The Role of Cue-Based Strategies in Skilled Diagnosis Among Pathologists.

OBJECTIVE: This research was designed to test whether behavioral indicators of pathology-related cue utilization were associated with performance on a diagnostic task. BACKGROUND: Across many domains, including pathology, successful diagnosis depends on pattern recognition that is supported by associations in memory in the form of cues. Previous studies have focused on the specific information or knowledge on which medical image expertise relies. The target in this study is the more general ability to identify and interpret relevant information. METHOD: Data were collected from 54 histopathologists in both conference and online settings. The participants completed a pathology edition of the Expert Intensive Skills Evaluation 2.0 (EXPERTise 2.0) to establish behavioral indicators of context-related cue utilization. They also completed a separate diagnostic task designed to examine related diagnostic skills. RESULTS: Behavioral indicators of higher or lower cue utilization were based on the participants' performance across five tasks. Accounting for the number of cases reported per year, higher cue utilization was associated with greater accuracy on the diagnostic task. A post hoc analysis suggested that higher cue utilization may be associated with a greater capacity to recognize low prevalence cases. CONCLUSION: This study provides support for the role of cue utilization in the development and maintenance of skilled diagnosis amongst pathologists. APPLICATION: Pathologist training needs to be structured to ensure that learners have the opportunity to form cue-based strategies and associations in memory, especially for less commonly seen diseases.

Providing medicolegal testimony.

One of the major goals of residency training is to prepare pathologists to communicate effectively in a variety of clinical settings. Well-educated pathologists are able to explain medical facts and offer cogent opinions to audiences that vary from other physicians to laypersons. As would be expected, there is an overlap between the skill-set required for medical communication and the skill-set necessary to participate effectively in malpractice litigation. However, residency curricula do not specifically prepare pathologists for the unique challenges posed by legal proceedings. The resulting lack of preparation may leave pathologists poorly prepared to be confronted by the "black-and-white" world in which attorneys try to live and work, but avoidance of that world is not always possible. Lawsuits against physicians are common, and even if the unpleasant experience of being sued is avoided, there is a high probability that one will, at least, be required to serve as a "fact witness" to provide sworn testimony if a suit has been filed against a physician colleague. In addition, some pathologists voluntarily provide the professional testimony required by the tort system, when it attempts to integrate science and Law. This paper is directed at pathologists who have had little or no prior experience with the legal system. The authors hope that the information provided therein will lessen physician vulnerability in and out of the courtroom, vis-à-vis malpractice litigation.

Tort reform: the pathologists' perspective.

Physicians who become ensnarled in malpractice litigation often feel that the tort system has treated them unfairly. This negative perception has fueled physician efforts to enact "reforms" intended to mitigate the damage that allegations of medical negligence currently have on both individual physicians and on the practice of medicine itself. Although physicians are generally enthusiastic about "reform," there is currently no definition that allows tort "reform" to be separated from related initiatives. Some physicians largely restrict the term to defendant-friendly changes in the rules and procedures governing the workings of the tort system, whereas others take a somewhat broader view. In the present paper, we have favored the broader approach to the topic, leading to a discussion of 30 measures that have been presented in the context of tort "reform." Although most of these measures involve changes in the complex rules governing the malpractice tort system itself (eg, capping jury awarded damages), our broader view of "reform" also includes attempts to exert influence on the tort system from the outside (eg, peer review of expert testimony) and measures designed to keep patient dissatisfaction out of the tort system (eg, apology for error). Some would argue for an even broader view of tort "reform" that would including measures for reducing the pool of dissatisfied patients. For example, trial lawyers have claimed that physicians have put far too much effort into "reforms" that reduce the legal consequences of committing medical errors, and not enough effort into "reforms" that would reduce the errors themselves. The latter point may or may not have some validity, but there is a natural demarcation between measures designed to align medical outcomes with patient expectations (eg, error reduction, better diagnostic technology) and others designed to improve the processes that resolve patient dissatisfaction. Only the latter meet our definition of tort "reform."

Medicolegal liability in pathology: an international perspective.

An inevitable outcome of modern Medicine in any country is that some patients will experience adverse events, some of which would have been preventable. Different nations have developed various approaches to such cases; their legal efficacies are probably dissimilar and dependent on a number of disparate variables. An international "snapshot" of the results of the interacting forces can be obtained by asking physicians in several countries how they view selected subjective facets of their tort systems. In the U.S., many physicians view the structure of malpractice torts as unfair, and that belief is shared by at least some pathologists. The American Medical Association has declared that a multiregional malpractice "crisis" exists which raises medical costs and threatens access to care. Furthermore, malpractice tort decisions are often flawed scientifically because lay jurors and judges cannot properly evaluate the quality of "expert" testimony given by adversarial witnesses. Despite these factors, there has been little effort to investigate the views of pathologists on malpractice actions outside the U.S. In this paper, the authors have collected the responses of an international group of pathologists to a questionnaire on that topic. The respondents practice in academic centers in 15 countries outside the U.S. As expected, a range of views was represented, with some pathologists reporting that malpractice litigation was uncommon and others noting a worrisome trend toward its growth. Interestingly, so-called "defensive medicine" was found to be relatively common in pathology in many countries.

Classification of error in anatomic pathology: a proposal for an evidence-based standard.

Error in anatomic pathology (EAP) is an appropriate problem to consider using the disease model with which all pathologists are familiar. In analogy to medical diseases, diagnostic errors represent a complex constellation of often-baffling deviations from the "normal" condition. Ideally, one would wish to approach such "diseases of diagnosis" with effective treatments or preventative measures, but interventions in the absence of a clear understanding of pathogenesis are often ineffective or even harmful. Medical therapy has its history of "bleeding and purging," and error-prevention has a history of "blaming and shaming." The urge to take action in dealing with either medical illnesses or diagnostic failings is, of course, admirable. However, the principle of primum non nocere should guide one's action in both circumstances. The first step in using the disease model to address EAP is the development of a valid taxonomy to allow for grouping together of abnormalities that have a similar pathogenesis. It is apparent that disease categories such as "tumor" are not valuable until they are further refined by precise and accurate classification. Likewise, "error" is an impossibly broad concept that must be parsed into meaningful subcategories before it can be understood with sufficient clarity to be prevented. One important EAP subtype that has been particularly difficult to understand and classify is knowledge-based interpretative (KBI) error. Not only is the latter sometimes confused with distinctly different error types such as human lapses, but there is danger of mistaking system-wide problems (eg, imprecise or inaccurate diagnostic criteria) for the KBI errors of individual pathologists. This paper presents a theoretically-sound taxonomic system for classification of error that can be used for evidence-based categorization of individual cases. Any taxonomy of error in medicine must distinguish between the various factors that may produce mistakes, and importantly, whether they are individual, small system (e.g., my histology laboratory), or big system (e.g., published diagnostic criteria). Because no overarching governing agency exists to coordinate this initiative, the recognition of need and effective implementation of EAP counter-measures must emanate from our specialty group itself.

Diagnostic precision and accuracy in interpretation of specimens from cancer screening programs.

Few areas in modern medicine provide a better example of evidence-based data than the anatomic pathologists' classification of fully developed malignancies. Beginning with the Papanicolaou (Pap) smear, morphologic tools also were applied to specimens obtained in cancer screening programs directed at large, asymptomatic patient populations. The Papanicolaou test was quickly responsible for a reduction in the incidence of invasive squamous cell carcinoma of the cervix, proving the concept that screening could interdict the development of advanced malignancy. Other screening programs followed the Papanicolaou test initiative, producing a revolutionary change in the specimens submitted to pathologists. Cancer screening generates specimens containing morphologic deviations from normal that are thought to put currently healthy patients at risk of future malignancy. However, translating morphologic findings in such samples into risk estimates raises a number of statistical and ethical problems. When diagnostic thresholds are set to favor specificity, unwanted false-negative results accrue. Conversely, aiming at sensitivity over specificity is associated with biologically false-positive results, which are likewise undesirable. Pathologists interpreting these specimens find themselves facing a screening paradox. These screening programs attempt to discover the very earliest changes of neoplastic transformation, but these same earliest changes are inherently the most difficult to identify with precision and accuracy. This paper discusses these challenges.

An observational examination of the literature in diagnostic anatomic pathology.

Original research published in the medical literature confronts the reader with three very basic and closely linked questions--are the authors' conclusions true in the contextual setting in which the work was performed (internally valid); if so, are the conclusions also applicable in other practice settings (externally valid); and, if the conclusions of the study are bona fide, do they represent an important contribution to medical practice or are they true-but-insignificant? Most publications attempt to convince readers that the researchers' conclusions are both internally valid and important, and occasionally papers also directly address external validity. Developing standardized methods to facilitate the prospective determination of research importance would be useful to both journals and their readers, but has proven difficult. In contrast, the evidence-based medicine (EBM) movement has had more success with understanding and codifying factors thought to promote research validity. Of the many variables that can influence research validity, research design is the one that has received the most attention. The present paper reviews the contributions of EBM to understanding research validity, looking for areas where EBM's body of knowledge is applicable to the anatomic pathology (AP) literature. As part of this project, the authors performed a pilot observational analysis of a representative sample of the current pertinent literature on diagnostic tissue pathology. The results of that review showed that most of the latter publications employ one of the four categories of "observational" research design that have been delineated by the EBM movement, and that the most common of these observational designs is a "cross-sectional" comparison. Pathologists do not presently use the "experimental" research designs so admired by advocates of EBM. Slightly > 50% of AP observational studies employed statistical evaluations to support their final conclusions. Comparison of the current AP literature with a selected group of papers published in 1977 shows a discernible change over that period that has affected not just technological procedures, but also research design and use of statistics. Although we feel that advocates of EBM deserve credit for bringing attention to the close link between research design and research validity, much of the EBM effort has centered on refining "experimental" methodology, and the complexities of observational research have often been treated in an inappropriately dismissive manner. For advocates of EBM, an observational study is what you are relegated to as a second choice when you are unable to do an experimental study. The latter viewpoint may be true for evaluating new chemotherapeutic agents, but is unacceptable to pathologists, whose research advances are currently completely dependent on well-conducted observational research. Rather than succumb to randomization envy and accept EBM's assertion that observational research is second best, the challenge to AP is to develop and adhere to standards for observational research that will allow our patients to benefit from the full potential of this time tested approach to developing valid insights into disease.

Evidence-based medicine and tort law.

Recent statutes and legal decisions have been aimed at bettering the quality of tort-law decisions by substantively improving "expert" testimony. However, in analogy to the experience of physicians attempting to upgrade medical practice using the principles of evidence-based medicine, lawyers and the courts have found it much easier to describe ideal science than to actualize it. This is particularly so in a system (the Law) that has traditionally not been very discerning about scientific rigor, and which has established procedural priorities that are often incompatible with strict scientific standards. This overview will examine the American tort system from an evidence-based perspective. We include a discussion of standards that could be used for "outcomes analysis" in the Law; recognition and classification of errors made by the courts themselves; the relationship between medical errors, "negligence," and standard of care; and the problem of reconciling the rights of plaintiffs with medical-scientific facts. We also consider selected impediments to developing a legal system that is capable of consistently reaching evidence-based decisions concerning complex scientific information, including pathologic interpretation of tissue specimens.

Diagnostic certainty is sometimes certainly an error.

We evaluated a low-density lipoprotein (LDL) subfraction separation method using polyacrylamide tube gel electrophoresis (PTGE) and compared it with the reference method, polyacrylamide gradient gel electrophoresis (PGGE-REF). Excellent intra-assay and interassay coefficients of variation were obtained (<4%) for PTGE. For 102 subjects, LDL subclasses correlated most significantly with triglyceride (TG) level, high-density lipoprotein (HDL) cholesterol level, total cholesterol/HDL cholesterol ratio, and non-HDL cholesterol level (P < .05). The distribution of large LDL (76%) was predominant for subjects with low TG levels (< 150 mg/dL [1.69 mmol/L]), while distribution of small LDL (79%) was predominant for subjects with high TG levels (>200 mg/dL [2.26 mmol/L]). Excellent agreement between the methods was observed (weighted kappa = 0.78). Of 51 samples classified as small, dense LDL by PGGE-REF, none were misclassified as lage LDL and 4 as intermediate LDL by PTGE (92% concordance); of 44 samples classified as small and 7 as intermediate by PTGE (77% concordance). The PTGE method is precise and compares favorably with PGGE-REF. It has the advantage of being simple, less expensive, and more suitable for use in the clinical laboratory.

Pathology expert witness testimony and pathology practice: a tale of 2 standards.

CONTEXT: Pathologists work in an environment in which, to the extent possible, diagnostic decisions are based on scientific principles. It can therefore be a rather shocking experience when a pathologist finds one of his or her diagnostic decisions being evaluated by a legal system developed and controlled by lawyers and judges rather than by scientists or pathologists. This experience can be even more troubling when a key participant in the proceedings is a fellow pathologist guiding a jury toward an unfamiliar interpretation of the pathology standard of care. OBJECTIVE: To provide the interested pathologist with the background information necessary to (1) understand the role of expert testimony in malpractice litigation and (2) understand why there can be a gap between expert opinions expressed in court and expert opinions expressed in a medical care context. DATA SOURCES: Medical literature review supplemented by review of subspecialty position papers, selected articles from newspapers and magazines, and legal decisions. The medical literature review was limited to articles published in English and was based largely on articles retrieved using the MeSH terms expert testimony/legislation & jurisprudence, and pathology/legislation & jurisprudence. CONCLUSIONS: Medical error has become an increasingly important topic for pathologists, and although errors or allegations of error are evaluated in many ways, the evaluation with the most impact on the individual pathologist is a malpractice case. During the last decade physicians have increasingly become aware of the critical role played by expert testimony in malpractice litigation. Some physicians have asserted that providing expert testimony is the practice of medicine, and that it is unacceptable for juries to be presented with expert testimony that incorrectly describes medical practice standards. However, this opinion has been vigorously opposed by attorneys who feel that juries are best able to come to a correct conclusion if they base their deliberations on a broad spectrum of opinion. Gaining an increased role in the oversight of expert testimony would allow physicians to establish a closer alignment between opinions expressed in court testimony and opinions expressed in clinical practice. However, despite some physician success in inserting themselves into the oversight process, both physicians and physician organizations attempting to take action against misleading expert testimony continue to be vulnerable to legal attack.