Pathologists and Medical Error Disclosure

Dont Wait for an Invitation

David A. Cohen, MD; Timothy Craig Allen, MD, JD

he recent insight of Gallagher and colleagues1 into the

disclosure of medical error to patients is cogent; and
their expertise on this sensitive topic is welcome. They
emphasize as paramount a patients right to honest
information shared with compassion about what happened
to him or her. . .(p1753); stress the importance of active and
complete investigation of possible errors; and emphasize the
(sometimes difficult) necessity that institutions provide a
protected environment for those activities.1
The authors particularly emphasized the joint responsibility for error disclosure in situations where a physician
identifies an error involving another physician who is or was
treating a patient. . . with both clinicians participating in
[the] disclosure conversation.1 They distinguish, however,
any physician who lacks direct contact with the patient,
such as pathologists and radiologists, suggesting that,
because the treating physicians physician-patient relationship facilitates disclosure conversations,(p1755) the disclosure be led by the [a]ttending physician on primary service
treating the patient, with the [pathologist or radiologist]
colleague invited to join [the] discussion.1(p1755)
Medical error disclosure to patients, to the extent it has
occurred at all, has been inconsistent and challenging, and
pathologists have typically not been directly involved.2 That,
however, must change. Pathologists cannot be content to
await an invitation to join the discussion; rather, pathologists should actively embrace the opportunity to become
involved in the sometimes delicate and difficult error
disclosure process. Undoubtedly, with direct involvement
in a potential medical error situation, pathologists should
not be content to hand responsibility to the treating
physician. Medical errors involving the laboratory are
frequently multifactorial, so ensuring that all details of the
error are accurately depicted may be difficult or impossible if
the pathologist is not actively engaged in the disclosure. An
uninvolved pathologist has no way to ensure a fair and
Accepted for publication March 25, 2014.
From the Department of Pathology and Genomic Medicine,
Houston Methodist Hospital, Houston, Texas (Dr Cohen); and the
Department of Pathology, University of Texas Medical Branch,
Galveston (Dr Allen).
The authors have no relevant financial interest in the products or
companies described in this article.
doi: 10.5858/arpa.2014-0136-ED
Reprints: Timothy Craig Allen, MD, JD, Department of Pathology,
University of Texas Medical Branch, Galveston, TX 77555 (e-mail:
tcallen@utmb.edu).
Arch Pathol Lab MedVol 139, February 2015

balanced disclosure and risks receiving little or no feedback

regarding the patients response to disclosure or whether
everything the patient needed or wanted to learn was
satisfactorily explained.
Pathologist participation in disclosure should be much
broader, however, and should not be limited only to
situations with direct pathologist or laboratory involvement.
Participation should occur even in some situations for which
the pathologist and laboratory are not directly involved.
Essentially, all patients have laboratory testing or diagnoses
as part of their diagnostic and therapeutic course, and
questions about test results or diagnoses may arise during a
disclosure for which the nonpathologist physician does not
have the answers. Without a pathologist as a member of the
multidisciplinary disclosure team, the circumstances of a
laboratory-related errorand how that error would be
prevented in the futuremight be unexplainable. The
presence of a pathologist could be essential for maintaining
patient trust.
Although the Gallagher and colleagues scenariofocusing entirely on a medical error entirely caused by a single
treating physicians actionsdo not envision pathologists
playing a central role in medical error disclosure, in many
situations involving potential medical error, pathologists
heavily involved in laboratory managementcan provide a
systems-based approach to better elucidate error-prevention methods. In fact, pathologists have historically had an
important disclosure roleviewed favorably by patients
familiesin the presentation of autopsy findings.3 As such,
pathologists should clearly communicate their willingness to
participate in all multidisciplinary medical disclosure situations to administrative and physician hospital leaders. Even
when coordination of a multidisciplinary team meeting
among multiple physicians with numerous time constraints
proves difficult, pathologists should nonetheless endeavor
to be present during the disclosure meeting to provide
answers for the patient because the patient deserves clear
answers.
Gallagher and colleagues limit their discussion of physician responsibilities to the situation where one treating
physician identifies a possible medical error by another
treating physician. Given the generality of their discussion,
their omission of direct patient involvement by pathologistsfor example, in the transfusion medicine and
cytopathology contextsis forgivable. Just as significantly,
their article does not address situations in which a
pathologist identifies a potential medical error by a nonpathologist colleague or by another pathologist, nor does
Pathologists and Medical Error DisclosureCohen & Allen 163

the article consider the situation in which a laboratory error

or other medical error is identified for which no specific
blame may be placed on a single individual, yet nonblameworthy process errors are frequent occurrences.
Nowhere do Gallagher and colleagues discuss medical
apologies, which are not the same as medical error
disclosures. The two should not be confused; medical
apology is potentially problematic. Popularized several years
ago as a mechanism for reducing the risk of medical
malpractice surrounding medical error disclosure,46 it has
since come under criticism. Although doing little to make
the health care setting safer for patients, apologies chill the
open disclosure of sensitive information and accompanying
frank discussion7(p316) necessary for improving patient
safety. Unlike other forms of disclosure, apology also
establishes responsibility, which is challenging, because in
many situations, individual assignment of shame and
blame unfairly open up the involved individuals and
organizations to liability and loss.7(p317) To the extent that
medical apology is typically offered merely for purposes of
risk management, it must be emphasized that the physicians duty to patients requires something more than
convincing them not to seek compensation through
litigation for injuries caused by negligent errors. . . [taking]
advantage of their weakened state.8(p342) Accounting to the
patient for a medical error via error disclosure, not apology,
can bridge the gap between adverse events and patient
expectations.7 Requiring the last person who touched the
patient to disclose without more than merely a persona of
humiliation, shame, and blamesimply represents an
iteration of the ineffective, individually oriented shame and
blame approach.9(p535)
In summary, as Gallagher and colleagues emphasize,
physicians rightly perceive the current medical liability
system as flawed and understandably worry that they may
not be treated fairly should a patient file a claim. But these
concerns do not obviate [physicians] duty to be truthful
with patients. . .1(p1753) If physicians expect society to

164 Arch Pathol Lab MedVol 139, February 2015

address the medical malpractice issue and provide future

professional protections, physicians would be well advised
to behave professionally now, and put the patients need
above their own.1(p1754) Like our clinical colleagues,
pathologists should not wait for an invitation to participate
in error disclosurefar from itpathologists should become active participants in discussing with patients the
events surrounding a potential medical error, how it was
discovered, and what is being done to ensure that the
medical error never happens again. They should absolutely
be involved in every situation for which there is potential
pathologist or laboratory error; they should invite themselves to actively participate in situations for which a
laboratory issue may have played an indirect role; and they
should liberally offer to participate in other, nonlaboratoryrelated, disclosure conversations in case a question or
concern regarding the laboratory arises. It is in such an
advocacy role that pathologists can best serve their patients.
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Pathologists and Medical Error DisclosureCohen & Allen