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The definition of a mistake in the practice of clinical medicine


Uma Sundram

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Recently I was discussing a situation at my institution with another colleague. A mutual colleague was sharing a service with a senior pathologist and they were the only two pathologists with specialized expertise in this area at the institution. The two service providers disagreed over a particular diagnosis for a case. Unfortunately, the senior pathologist thought that her junior colleague's interpretation was 'a mistake' and made the decision to not share a portion of the service with him. On hearing this story, I was interested in the whole question of what constituted a mistake in the practice of surgical pathology, dermatopathology, and medicine in general. In most cases, the diagnosis of an intradermal melanocytic nevus is irrefutable; but some cases of intradermal nevi are actually nevoid melanomas in disguise. In the situation of melanocytic lesions, what constitutes 'a mistake'? Differences in interpretations among colleagues? In those cases, who has the final say? The most senior colleague? The division chief? What makes the most sense for the patient?
After seeing scenarios like this play out multiple times, I have come to the realization that as physicians we must not lose sight of what's at stake when we make our interpretations. It is true that if we jump to the diagnosis of melanoma in an ambiguous lesion, we have certainly ensured that we will never be wrong. However, we may give someone a diagnosis of melanoma they don't necessarily deserve. In some cases, ambiguity may never be removed from a lesion. So, if you are in a situation where there are differences in opinion about a melanocytic lesion (or any lesion), let the pathology report reflect that ambiguity. Include all opinions. Solicit external opinions. The most senior colleague or the division chief should not be the ones determining what's' a mistake', if such a comment can even be made in the face of difficult melanocytic lesions. In these instances, clinical outcome is the true determinor of what consitutes a mistake--not personal opinion.
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