Errors in Oncology Pathologies

Karen Cosby kcosby40 at GMAIL.COM
Thu Aug 15 19:07:51 UTC 2013

I agree with Dr. Gordon (and of course I am a practicing emergency
physician).  Listening to this dialogue, I am surprised how awkward the
exchange of clinically relevant information is when it is indirect, say via
a search of the medical record or review of an order. Whenever possible I
find a first hand conversation is the most effective way to yield useful
information.  Both sides can ask questions, discuss nuances of the case,
and question each other's findings.  Back when I was a student and attended
"tumor board" I was amazed at how often pathologists and radiologists
altered their opinion when provided background and context.  Many of the
significant errors I've seen reported have to do with generalists
mis-interpeting written reports or specialists not fully understanding
clinical context.  Why is our practice designed to make a conversation the
exception rather than the rule?

On Wed, Aug 14, 2013 at 3:07 PM, David Gordon, M.D.
<davidc.gordon at>wrote:

> I wanted to share some other thoughts in hope of contributing to this very
> useful discussion. This comes from the perspective of an emergency
> physician practicing at an academic center with many radiology
> interpretations coming preliminarily from residents - not board certified
> attendings, so not all of this may be generalizable to practice at-large.
>  (I also can't speak to how this applies to pathology as I do my best to
> avoid these services in my line of profession).
> 1) In terms of measuring overall diagnostic accuracy in radiology, I
> wanted to echo a point made by Stefanie Lee in a separate thread that there
> can be value in engaging the radiologist prior to the study being performed
> to make sure the correct study has been ordered in the first place (e.g., a
> chest CT to evaluate for pulmonary embolism will be protocolized
> differently for one to exclude aortic dissection).  I have a general sense
> for the protocols out there, but also know there are times where I need to
> confer with my radiology colleagues.   So in asking overall  whether
> clinical information helps or hinders radiologic diagnosis, not only
> correct image interpretation but also correct study acquisition should be
> considered.
> 2) I take a variable approach in terms how much information I provide to
> the radiologist and more specifically whether I just provide "clinical
> data" or additionally provide a preliminary "clinical impression."  This is
> based on whether the patient is still broadly undifferentiated or whether
> there is a specific disease process I am worried about. I always provide
> clinical data (e.g., location of pain, presence of fever, leukocytosis,...)
> and if the patient is undifferentiated  that is all I provide. If, however,
> there is a diagnosis jumping out at me that I am specifically looking out
> for, I will also include this preliminary impression  in the form of
> "concern for..."  Perhaps never providing a clinical impression will prove
> to be best, but I wanted to toss out the idea that how differentiated a
> patient is prior to the radiologic study may be an important variable.
> 3) In terms of asking overall what model of information exchange will
> provide the best diagnostic yield, I wanted to toss out the role of the
> clinicians looking not only at the impression of the radiologist but also
> the images themselves. This may be more relevant at a teaching hospital and
> more feasible in an emergency medicine setting where the time frame is
> condensed, but by looking at the area of interest that correlates with
> concerning physical exams findings, we have had good "catches."  It has
> forced the review of specific images that broadly "just don't look right"
> to  the emergency medicine physician.  This is typically done after the
> radiologist has viewed the images independently to avoid bias. For unclear
> or complicated cases, going over the clinical data as well as images
> together may be an important step.
> Thanks,
> David
> David Gordon, MD
> Assistant Clinical Professor
> Division of Emergency Medicine
> Duke University
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> ________________________________________
> From: Follansbee, William [follansbeewp at UPMC.EDU]
> Sent: Wednesday, August 14, 2013 2:20 PM
> Subject: Re: [IMPROVEDX] Errors in Oncology Pathologies
> I have been following this conversation with interest.  I would concur
> with Mark and others' comments relative to risk of framing bias in
> interpretation of studies. Just to give a different example, I have been
> reading nuclear cardiology studies for ~ 30 years. I have always had as a
> standard practice in our department that we do not want to know anything
> about the patient until we have finished reading both the stress and the
> imaging portions of the tests. Only then are the fellows allowed to present
> the clinical information, which is then used to modify or fine tune the
> interpretation as appropriate. If the clinical information is presented in
> the beginning, it can heavily bias the interpretation of the imaging
> studies, which by their very nature are subjective.
> At least in our relatively uncomplicated situation, it has not been
> difficult to make the approach standard practice, but I could envision it
> being more complicated with pathology interpretations, for example. One
> issue is the availability of the clinical information (easy for us, less
> easy for pathologists), and the other is the sequence as to when in the
> interpretation process the clinical information is accessed and utilized.
> Bill
> William P. Follansbee, M.D., FACC, FACP, FASNC
> The Master Clinician Professor of Cardiovascular Medicine
> Director, The UPMC Clinical Center for Medical Decision Making
> Suite A429 UPMC Presbyterian
> 200 Lothrop Street
> Pittsburgh, PA 15213
> Phone: 412-647-3437
> Fax: 412-647-3873
> Email: follansbeewp at
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> -----Original Message-----
> From: Graber, Mark [mailto:Mark.Graber at VA.GOV]
> Sent: Wednesday, August 14, 2013 9:56 AM
> Subject: Re: [IMPROVEDX] Errors in Oncology Pathologies
> I like Ehud's suggested approach too, a lot.  (I copied it just below my
> message, as it seems to be on a different string at this point).  Reviewing
> the clinical history AFTER you've performed your first look seems to be an
> ideal solution.  You avoid the initial possibility of framing and
> ascertainment bias, you have the chance to incorporate the clinical
> information, and you enjoy the added benefit of second thoughts -  along
> the lines of Robert Trowbridge's diagnostic 'time out' concept, or Mamede's
> 'reflective practice'.
> This would seem to be a great research project (comparing accuracy of
> diagnosis with first vs last review of clinical data) for someone out there
> (I'm thinking Jena .......).
> I hadn't really thought about it, but I actually enjoy using Ehud's
> approach when I do a urinalysis (I'm a Nephrologist). I do the UA first and
> then try to GUESS the clinical scenario after I see the findings.  It
> changes the clinical puzzle into  a game, making it more interesting for me
> and the trainees.  There is actually some good literature that this kind of
> mental activation improves decisions and problem solving skills ( and I can
> use all the help I can get!)
> Listserv discussions are one thing, but the real question is how we could
> translate this suggestion into practice.  Is it ready for prime time or
> does it need research validation?  How could we move this idea into trials
> or practice ??  Someone (Ehud - this has your name on it) needs to publish
> this !
>      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
> The earlier comments from Ehud Zammir:
> "I believe both of the above are true. Accurate clinical info should be
> provided to anyone who is required to diagnose, whether it is a
> radiologist, a pathologist or a colleague clinician asked to provide a
> second opinion. However, the radiologist/pathologist/clinician providing a
> second opinion should, in my opinion, keep that referral information to the
> end of their diagnostic routine. An unbiased, fresh diagnostic process is
> priceless. If, at the end of an independent assessment (without reading the
> referral), one reaches a conclusion which is consistent with previous
> diagnoses,  the diagnosis is likely to be correct (the odds of two
> independent observes making the same error are fairly slim). If there is a
> discrepancy, one should go back and reassess, with the clinical information
> in mind. The conclusion may remain the same (e.g. if referrer's diagnosis
> is incorrect) or change (initial impression of diagnostician/second opinion
> incorrect).
> If, however, one reads the referral prior to independently assessing the
> patient/Xray/path slide, there is a potent bias introduced into the
> process. I call it "the bias of the question posed" and I have seen
> examples where even the most obvious findings are repeatedly missed by
> multiple doctors due to such questions. If not allowed to independently
> assess the data first, many competent doctors will be distracted by the
> referrer question in the same way the participants in the "Invisible
> gorilla" experiment did (see YouTube if you don't know it). As an
> ophthalmologist I see patients who come from other ophthalmologists or from
> optometrists for a second opinion . I make it a point to ignore the
> referral information until after I have taken an independent history and
> examined the patient myself. Many pathologists and radiologists follow the
> same routine. I think the issue is not whether or not clinical info is
> available, but whether that info is allowed to colour the diagnostic
> process. Keep it till the end and you will have a truly SECOND opinion,
> free of assumptions and distractions."
> Ehud
> ________________________________
> From: "'croskerry at eastlink. ca'" <croskerry at>
> Reply-To: Society to Improve Diagnosis in Medicine <
> IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, "'croskerry at eastlink. ca'" <
> croskerry at>
> Date: Wed, 14 Aug 2013 09:01:32 -0400
> Subject: Re: [IMPROVEDX] Errors in Oncology Pathologies
> 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
> 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>
> 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
> e-mail: alanhmorris at
> 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>
> >> Reply-To: Society to Improve Diagnosis in Medicine
> >><jennifer.giltnane at>
> >> Date: Tue, 13 Aug 2013 15:43:56 -0400
> >> 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
> >>
> >>
> >>
> >>
> >>
> Moderator: Lorri Zipperer Lorri at, Communication co-chair, Society
> for Improving Diagnosis in Medicine
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