Errors in Oncology Pathologies

Rose, Barbara (VHA) Barbara.Rose2 at VA.GOV
Wed Aug 14 10:53:24 UTC 2013


I would say that sending information about symptoms and signs is better than labeling a patient with a presumptive diagnosis. At least then you have a fighting chance of making a choice from a list of potential diagnoses rather than falling in line with someone else's opinion.

Barbara Rose, PhD, RN
Clinical Quality Specialist
Risk Management Program
Office of Quality, Safety, and Value (10A4E RM)
810 Vermont Avenue, NW 
Washington, DC 20006

(O) 202-461-1505
(M) 202-870-2812


-----Original Message-----
From: Graber, Mark [mailto:Mark.Graber at VA.GOV] 
Sent: Tuesday, August 13, 2013 4:51 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
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


________________________________
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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