It’s Our Turn

“Some of us – Mark Graber and associates – who appreciated the scale of the problem decided that it was essential to convene an Institute of Medicine committee to evaluate all the literature on diagnostic error and come to some sort of conclusion as to how to improve matters. And the fundamental take-home message for my fellow pathologists is this: it’s our turn! The door has finally been opened – if you thought you’d been ignored, if you thought your information was unimportant to the treating physician, that changes now. But that also means that we have a responsibility to provide useful, important information. We must bring to bear the whole of clinical and anatomic pathology, not just what we see in microscope slides. We must learn about every individual laboratory test, be articulate about it, put together all the genetic and molecular pieces, and be valuable, indispensable members of the diagnostic team.

And that teamwork aspect is the second take-home message. In the IoM report, we concluded that the diagnostic process should involve collaboration. One important aspect of that is partnering with radiologists – I believe that pathologists have to expand what they do to include all diagnostic information, and that means connecting with the radiologists, because getting a diagnosis also involves imaging.

So taking responsibility for and learning the whole of pathology, having valuable conversations with treating physicians and partnering with our other diagnostic colleagues are the major points for the pathology community to consider. But my biggest fear is that pathologists won’t walk through this open door. Because if we continue to practice the way we have - “Let me read my 500 slides and write a report on them, and don’t bother me” – then we won’t have the impact that we can and should.

It’s unfortunate that not all pathologists are aware of the IoM report. The Institute’s reports that cover quality of care issues are not always willingly accepted by people in medicine, partly because they uncover some uncomfortable truths. Our first report in the series on quality – ‘To Err is Human’ (1999) – appeared to indicate that there were approaching 100,000 deaths every year from surgical and pharmaceutical errors, and some people were up in arms about the whole thing. However, if you look at all the safety changes since that report – like the operating room ’time out’ principle, where anybody in the OR can say ’stop’ if they think something’s wrong – you have to conclude that the IoM’s investment in these quality reports has paid off. But the reports aren’t always immediately accepted, and in this case I think the biggest reason for resistance is that people are scared that error disclosure could be the end of their professional life, and so they think it’s better to let the sleeping dog lie.

The report explicitly recognized that fear, of course. One of the changes we recommend is a complete rethink of the procedures for reporting medical error, to take it out of the courtroom and into Communication and Resolution Programmes (CRPs). We don’t talk about negligence; we talk about standard of avoidability, which recognizes that some errors arise from very difficult diagnostic problems. The error disclosure procedure should include having somebody in the institution who is totally dedicated to patient safety, and also supportive of physicians and with a good understanding of diagnostic issues, such that all doctors would feel comfortable about approaching this person to establish if there has been harm and if so how to disclose it without destroying their careers.

Other recommended changes include alterations to the payment system, so that pathologists get paid for doing all the things that contribute to identifying, learning from and preventing errors. Because at present in the US, if all you do is help people with laboratory test selection and interpretation, you cannot make a living because those activities are not reimbursed. Therefore, pathologists can’t provide that critical level of safety input regarding the most appropriate test. So the incentives for error prevention and disclosure are all misaligned at the moment, and that’s what we hope to change with this report.

In conclusion, the IoM wants to change things, so that we can start talking about errors without threatening people’s careers – that means dealing with errors not in a courtroom but in a different setting, such as via CRPs. I think that people will accept the easier recommendations of the report quite quickly, maybe within a couple of years – for example, internal systems such as the CRPs could be set up quite quickly, and this concept of diagnosis as a team sport is really just a matter of opening a dialog, and how hard is that?  But the cultural shift away from reacting to errors with litigation will take longer – it’s more aspirational at this stage, at least in the USA. Changing the court system in America is going to be hard!”