Pathologists want to play a more active role in conversations about errors with patients, instead of turning to the treating physician to handle it, according to a recent study.1

“I was pleasantly surprised that some of these pathologists were willing to play a more active role in conversations about errors with patients, rather than taking the easy way out of hiding behind their microscope and letting the treating physician handle the discussion with the patient,” says Thomas H. Gallagher, MD, one of the study’s authors. Gallagher is a professor in the department of bioethics and humanities at the University of Washington in Seattle.

Researchers held five structured focus groups in Washington and Missouri with 45 pathologists in academic and community practice. Participants discussed the nature of pathology errors, how clinicians respond to pathology errors, and what roles pathologists should play in error disclosure to patients. Some findings include the following:

Most pathologists lack training in error disclosure.

Regardless, the majority believed that, going forward, pathologists should offer to participate more actively in error disclosure to patients.

Pathologists believe neither treating physicians nor patients understand the subtleties and limitations of pathologic diagnoses.

“It would be especially surprising to patients, and some clinicians, how pathologic diagnoses are not black and white,” says Gallagher. Rather, the diagnoses require considerable judgment and interpretation.

This complexity complicates discussions about pathology errors. “What would seem like a straightforward question — ‘Is there cancer present on this specimen?’ — can be much harder to answer definitively than patients and other providers think,” says Gallagher.

This complexity in diagnosis makes it hard to know what constitutes a pathology error. “It’s difficult to determine how to best communicate about these events,” says Gallagher.

Pathologists’ lack of confidence in communication skills, and fear of being misrepresented or misunderstood, are major barriers to their participation in disclosure discussions.

“I was surprised at the degree to which some pathologists feel isolated,” says Gallagher. “On the one hand, they are critical team members. But they’re often working alone, and may have not direct contact with the treating team.”

Pathologists face not one, but two challenging conversations when disclosing errors — one with the treating physician, another with the patient. Pathologists in the study felt they were poorly prepared for these discussions, a problem that was identified in previous research on disclosure of radiology errors.2 “Pathologists don’t feel like they are prepared to handle either of these complex conversations,” says Gallagher.

Gallagher says the study highlights these two important ethical issues:

• how challenging it can be to implement what seems like a straightforward ethical principle
of truth-telling after errors;

• that much more work is needed to fully understand the nature of “collective accountability” of multidisciplinary teams.

“How do we understand roles, responsibilities, and accountability when something has gone wrong in the patient’s care?” asks Gallagher.

In addition to providing much-needed education to pathologists on error disclosure, ethicists can act as coaches or consultants.

“Ethicists can provide real-time support in the process of helping a team understand what happened and prepare to communicate with the patient — and with each other — about what happened,” says Gallagher.

REFERENCES

  1. Dintzis SM, Clennon EK, Prouty CD, et al. Pathologists’ perspectives on disclosing harmful pathology error. Arch Pathol Lab Med 2017 Mar 31; [Epub ahead of print].
  2. Brown SD, Lehman CD, Truog RD, et al. Stepping out further from the shadows: Disclosure of harmful radiologic errors to patients. Radiology 2012; 262(2): 381–386.

SOURCE

  • Thomas H. Gallagher, MD, Professor, Department of Bioethics and Humanities, University of Washington, Seattle. Phone: (206) 616-5360. Email: thomasg@uw.edu.