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.