Originally published December 2019
Healthcare providers have an ethical, professional, and legal obligation to disclose to patients harm that arises from healthcare delivery. In cases where pathological analysis or diagnostic imaging have been misinterpreted, it may be appropriate for the pathologist or radiologist to participate in the disclosure process. Participating in discussions with patients is often complicated by the fact that pathologists and radiologists typically do not have direct interaction with patients.
This article provides guidance for disclosing harm to patients involving physicians who do not usually have direct contact with patients. The CMPA handbook, Disclosing harm from healthcare delivery: Open and honest communication with patients,1 has more information and recommendations for physicians in general about the disclosure process, and is available on the CMPA website.
Case example 1: Atypical cells are concerning, but benign
A 40-year-old male with a family history of bowel cancer has a rectal polyp biopsied at colonoscopy. The pathologist who analyzes the biopsy feels that many of the cells are atypical and considering the family history, the clinical features, the presence of atypia, and the possible consequences of missing a diagnosis of cancer, reports the biopsy as malignant. The patient goes on to have a lower anterior resection. When the pathologist reviews the resected tissue, no malignancy is identified. She rereads the initial biopsy, and in retrospect feels that she may have over-called the polyp. She asks a colleague to blindly review both samples and the colleague feels both samples were benign. Faced with these new facts, she wonders what the surgeon will tell the patient.
Case example 2: Biopsy reveals previously missed carcinoma
A 47-year-old female undergoes breast cancer screening including a mammogram. No worrisome lesion is identified. Nine months later, she notices a breast lump and visits her family physician, who orders a diagnostic mammogram and ultrasound. The radiologist reviews the previous mammogram and identifies an anomaly, which he interprets as suspicious for cancer. A biopsy reveals invasive ductal carcinoma. The family physician wonders whether the previous normal mammogram result represents a diagnostic error, and is unsure how to discuss the issue with her patient.
Who should disclose?
Once pathologic analysis or diagnostic imaging reveals a diagnostic discrepancy, it may be unclear who among the healthcare team should be involved in disclosing the issue to the patient. Treating physicians may have limited information about the discrepancy, but have a direct relationship with the patient. On the other hand, pathologists or radiologists, who generally have more context around the issues, may not feel comfortable engaging in a disclosure discussion due to their limited interaction with the patient. Indeed, one study reports that pathologists typically entrust disclosure to their clinical colleagues, despite worrying that clinicians “may find themselves with limited firsthand knowledge of the error event and may not be aware of certain pathology-specific relevant information worth sharing with the patient during the disclosure process.”2 Consequently, in instances where patient harm is associated with potential issues involving pathology or diagnostic imaging, a team approach to disclosure may be in the best interest of patients.2, 3
While pathologists and radiologists have the same duty as their clinical colleagues to disclose to patients harm arising from the provision of healthcare, many discharge their obligation by alerting the referring physician. In some cases, active participation in the disclosure discussion by pathologists or radiologists may help support the treating physician, strengthen collegial bonds, and provide patients with a better understanding of the facts.
The prospect of a disclosure discussion with a patient with whom there is no direct interaction can be intimidating, but may ultimately be beneficial. Guidelines and policies within an organization help clarify responsibilities and processes for disclosure, promote transparency, and enable patients to receive relevant information. In one study, pathologists who were present during the disclosure discussion alongside the treating physician “expressed relief in being allowed the opportunity to provide the patient a better understanding of the circumstances surrounding the error and to have the opportunity to apologize for the error.”3
The bottom line
- If you are a pathologist or radiologist and you suspect a diagnostic discrepancy, promptly discuss the discrepancy with the treating physician and consider reporting it to an institutional quality assurance program, if applicable.
- If you are involved in a patient safety incident, consider opportunities to participate in the disclosure process. This may include contacting the most responsible physician to review the facts, planning the disclosure to the patient, and offering to attend the disclosure meeting to provide your perspective.
- Canadian Medical Protective Association [Internet]. Ottawa (CA): CMPA; 2015 (revised 2017 March). Disclosing harm from healthcare delivery: Open and honest communication with patients [cited 2019 June 3]. Available from: https://www.cmpa-acpm.ca/en/advice-publications/browse-articles/2015/disclosing-harm-from-healthcare-delivery-open-and-honest-communication-with-patients
- Perkins I. Error Disclosure in Pathology and Laboratory Medicine: A Review of the Literature. AMA J Ethics [Internet]. 2016 Aug [cited 2019 June 3]. 18(8):809-816. doi: 10.1001/journalofethics.2016.18.8.nlit1-1608. Available from: https://journalofethics.ama-assn.org/article/error-disclosure-pathology-and-laboratory-medicine-review-literature/2016-08
- Dintzis S, Clennon E, Prouty C, et al. Pathologists’ Perspectives on Disclosing Harmful Pathology Error. Arch Pathol Lab Med [Internet]. 2017 [cited 2019 June 3];141:841–845; doi: 10.5858/ arpa.2016-0136-OA. Available from: https://www.archivesofpathology.org/doi/pdf/10.5858/arpa.2016-0136-OA