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Pⁿ Blog
The Pⁿ Blog is a forum for opinions, questions, controversies, and instructive discussions across the field of pathology and its relevant subspecialties.
Monday, March 26, 2012
What if the Doctor is Wrong?
A recent article in the "Informed Patient" section of the Wall Street journal is entitled, "What if the doctor is wrong?"  It's written by resident Wall Street Journal columnist Laura Landro.   Like any good pathologist, I was prepared to hate this article, but it's actually a relatively balanced discussion of this topic.  The article begins with the description of a woman with a pelvic mass initially thought to be an ovarian carcinoma, but ultimately determined to be a difficult to diagnose follicular lymphoma.   The initial biopsy was interpreted as inconclusive and a subsequent larger biopsy was required for the diagnosis.  The (mis)interpretation as probable ovarian carcinoma was based on clinical and radiographic observations, not a pathologic misdiagnosis.
 
The article then discusses the value of and indications for second opinions, particularly with regard to radiographic and pathologic diagnoses.   To its credit the article does not get bogged down regarding nuanced differences in diagnosis (atypical ductal hyperplasia v. intraductal carcinoma, for example), rather it focuses on differences in diagnosis that have important clinical consequences.  A number of interesting statistics emerge.  For example, more than half of women having mammograms for a decade will have a false positive recall for a repeat screen.   A spokesman for M.D. Anderson indicates that for certain high-risk diagnoses such as lymphoma, up to 25% of patients undergo revision of their original outside diagnoses.  The article also reviews a study of 742 cancer diagnoses referred for second opinion.  9% had their diagnoses revised.  What is unclear is whether these revisions were minor or clinically meaningful.  Interestingly, the highest number of revisions (16%) was for the diagnosis of thyroid carcinoma.  My suspicion is that this was the result of the overdiagnosis of the follicular variant of papillary carcinoma.  The second highest revision rate (11%) was for salivary gland malignancies.  I suspect that most of these were minor terminology differences of little if any clinical significance.  A spokesman from Hopkins indicated an 8% clinically significant disagreement rate with reviews of outside pathology for patients admitted to their institution.
 
At the University of Virginia, all patients admitted for outside-diagnosis-based therapy are required to have their outside pathology material reviewed prior to initiation of therapy unless emergent treatment is required or confirmatory biopsy material can be obtained at the time of the therapeutic procedure, but before its initiation.  Our own signficant disagreement rate is in the range of 3-6%.
Of course, as the old saying goes, "A man with two watches never knows what time it is."  When there are two diagnoses, who's to say which is correct?  Being an academic medical center most certainly does not insure infallibility.  In our department, descrepant diagnoses on examination of outside material are always reviewed by at least two and sometimes several more concurring pathologists before a differing report is issued. 
 
As the article rightly points out, not all diagnoses require second opinions, and the overuse of this approach can leave patients overwhelmed by conflicting information.  Ultimately, patients may be better served if they pick a physician they trust and accept his or her recommendations regarding treatment or the need for second opinions. 
 
The article only touches in passing on the need for and use of internal reviews.  In many larger institutions, including my own, this function occurs frequently among my collegues on virtually any diagnostically difficult case, and then occurs more formally when virtually all significant diagnoses are reviewed at corresonding multidisciplinary treatment boards (ENT tumor board, colposcopy board, liver board, thoracic surgery board, gastroenterology board, etc, etc)
 
Overall, I found this to be a balanced and factual article and I think most pathologists would enjoy reading it.  Just don't read the "doctor bashing" comments from the readership. ...but then, I recommend not reading the comments after ANY on-line article.  The "signal to noise" ratio there is always extremely low.
4/2/2012
Diane J. Schecter said:
Another viewpoint. It took a month at MD Anderson to make a diagnosis of lymphoma,and this after a hysterectomy(standard Rx for lymphoma?)This case does not illustrate the benefits of a second opinion;rather that a complete workup takes time and is necessary for diagnosis.The WSJ accepts the 25% lymphoma diagnosis error rate (read "pathology diagnosis error") but many pathologists would be skeptical of this statistic.Also cited is the study of 742 FNAs with a 9.3% major disagreement rate,but no mention that follow-up on 1/3 of these cases showed the original dx to be more accurate (Cancer Cytopathology 2009;117:237-46).Second opinion pathology review is a great idea. It provides the patient with piece of mind and may catch those rare cases of outright error. However, I submit that articles on second opinion pathology may overemphasize the magnitude and consequences of changes in pathology diagnoses-how often do they acknowledge grey-zone diagnoses? And the media plays into this.
About the Author

Stacey E. Mills, MD
Stacey E. Mills, MD, a graduate of University of Virginia (UVA) and the UVA Medical Center, has authored nearly 230 articles, 20+ books, atlases and monographs—including the renowned Sternberg's Diagnostic Surgical Pathology. He has been a practicing Professor and Staff Pathologist at UVA for 30+ years and is Director of Surgical Pathology and Cytopathology. His clinical specialty is general surgical pathology with emphasis on neoplasms and neoplasm-like lesions. Dr. Mills is also Editor-in-Chief of The American Journal of Surgical Pathology.