Difficulties With Diagnosis

I’m impressed that the Boston Globe printed a number of insightful letters in response to its Mistakes that matter
article, which discussed the case of two patients whose prostate cancer
biopsies got mixed up. (One had cancer, the other didn’t. The one
without cancer got surgery as a result of the mixup, the one with
cancer had delayed treatment and possibly negative consequences as a

Two of the four letters are from patients who were tested for
cancer. The best is one from Irving Sacks of Peabody, documenting how
he searched widely for alternative treatments after being diagnosed
with cancer of the esophagus. In the end he found out from a medical
center in California that he had another condition –not cancer– and
didn’t need the proposed surgery to remove his esophagus. He says (and
I concur):

When confronted with a life-threatening
medical assessment, do not rely on a single diagnosis, and, when
getting a second opinion, go outside the network, even to another city.

Edgar Dworsky of Somerville wasn’t persuaded that he had prostate
cancer after the first pathologist said the slides were “suspicious for
cancer,” so he took the same slides to another pathologist who said he
“definitely” had prostate cancer and a third who said the slides were
“highly suspicious for prostate cancer.” Based on that set of findings
he’s decided he doesn’t (yet) have prostate cancer and has embarked on
a program of watchful waiting rather than active treatment. At least
from what he’s written it’s a little hard to follow his logic but for
his sake I hope he’s right.

Arthur Rosenthal of Salem points to a New England Journal of Medicine article (Mortality Results from a Random Prostate-Cancer Screening Trial)
that showed screening didn’t make it less likely that those tested
would die from cancer. As Rosenthal points out, screening may not save
you from dying from cancer but it can induce worry by making you think
you do have cancer. I agree with that.

Finally, Dr. Donald Ross,
past president of the Massachusetts Society of Pathologists, but
writing on his own behalf, says the problem is profit-driven corporate
labs. Unlike hospital-based practices such as his, which he asserts
follow precautions to avoid mix-ups, such labs drive through so much
volume that they increase workload and lead to errors. I’m willing to
keep an open mind on Ross’s point, but he doesn’t cite evidence showing
lower error rates. I’m also unconvinced that profit-seeking companies
are any more interested in revenue than independent physicians.

In any case I’m glad to see the Globe provide so much information on the practical challenges in getting the right diagnosis.

David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma, biotech, and medical devices. Formerly with BCG and LEK. He blogs regularly at the Health Business Blog, where this post first appeared.

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5 replies »

  1. Dr. Esties, I am not sure why you implicate computers in your cited reference. I find the article confusing and incomplete, as might be expected of a reporter’s understanding of a complicated issue. For instance, pathologists typically do not review every negative pap smear; they are screened by certified cytotechnologists. Are you saying these slides underwent computer screening instead?
    Other allegations are intriguing but one must try to read between the lines. I’d have to say, “need more information”.

  2. Most physicians I work with are pulmonary docs. We do a lot of bronchoscopy biopsies on smokers in the lab, sometimes with the pathologist there. When the path doc is present, I’m always fascinated by their discussion about the tissue, history, onset of symptoms, etc. It’s like putting together a 10,000 piece puzzle of the sky. We’re all trying to find that right shade of blue piece to make it all fit together. They really do go back and forth always trying to get the right diagnosis.
    But when we send samples to the lab, that is a different story as bev M.D. points out. Did the sample get labeled properly. Did it get handled properly and documented on properly.
    These are two very real and different issues and I think bev M.D. stated it best on both points.

  3. This post conflates two separate issues. The Globe article was about process errors resulting in prostate biopsies being read out on the wrong patients, not diagnostic error. The letters, apparently, concerned actual errors in diagnosis on patients – in other words, errors of medical knowledge or opinion. It is important to distinguish between these two vastly different sources of error, as the fixes are different.
    Dr. Kent Bottles, a fellow pathologist, said it best in a comment on another post – while a pathology report is often regarded as the final word (similar to a lab test), it in fact is simply an expert opinion. Everyone knows experts may disagree, and there are varying degrees of expertise. Most cancer diagnoses are straightforward, but limited amounts of tissue, pathologist inexperience, or just plain mistakes may lead to inaccurate diagnoses, just as in any other specialty.
    Advances in research on genetic/molecular/metabolic signatures of tumors will someday provide much more objective, and accurate, cancer diagnoses. I do not know any ethical pathologists who do not look forward to that day.

  4. “Tissue is the issue” is a common phrase in the oncology setting. Even with tissue, the quality of the pathological review is sometimes inadequate as described in this post. While second opinions are frequently requested by patients on treatment questions, they are not as often requested on the actual diagnosis.
    Even among fellowship trained oncology pathologists, there is not always agreement on whether a specimen is, in fact, malignant. It is common practice to have equivocal slides evaluated by another or sent to a specialist in the disease in question.
    In the academic setting, pathologists are able to focus their attention on a very limited number of diseases. In the community, a pathologist usually does not have that luxury. A second opinion from a specialist can provide a community pathologist an important resource in ensuring that the right call is made.

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