Errors in Oncology Pathologies

Pat Croskerry croskerry at EASTLINK.CA
Wed Aug 14 13:01:32 UTC 2013


Good discussion. Certainly, the context of specific findings is critical to
their correct interpretation, so ideally some minimum set of objective data
should be provided with specimens and for imaging studies.

But the framing bias that Mark mentions, and ascertainment bias (slightly
different but amounting to 'you see what you expect to see') are extremely
powerful and can be shown to influence decisions without the decision maker
being aware of them.

I strongly support Ehud's approach. The potential for bias to interfere with
judgment seems to depend very much on what stage someone else's thinking is
introduced - it seems best to delay any decision until you have
independently made your own. One strategy we use in emergency medicine is
not to read the triage note or the nurse's note (or even listen to any
comments from others) until after we have seen the patient. This is
cumbersome and redundant at times, but seems to work. I remember a savvy and
well regarded radiologist who used to insist on not being told anything
about the patient until after he had made his first interpretation of the
film. He also used to talk about the benefit of 'not having seen the
patient' - implying that patients too can be misleading in the way they
frame information to you. 

 

_____________________________________________________________

Pat Croskerry MD, PhD, FRCP(Edin)

Professor,Department of Emergency Medicine, 

Director, Critical Thinking Program, Division of Medical Education,

Faculty of Medicine,

Dalhousie University,

QE II - Health Sciences Centre,

Halifax Infirmary, Suite 355

1796 Summer Street, Halifax, Nova Scotia, B3H 2Y9 

CANADA

 

Phone:  902 821 2014 (home)

               902 225 0360 (cell)

 

From: Michael.H.Kanter at KP.ORG [mailto:Michael.H.Kanter at KP.ORG] 
Sent: Wednesday, August 14, 2013 2:03 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Errors in Oncology Pathologies

 

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

NOTICE TO RECIPIENT:  If you are not the intended recipient of this e-mail,
you are prohibited from sharing, copying, or otherwise using or disclosing
its contents.  If you have received this e-mail in error, please notify the
sender immediately by reply e-mail and permanently delete this e-mail and
any attachments without reading, forwarding or saving them.  Thank you.




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
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> 
>> For additional information and subscription commands, visit:
>>  <http://www.lsoft.com/resources/faq.asp#4A>
http://www.lsoft.com/resources/faq.asp#4A
>> 
>>  <http://list.improvediagnosis.org/> http://LIST.IMPROVEDIAGNOSIS.ORG/
(with your password)
>> 
>> Visit the searchable archives or adjust your subscription at:
>>  <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>> 
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>>Society for Improving Diagnosis in Medicine
>> 
>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>> <a 
>>href="
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPR>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPR
>>OVEDX&A=1" 
>>target="_blank">
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?S>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?S
>>UBED1=IMPROVEDX&A=1</a>
>> </p>
>> 
>> 
>> 
>> For additional information and subscription commands, visit:
>>  <http://www.lsoft.com/resources/faq.asp#4A>
http://www.lsoft.com/resources/faq.asp#4A
>> 
>>  <http://list.improvediagnosis.org/> http://LIST.IMPROVEDIAGNOSIS.ORG/
(with your password)
>> 
>> Visit the searchable archives or adjust your subscription at:
>>  <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>> 
>> Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair,
>>Society for Improving Diagnosis in Medicine
>> 
>> To unsubscribe from the IMPROVEDX list, click the following link:<br>
>> <a 
>>href="
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPR>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPR
>>OVEDX&A=1" 
>>target="_blank">
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?S>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?S
>>UBED1=IMPROVEDX&A=1</a>
>> </p>
>> 
>
>To unsubscribe from the IMPROVEDX:
>mail to:IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG
>or click the following link: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
>Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
>
>For additional information and subscription commands, visit:
> <http://www.lsoft.com/resources/faq.asp#4A>
http://www.lsoft.com/resources/faq.asp#4A
>
> <http://list.improvediagnosis.org/> http://LIST.IMPROVEDIAGNOSIS.ORG/
(with your password)
>
>Visit the searchable archives or adjust your subscription at:
> <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX
>
>Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
>for Improving Diagnosis in Medicine
>
>To unsubscribe from the IMPROVEDX list, click the following link:<br>
><a 
>href="
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPRO>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPRO
>VEDX&A=1" 
>target="_blank">
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SU>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SU
>BED1=IMPROVEDX&A=1</a>
></p>



For additional information and subscription commands, visit:
 <http://www.lsoft.com/resources/faq.asp#4A>
http://www.lsoft.com/resources/faq.asp#4A

 <http://list.improvediagnosis.org/> http://LIST.IMPROVEDIAGNOSIS.ORG/ (with
your password)

Visit the searchable archives or adjust your subscription at:
 <http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?INDEX

Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
for Improving Diagnosis in Medicine

To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
" target="_blank">
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1>
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1
</a>
</p>



  _____  



To unsubscribe from IMPROVEDX: click the following link:
http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX
<http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=
1> &A=1 

or send email to: IMPROVEDX-SIGNOFF-REQUEST at LIST.IMPROVEDIAGNOSIS.ORG



Moderator: Lorri Zipperer Lorri at ZPM1.com, Communication co-chair, Society
for Improving Diagnosis in Medicine

To learn more about SIDM visit:
http://www.improvediagnosis.org/


Save the date: Diagnostic Error in Medicine 2013. September 22-25, 2013 in
Chicago, IL. 
http://www.dem2013.org








To unsubscribe from the IMPROVEDX list, click the following link:<br>
<a href="http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1" target="_blank">http://list.improvediagnosis.org/scripts/wa-IMPDIAG.exe?SUBED1=IMPROVEDX&A=1</a>
</p>

HTML Version:
URL: <../attachments/20130814/fbd8b729/attachment.html>


More information about the Test mailing list