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Admitting Error


Mark A. Hurt MD

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Admitting Error


by Mark A. Hurt, MD

Perhaps too much is written on this subject, but I don't think it's possible to over-stress the fact that you (and I) will make many errors in diagnosis over the course of many years.

This is an unpleasant experience, but it need not be a fatal one for you or your patients or your practice. Here are some guidelines that I use to help minimize error and to correct errors when they are made.


1. Learn to anticipate error. With experience, you will be able to tell that some cases are simply prone to error. As Dr. McKee pointed out recently, for example, all apparent scars for which there is no known history should be given special weight diagnostically. Some of them are likely to be desmoplastic melanomas. You will also see many pigmented lesions with a clinical diagnosis of "lentigo" vs "lentigo maligna." If you have any suspicion of a melanocytic lesion but are having trouble defining it histopathologically, stain it with Melan-A or S-100 protein (or both); often times you won't be sorry you did so.

2. Perform the appropriate diligence on known scar fields. Don't simply read that the prior lesion was a basal cell carcinoma; go get the prior and review it. This is the time to make certain that everything is correct: the initial diagnosis, and the residuum or scar, or both, in the excision. You will regret it if you don't do this and you learn later that the diagnosis was wrong from the beginning, especially with melanocytic lesions. This is often the only chance to get it right or to correct an error before a patient is harmed.

3. If you are working with colleagues, and if you find an apparent error one of them has made, return case to the colleague for integrated correction, if necessary. The one who made the error is usually in the best position to correct it. Furthermore, some are quick to judge the apparent errors of others when those "errors" are not actual errors but simply various interpretations of complex information on glass slides. Nonetheless, when the same person follows a case from the initial biopsy through the excision, there is much more of a chance for continuity.

4. With inflammatory conditions, always address all of the differential diagnosis offered by the clinician. This is the time for you to shine as a dermatopathologist, because you can be very helpful in the process of inclusion and exclusion. You can state that the diagnosis is Mucha-Habermann disease (for instance), you can offer a differential diagnosis, and you can exclude diagnoses from the differential offered by the clinician. You can do this, however, only if you actually address the differential and consider systematically every condition proposed. In my experience with certain clinicians, they simply demand that every disease listed in the differential be addressed. By doing so, and by attempting to expand their differential, you can avoid error, and you can develop a good working relationship with the clinician.

5. Lastly, when you find an error you have made, make every attempt to correct it in writing -- as soon as possible. Telephone calls are often necessary -- and they aren't very much fun to make! Fortunately, some of these errors are simple ones, and they can be corrected easily before anything is done that has untoward effects on a patient. However, some errors, such as those in which there is an identification of a melanoma that was thought to be a melanocytic nevus (and, rarely, vice versa), must be addressed -- no matter how uncomfortable the situation. Some of these cases will require the counsel of an attorney, but they still must be addressed, eventually, in writing.


These are only a few guidelines that I use daily; I am curious to learn whether any of the readers have other suggestions to offer or whether they have any criticisms of my comments.
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Dr. Mona Abdel-Halim

Posted

This is really a great blog, thanks Dr Mark for sharing with us those valuable guidelines,,
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Dr. Phillip McKee

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Great blog. I too have had to call the clinican to tell them of a mistake. It certainly is not a pleasant experience but it has to be done. Paying attention to the clinical information is critical. If a clinician is worried about a nevus, perhaps irregular pigmentation, it is essential that the pathologist looks carefully enough to identify the features that resulted in the clinically worrying appearance.
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