Patients are becoming more and more adept at taking control of their own health care, and this often involves seeking a second opinion of their presumptive diagnosis. However, in far too many cases in which cancer or precancerous conditions are diagnosed, the consultation is at the level of another treating physician, without confirmation that the patient’s pathologic diagnosis is correct. In cases where clinical management decisions and prognosis hinge on the pathology report, it is vital to have confidence in the pathologic diagnosis.
Pathologists are physicians who specialize in laboratory medicine. When a pathologist interprets tissue samples, a service within the field of surgical pathology is being performed. Just like other physicians, surgical pathologists may have particular areas of expertise and varying degrees of experience and competence, and should not be viewed as a commodity.
So what do patients know about the surgical pathologist who diagnosed their tissue sample? Most often, it is little or nothing. Patients assume that because they have trust in their physician, their doctor will see to it that their precious tissue sample will be interpreted by an experienced pathologist who will issue a reliable diagnosis.
In fact, managed care has seen to it that the patient’s doctor usually has no input into who interprets their tissue samples, which are often sent to laboratories awarded contracts for being the lowest bidder. Even in hospitals where staff physicians are able to send their specimens to a group of pathologists at the same hospital, the pathologist rotation schedule determines who interprets your specimen, which can be a form of Russian roulette. It is ironic that in a society in which many of us go to great lengths to select who cuts our hair or does our taxes, we typically blindly accept our tissue diagnosis that is made by a pathologist we never met or selected, and about whom we know nothing. Since it is your pathologist’s diagnosis that determines your treatment plan and prognosis, an incorrect diagnosis can have devastating consequences
Previous studies have shown that serious errors in pathologic diagnosis occur at rates that vary depending on the type of tissue under examination. For tissues of the female reproductive tract, this error rate is roughly 5%. Within this field of gynecologic pathology, there are particular “hotspots” of misdiagnosis. One of these areas is endometrial hyperplasia, which is overdiagnosed about 20% of the time.
Expert second opinions are also particularly valuable if the patient’s initial diagnosis is inconclusive or supposedly diagnostic of a rare or unusual tumor. In addition to identifying incorrect diagnoses, in many other cases an expert second opinion can fine-tune a diagnosis in a way that may be significant, such as reclassifying the subtype of a lesion or changing the grade or stage of a tumor. Even when the expert consultation results in no change in the diagnosis, it provides the patient with peace of mind that their diagnosis is correct.
Nearly all misdiagnoses within the field of pathology are made by board-certified pathologists. Patients should expect that their pathologist is board certified, but this is not enough to ensure an accurate diagnosis. To determine if the pathologist’s diagnosis can be trusted, it is helpful to get answers to the following questions: (a) Where did the physician train to become a pathologist? (b) How many years of experience does the pathologist have? (c) Does the pathologist have subspecialty expertise in the particular area of pathology that pertains to your tissue sample? (d) How is the pathologist regarded by his peers and by your personal physician? (e) Does the pathologist have any publications or awards within the subspecialty of pathology that is relevant to you? and (f) What is the pathologist’s malpractice history?
Unfortunately, answers to these questions are often difficult to obtain. A good rule of thumb is that whenever you are in doubt about the qualifications of your pathologist, and your treatment and prognosis depend on the diagnosis given in your pathology report, it is a good idea to get an expert second opinion on your pathology slides from a pathologist who has subspecialty expertise in handling your type of tissue.
Roger Reichert is a pathologist and is the author of Diagnostic Gynecologic and Obstetric Pathology.