "suspicious, atypical, cannot rule out, suggest clinical correlation, 
ect.  In my view, the main reason to look at the clinical histtory and 
information is to understand what question is being asked by the person 
doing the biopsy and what information will best help the patient.  So, if 
one gets a lung biopsy in the clinical setting of a lung mass that is 
suspicious for cancer and sees interstitial fibrosis, the interpretation 
and report will be very different than if the biopsy is from someone with 
diffuse interstitial lung disease seen on x ray where the pathologist 
should be noting if the findings are consistent with UIP rather than is 
cancer present or are there atypical cells.  So, in the setting of diffuse 
interstitial lung disease, without the history, the pathologist will 
likely just give a description of what is on the slide rather than an 
informative interpretation.  The idea is that if the pathologist has some 
sense of the clinical setting, in cases where the slides are not clearly 
diagnostic of something, a more reasonable differential diagnosis can be 
made. 
         Moreover, a better diagnostic work up can be done by the 
pathologist.    In the lymph node biopsy example below, the interpretation 
if benign looking may consider infectious diseases are cause the 
pathologist to order fungal stains or other stains/cultures than if in an 
afebrile pt with a history of melanoma.  Sometimes outright errors can be 
prevented as well.   A bone biopsy in a benign looking x ray can look very 
worrisome for malignancy if interpreted without thinking of the x ray.
Perhaps the analogy would be if an internist tried to do a physical exam 
without any history.  What we he/she examine and how would it all be 
interpreted? 

In terms of getting second opinions in all cases with small biopsies, I 
usually reccommend that people get an odd number of opinions. 

Michael Kanter, M.D.
Regional Medical Director of Quality & Clinical Analysis
(626) 405-5722 (tie line 8+335)
THRIVE By Getting Regular Exercise

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From:   Alan Morris <Alan.Morris at IMAIL.ORG>
To:     IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Date:   08/13/2013 05:00 PM
Subject:        Re: [IMPROVEDX] Errors in Oncology Pathologies



This discussion concerns a version of confounding by intention.  However,
since all diagnostic conclusions are influenced by prior probabilities,
withholding information is often a bad idea.  In the 1970s, when we
developed our first rules for interpreting lung function tests, we
required a brief history and physical, and (most important) an
articulation of the question the clinician wanted addressed, before we
would perform lung function testing.  The current state of clinical
practice no long allows that kind of rigor.  Diagnostic rules that
incorporate the pertinent clinical information, with their associated
probability inferences, can deal with this issue of confounding by
intention.  More information, as long as the interpretive rules are
comprehensive and adequate explicit, seems clearly the better approach.
Have  a nice day.

Alan H. Morris, M.D.
Professor of Medicine
Adjunct Prof. of Medical Informatics
University of Utah

Director of Research
Director Urban Central Region Blood Gas and Pulmonary Laboratories
Pulmonary/Critical Care Division
Sorenson Heart & Lung Center - 6th Floor
Intermountain Medical Center
5121 South Cottonwood Street
Murray, Utah  84157-7000, USA

Office Phone: 801-507-4603
Mobile Phone: 801-718-1283
Fax: 801-507-4699
e-mail: alan.morris at imail.org
e-mail: alanhmorris at gmail.com



On 8/13/13 4:33 PM, "Robert Bell" <rmsbell at ESEDONA.NET> wrote:

>Good point Mark.
>
>Would symptoms only and other "tests" work better?
>
>Rob Bell
>
>Sent from my iPad
>
>On Aug 13, 2013, at 1:50 PM, "Graber, Mark" <Mark.Graber at VA.GOV> wrote:
>
>> 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
>> 
>> 
>> ________________________________
>> From: Jena Giltnane <jennifer.giltnane at vanderbilt.edu>
>> Reply-To: Society to Improve Diagnosis in Medicine
>><IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Jena Giltnane
>><jennifer.giltnane at vanderbilt.edu>
>> Date: Tue, 13 Aug 2013 15:43:56 -0400
>> To: <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> Subject: Re: [IMPROVEDX] Errors in Oncology Pathologies
>> 
>> Peggy Zuckerman writes, "Clinicians can assist pathologists with more
>>accurate analysis of underlying disease by providing pertinent clinical
>>information and radiologic testing to the pathologists. 4" As a junior
>>pathologist, I am ever so grateful that she included this simple
>>statement. All of the missed and delayed diagnoses I have encountered so
>>far (thankfully, few, but more than I imagined) had a significant
>>component of minimal to no supporting clinical information, or even
>>misleading information. I insist that all of my family and friends get a
>>second oncology and/or pathology opinion when a major treatment decision
>>is based on a limited biopsy. Thankfully, referral pathology is often a
>>"package deal" when a patient seeks a second oncology opinion, and so
>>this may be the best route for patients to pursue. It works best,
>>however, when the pathology material can be received and reviewed with
>>ample time before the patient's visit.
>> 
>> Best regards, Jena
>> Jennifer M. Giltnane, MD, PhD
>> Dept. of Pathology, Microbiology, and Immunology
>> Division of Investigative Pathology
>> Arteaga Lab @ Vanderbilt University School of Medicine
>> jennifer.giltnane at vanderbilt.edu
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
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