Errors in Oncology Pathologies

Brian Goldman brian.goldman at CBC.CA
Wed Aug 14 13:15:47 UTC 2013


I bow of course to Pat Croskerry's expertise in cognitive biases.  However,
not all framing leads to framing errors!  When it comes to assessing a
frail senior with and sometimes even without mild dementia who has complex
disease and 12 or more meds, meeting the patient virtually before a face to
face by looking at old records is essential to getting the most out of the
encounter in the flesh.


On Wed, Aug 14, 2013 at 9:01 AM, Pat Croskerry <croskerry at eastlink.ca>wrote:

> 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
>
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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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