The Daily Sign-Out

Second opinions in pathology and medicine

Laura Landro, in her Wall Street Journal column, "The Informed Patient," has taken on the controversial subject of second opinions in medicine.  

Inevitably, the "attention-grabber" of such an article is an anecdotal patient initially "misdiagnosed" at one institution who goes to another institution, gets the right diagnosis (and the right treatment), and is healthy now.  I certainly don't want to minimize the issues here--not at all.  But pathologists really need to get out in front of this issue.  Hopefully, the College of American Pathologists will officially provide a response.

But more importantly, we must implement and communicate the quality assurance activities in place designed to minimize misdiagnosis in surgical pathology and cytopathology.  The author does quote Hardeep Singh, chief of the health policy and quality program at Houston's DeBakey VA Medical Center as stating that "a growing number of centers are requiring an internal second review of pathology reports to prevent misdiagnosis. If the second opinion differs markedly, a third opinion may be necessary to get a consensus on what course of treatment is best."  Who isn't already doing this?  A more nuanced and balanced approach to this article might have been to interview a (at least one!) practicing pathologist to get some context (check out the sidebar "Changing the Diagnosis"--where did this come from?) as well as specifics on the challenges of making diagnoses and what we do to confirm diagnoses--especially when cancer is being considered.  There has been a great deal of pathology literature in the last ten years identifying and addressing the problems and concerns raised in this article.  It sure would have been nice if this had been noted.

Despite what the public is led to (or wants to) believe, there is no infallible, 100% guaranteed diagnostic test out there for cancer--and (sorry!) never will be (with all due respect to the Human Genome Project). Sure, a wand would be nice.  But, in the meantime, there will be an irreducible level of uncertainty because of variation at every step of the diagnostic process from the patient herself through molecular testing on the tumor to individual response to treatment.  We cannot be nihilistic about this and must try to minimize variation at the diagnostic/interpretive level.  But we can also clearly communicate to ourselves, our colleagues, and the public the steps we are taking to minimize misdiagnoses.

Please share any innovative strategies you or your colleagues are taking for quality assurance in surgical pathology.

Failure can be a good thing

I read this article in the Wall Street Journal yesterday and it reminded me of Dr. Jeffrey Myers' excellent keynote address on innovation at CAP Futurescape earlier this year.

Amid worries that we are becoming less innovative, some companies are rewarding employees for their mistakes or questionable risks. The tactic is rooted in research showing that innovations are often accompanied by a high rate of failure.

"Failure, and how companies deal with failure, is a very big part of innovation," says Judy Estrin of Menlo Park, Calif., a founder of seven high-tech companies and author of a book on innovation. Failures caused by sloppiness or laziness are bad. But "if employees try something that was worth trying and fail, and if they are open about it, and if they learn from that failure, that is a good thing."

The laboratory seems so conditioned to avoiding errors and minimizing risks that it is counterintuitive to ask staff to try new ideas with the expectation of failure.  But, like our lab's experience with Lean production principles, the lab is arguably the best place in the hospital to be an incubator for innovation for the hospital.  However, a successful for innovation appears to need an atmosphere of open and effective communication and a culture that studies rather than blames failure.  Likely the biggest change would need to be with leadership and the "culture" of the lab working environment.

However, all innovative companies tend to be alike in certain ways, Ms. Estrin says. They encourage coworkers to trust each other, comment on each other's work and take criticism in stride. Also, managers encourage intelligent risk-taking, tolerate failure and insist that employees share information openly.

If you have any experience with fostering innovation at your lab, I invite you to share them.  It would also be interesting what changes you made yourself as a manager or change agent.