EXECUTIVE SUMMARY
Although virtually all pathologists reported being involved in an error, only about a third knew if the error had been disclosed to the patient, says a recent survey. Some ethical concerns include the following:
- Pathologists worry that providers don’t fully understand how the error occurred.
- Most pathologists are unaware of institutional disclosure policies.
- Providers may inaccurately imply the error was the pathologist’s fault.
Virtually all pathologists (97%) reported being involved in a minor or serious error, but only about 39% knew whether the error had been conveyed to the patient, according to a recent survey of 106 pathologists, presented at the 2015 annual meeting of the College of American Pathologists. Other key findings include the following:
- Only 11% of practicing pathologists reported that they had participated directly in disclosing a serious error to a patient.
- Less than half (40.7%) of practicing pathologists were aware of their hospital’s error disclosure policy.
There are many reasons why pathologists may not feel comfortable disclosing errors to patients, providers, or colleagues, says Melissa Austin, MD, MBS, a Bethesda, MD-based pathologist affiliated with Walter Reed National Military Medical Center.
“Lack of training, lack of experience, and lack of necessity all contribute,” she says. Some pathologists view the provider as their client rather than the patient, since they have more direct interaction with providers.
“That said, I would assert that institutional culture probably plays the greatest role in determining how likely the pathologist is to be involved in error disclosure,” says Austin. She says bioethicists should work to create a focus on quality improvement that destigmatizes errors and error disclosure.
“Pathologists are viewed as partners in the care team, rather than as detached consultants,” says Austin. “It becomes easier and more natural for them to be actively engaged.”
COMMUNICATION LACKING
Pathologists often view their role as consultants to physicians instead of caregivers to patients, says Suzanne M. Dintzis, MD, PhD, associate professor of pathology at University of Washington Medical Center in Seattle.
A 2011 survey conducted by Dintzis and colleagues showed that many pathologists regarded the end point of the disclosure to be when the error was revealed to the treating physician.1 They worried, however, that physicians didn’t really understand the nature of the error to adequately convey the information to patients and families.
“A lot of the issue involves communication,” says Dintzis. “There is also a general feeling that pathologists are not comfortable with their communication skills.”
Pathologists aren’t sure that providers or patients fully understand what they do. “They worry that the ambiguity of pathology diagnosis isn’t fully understood,” says Dintzis. “Some of these diagnoses are very subjective, and a lot of what we do is interpretation.”
In focus groups, pathologists themselves disagreed on which types of errors should be disclosed. “Many people think that disclosing near misses, where a lab error is caught before it harms a patient, would be unhelpful and possibly deleterious,” Dintzis says. Although all the surveyed pathologists believed serious errors should be disclosed, “we know that’s not always happening,” she adds.
DIRECT DISCLOSURES?
Pathologists worry that patients may be given misinformation about the error or how it occurred, or that providers never disclosed the error at all. “There’s a lot of difference of opinion on how aggressively they should insert themselves in trying to disclose the error, because they don’t have a relationship with the patient,” says Dintzis.
On the other hand, pathologists want to be sure the error is disclosed, and that it is a true representation of an often complex situation. “There could be a clear-cut explanation for the error that would relieve patient stress,” says Dintzis.
When the pathologist is not present, “we worry we will be thrown under the bus,” says Dintzis. “For all we know, the clinician might tell the patient, ‘The pathologist just totally screwed this up.’”
Many focus group participants felt that pathologists should take the initiative in joining the discussion with the patient. “But almost all didn’t think they should do it without the treating clinician’s approval, because that’s intrusive,” Dintzis says.
Most pathologists received no training in error communication and were not aware of resources at their institution. “They thought coaching would be incredibly helpful, but didn’t even know that option existed,” Dintzis says.
Professional guidelines are silent on the issue of whether a pathologist should ever directly disclose an error to a patient or family. “Most pathologists would feel we don’t want to intrude on the relationship,” says Dintzis. “But we want to make sure that the information and apology is complete.”
REFERENCE
- Dintzis SM, Stesenko GY, Sitlani CM, et al. Communicating pathology and laboratory errors: anatomic pathologists’ and laboratory medical directors’ attitudes and experiences. Am J Clin Pathol. 2011; 135(5):760-765.
SOURCES
- Melissa Austin, MD, MBS. Department of Pathology, Walter Reed National Military Medical Center, Bethesda, MD. Email: [email protected].
- Suzanne M. Dintzis, MD, PhD, Associate Professor of Pathology, University of Washington Medical Center, Seattle. Phone: (206) 598-1986. Fax: (206) 598-3803. Email: [email protected].
