Histopathology 2011, 59, 359–367. DOI: 10.1111/j.1365-2559.2010.03710.

REVIEW

Non-technical skills in histopathology: definition and

discussion
Peter W Johnston,1,2 Evie Fioratou3 & Rhona Flin3
1
Department of Pathology, Aberdeen Royal Infirmary, 2NHS Education for Scotland, North of Scotland Deanery, and
3
Industrial Psychology Research Centre, University of Aberdeen, Aberdeen, UK

Johnston P W, Fioratou E & Flin R

(2011) Histopathology 59, 359–367
Non-technical skills in histopathology: definition and discussion

Health care is a high-risk industry, with most docu- anaesthesia and surgery, a variety of non-technical
mented adverse incidents being associated with ‘human skills are identified and described in the context of
factors’ including cognitive and social skills termed histopathology to illustrate the role each plays, often
‘non-technical skills’. Non-technical skills complement collectively, in daily practice. The generic non-technical
the diagnostic and specialist skills and professional skills are defined as situation awareness, decision-
attributes required by medical practitioners, including making, communication, teamwork, leadership, man-
histopathologists, and can enhance the quality of aging stress and coping with fatigue. Example scenarios
practice and delivery of health-care services and thus from histopathology are presented and the contribu-
contribute to patient safety. This review aims to intro- tions to outcomes made by non-technical skills are
duce histopathologists to non-technical skills and how explained. Consideration of these specific non-technical
these pertain to everyday histopathological practice. skills as a component in histopathology training may
Drawing from other domains in medicine, specifically benefit practitioners as well as assuring patient safety.
Keywords: error, histopathology, human factors, non-technical skills, patient safety
Abbreviations: ICC, immunocytochemical; MDT, multidisciplinary team meeting; NTS, non-technical skills

Medical Council. There is a literature on perceived error

Introduction
Histopathologists recognize the report produced at the
end of the consideration of a case as the speciality’s
main contribution to patient care. The processes
behind delivering that report, the diagnostic skills that
underpin it and the means by which these skills are
acquired and maintained are the focus of training and
continuing professional development. Work has been
carried out to ensure that standards of reporting are
defined and maintained in training by the Royal
College of Pathologists and similar institutions, regu-
lated, for example, by bodies such as the General
Address for correspondence: Dr P W Johnston, Department of
Pathology, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25
2ZD, UK. e-mail: peter.johnston@abdn.ac.uk
 2011 Blackwell Publishing Limited.
rates in diagnostic surgical pathology1–3 and an
acknowledgement that mistakes relevant to diagnosis
can occur in all parts of the laboratory process.4,5 The
background of potentially costly and harmful mistakes
in health care goes back for many years,6 with a
described epidemiology.7 Episodes concerning pathol-
ogy are relatively few, but have caused considerable
concern when they have arisen as systematic events8–10
or individual incidents.3,11 Discrepancies between diag-
nostic methods, for example cytology and biopsy, have
been carried out9,12 and between observers looking at
the same material.13–16 Overall, published ‘error rates’
for histopathology range from 1% to 5%,11 with a
clinically significant error rate of 0.08%.13 Controlling
workload is a problem for histopathology, and several
solutions have been offered.17–19 The relationship
360 P W Johnston et al.
of error to workload in histopathology has attracted
some interest,20,21 but no clear relationship has been
established. The focus of the papers cited above is upon
what is printed on the histopathologist’s report and
whether that stands up to scrutiny; but does this
approach do justice to what is actually happening in
the histopathologist’s mind when reflection or review
reveals a divergence of opinion or clinically relevant
error? Probably not, is the answer, because what this
literature does not do is examine human factors that
may contribute to or underlie what is eventually
classified as a misinterpretation, discrepancy, mistake
or error.
Human factors are involved in up to 80% of adverse
events in a variety of industrial settings, incorporating
the aviation, nuclear power and oil and gas exploration
and extraction industries.22 Human factors as a descrip-
tor have been defined variously, but a widely accepted
definition is that of the Health and Safety Executive
(HSE: UK industrial safety regulator): ‘Human factors
refer to environmental, organisational and job factors,
and human and individual characteristics which influ-
ence behaviour at work in a way which can affect
health and safety. A simple way to view human factors
is to think about three aspects: the job, the individual
and the organisation and how they impact on people’s
health and safety-related behaviour’.23 These factors
have been classified further as ‘non-technical skills’
(NTS) which complement technical or, in the case of
histopathology and the present paper, diagnostic skills.
Flin et al.24 defined these as ‘the cognitive, social and
personal resource skills that complement technical skills
and contribute to safe and efficient task performance’.
These non-technical behaviours are not new discover-
ies,22 but more a recognition of how individual and
team-based performance is optimized or jeopardized by
aspects other than the technical considerations of the
matter in hand but which, none the less, relate to the
people carrying them out. Histopathologists work in
several teams of staff with varying roles in the labora-
tory, wards, operating theatres and clinics. Histopathol-
ogists report cases alone or surrounded by others, who
interrupt, convey information, ask questions, present
demands and divert attention. All these interventions
(and many more) have the potential of affecting the
reporter’s performance.
Flin et al.22 have identified that NTS constitute a set
of seven skills defined as:
• situation awareness;
• decision-making;
• communication;
• teamwork;
• leadership;
• managing stress; and
• coping with fatigue.
The relevance of identifying and attending to behav-
iours in individuals that contribute to adverse out-
comes in stressful and changing situations in medicine
is increasingly recognized.25,26 Much of the work
which has examined the relevance of NTS in clinical
environments has been centred on acute settings, most
notably anaesthesia,27,28 laying out what is described
as Anaesthetists’ Non-Technical Skills (ANTS).29 This
work, based on the methods used to develop the
NOTECHS system from the aviation industry,24,30,31
produced a taxonomy or descriptive framework of skills
as well as associated observable behaviours with which
to identify NTS as they pertain to the practice of
anaesthesia in the operating theatre. This has formed
the basis of the design of a training course constructed
to promote recognition and learning of NTS in anaes-
thetists and their application to daily practice.32,33
Surgery developed the ‘Non-technical Skills for Sur-
geons’ (NOTTS),34 arising from work by Yule
et al.,35,36 to explain and define a taxonomy relevant
to theatre-based surgical practice. Recently, the prin-
ciples of NTS have been applied in other domains of
health care; for example, the labour ward.37
All these developments have in common the goal of
enhancing patient safety in carefully defined real
situations of high risk but in which outcomes of
decisions made by individual doctors or teams involved
in care have serious and long-lasting consequences for
patients’ health and wellbeing. Further, an objective is
to raise awareness in practitioners of the non-technical
aspects of what they do in various circumstances
within these environments to encourage positive
behaviours and modify unhelpful ones. The aspiration
is that there is benefit with regard to patient safety and
outcome, and also for doctors, nurses, scientists and
others involved, because performance is enhanced and
the personal and professional risks and consequences
attached to adverse incidents might be minimized. The
investigation of error in histopathology emphasizes the
diagnostic skills required. Accordingly, histopathology
training and career professional development (CPD) are
centred on the acquisition of technical competencies,
such as writing reports including the detail and
nuances of a range of ways of saying things which,
arguably, mean more to the histopathologists who
review these reports than they do to those who receive
them. The remaining non-technical components are
left largely to osmosis by trainees or are learned or not
by observation of trainers’ behaviour, which is then
available to be copied depending on the trainee’s
perception of its worth.
 2011 Blackwell Publishing Ltd, Histopathology, 59, 359–367.

The current paper sets out to explore the potential
value of awareness of non-technical skills in histopa-
thology and to consider the implications of directing
aspects of training towards enhancing these skills. We
know that histopathologists make mistakes and the
literature for other high-risk occupations indicates that
a significant proportion of these errors stem from
human rather than technical failings. Hence, there is a
case to approach the subject as it pertains to this
speciality with the intention of defining relevant
components of practice and identifying how non-
technical skills play a role. With this information, it is
proposed that diagnostic safety can be refined further
and histopathologists may see benefit in their working
lives. We now present an overview of the main non-
technical skill categories applied in other safety-critical
jobs and suggest why they might have relevance for
histopathology, with particular reference to the task of
diagnosis and reporting.
Defining non-technical skills in
histopathology
The cognitive and social skills that constitute the non-
technical skills are described below. ‘Cognitive’ skills
are those that relate to a person’s capacity to think
and formulate actions; for example, with regard to
being ⁄ becoming aware of what surrounds us and
making decisions. ‘Social’ skills are how we interact
with other people. The following paragraphs expand
upon the classification of NTS and place them in the
context of histopathology practice.
situat ion a wareness
In simple terms, situation awareness is about develop-
ing and maintaining an all-round perception and
appreciation of the changing circumstances during
task execution. The most widely accepted definition is
‘the perception of the elements in the environment
within a volume of time and space, the comprehension
of their meaning and the projection of their status in
the near future’.38 Thus it has three elements, acquir-
ing information, comprehension and anticipation. In
histopathology, situation awareness includes gathering
and understanding information relating to the compo-
nents of the laboratory environment, interaction with
tissue and sections, the microscope and other equip-
ment, the timely gathering and assimilation of relevant
patient data and interaction with people. The people
comprise those with whom we are training or by whom
we are being trained, laboratory scientific and technical
staff and administrative staff in the department, ward
 2011 Blackwell Publishing Ltd, Histopathology, 59, 359–367.
Histopathology non-technical skills 361
and community-based colleagues and patients them-
selves, even though the last group may well be unseen.
The skill has relevance to the present time, but also
predicting and re-evaluating and re-predicting what is
about to happen or will do so in the more distant
future.
decision -making
The second cognitive skill is decision-making. Histop-
athologists make hundreds of clinically relevant deci-
sions every week and require the skills of identifying
options, balancing risks and selecting options and
re-evaluating. These are about the management of
cases (to whom to book in or allocate a specimen), the
processes of the surgical cut-up (specimen identifica-
tion, site, nature, how to describe, block, record the
process) and reporting. The last is the major theme of
this paper. The process of the interaction of the
histopathologist with tissue sections has been described
as ‘an extremely complex process involving a wide
range of human sensory, perceptual and cognitive
processes’.39 To the uninitiated, histopathologists look
at the slide on the microscope stage and a diagnosis is
verbalized. The steps between these two events, how-
ever, are several. Some simple questions are as follows:
• What am I looking at?
• Is it what I expect to see, having read the
accompanying request form completed by the doctor
who took the sample from the patient? This question, by
the way, sets us a whole set of further inquiries about
cognitive dispositions to respond, in other words how
what we see depends upon what we are seeking to see.40
• Do I know what the features indicate?
• Can I make a definite diagnosis?
• Can I make a prognostic statement?
• Can I do either of these things now or do I need
more information, either clinically, about imaging, or
from laboratory tests already performed (e.g. biochem-
istry, haematology)?
• Do I need to investigate the specimen further with
more sections into the block, special stains ⁄ immuno-
cytochemistry ⁄ in situ hybridization?
• Can I ask for that now?
• Do I need to ask a colleague for help or a
confirmatory view?
• Can I produce a report that will address the
pathological issues in the appropriate clinical context?
• Who needs to receive the report?
• Do I need to call someone with an urgent result or
to obtain more information; if so, whom should I call?
Histopathologists will recognize these questions, but
also how they vary as the section is examined – the
362 P W Johnston et al.
examination process is active and iterative where we
look, search, check, review, question until we are
satisfied with the result. The expert’s skill is in knowing
when or not that point is reached. Overall, making
clinical decisions is a matter of balancing risks, making
reasonable and reasoned pictures to reach a point of
judgement where pieces of the jigsaw are missing.
c o m mu n i c a t i o n
In the NTS context, communication is defined typically
as what information is passed on, how this is achieved,
why it occurs and to whom.22 It is a basic generic
competence required for anyone engaged in the
practice of medicine as it relates to interactions with
patients, other histopathologists and other profession-
als within the organization. The UK General Medical
Council is explicit about the need for this.41 Plainly,
there is no purpose for histopathology if the diagnostic
product is not communicated to the patient or at least
those directly responsible for a particular episode of
care; medicine as a whole is powered by communica-
tion. For this reason, the histopathology report is
central to the process and has recognized formats and
conventions which ensure that it is safe and useful. The
language used is chosen carefully to provide the reader
with a check on the nature and site of the specimen, a
coherent description and a diagnostic comment which
indicates a level of certainty or otherwise expressed by
the reporter.
Telephone conversation is also common, both for the
histopathologist to find out more about a patient and to
communicate urgent results. The former is possibly
more interesting in that it demonstrates the testing of
hypotheses by the pathologist against information that
ward- or clinic-based colleagues may have, attempting
to synchronize contextually histological findings clin-
ically. What a clinical colleague will say or divulge may
well cause the histopathologist to review, rethink or
completely revise an opinion; or it may serve to assuage
doubt and strengthen a diagnostic understanding.
The discussion of cases at multidisciplinary meetings
serves a similar purpose, and is an extension of the
diagnostic process where review is built in. Again,
more information might be available in such meetings,
which will result in histopathologists reconsidering a
previously stated opinion.
team working
Modern histopathology, in common with the rest of
health care, is team-based. Teams are several and
varied and include those within departments; for
example, scientific and technical, administrative and
secretarial and beyond into the multidisciplinary teams
with whom histopathologists interact about the man-
agement of individual patient’s cases. What constitutes
a team42 and the elements of team working22 are
interesting topics, but for now we need to be aware
only that histopathologists are valued members. In
common with experience in anaesthesia29 and sur-
gery,34 team working involves coordinating activities
towards shared, understood goals, exchanging infor-
mation in a timely and appropriate manner and
working collaboratively in a professional and purpose-
ful way to the benefit of patient care.
leadership
Consultant staff and their equivalent are charged with
the leadership of departments and clinical service
development. As such, they drive innovation, setting
and maintaining standards of laboratory practice,
taking responsibility for the delivery of departmental
and delegated personal tasks as well as for the
organization and working of teams as described above.
Principally, this means supporting others both intel-
lectually and emotionally. Underlying these duties are
motivation, energy, commitment and the ability to
exercise authority while displaying sound judgement
diagnostically and clinically, as well as in relation to
the organizational aspects of departmental life.
Leadership has been described variously,22,43–45 and
incorporates a range of styles. These need not be
explored here, save to define the principle that a leader
is someone who directs or coordinates others to achieve
agreed goals, whether the authority to do so is a result of
election, appointment or an informal process of choice.46
managing stress
Many factors act as stressors in the workplace, as they
do in life in general. What may be pleasant stimulation
under some circumstances, for example the need to
report a challenging biopsy, can be stressful in another –
when faced with 10 challenging biopsies all required
urgently. Histopathologists are familiar with a range of
stressors, although may be unaware of the impact
these can have. Stress can affect individuals, teams
and organizations with varying effects. For example,
chronic stress can result from excessive workload,
difficult relationships with colleagues, frequent inter-
ruptions, the need to carry out several tasks at once,
restricted budgets that limit the ability to practise to a
desired or desirable standard and bureaucracy that
demands large amounts of time to be spent upon it to
 2011 Blackwell Publishing Ltd, Histopathology, 59, 359–367.

no perceived benefit. Acute stress relates to the arousal
or anxiety experienced when perceived task demands
feel as if they are exceeding one’s resources to cope.
Causal factors include increasing expectations, e.g.
turn-around times as opposed to clinical urgency,
trying to reach a diagnosis where relevant information
is absent or inexperience in dealing with uncertainty.
During operations, surgeons can experience acute
stress due to distractions, unavailable equipment,
patient complexity, unexpected bleeding, etc. and the
resulting anxiety can then hamper their ability to think
clearly and take appropriate actions.47 The non-tech-
nical skills required for acute stress management
include being able to identify stress in self and others
and learning coping strategies to reduce exposure or
effects, such as better preparation, mental rehearsal,
dealing with interruptions, stepping back from the task
and relaxation techniques.47,48 Rudeness and incivility
among colleagues may also invoke risks to safety49 in
already stressful environments.
c o p i n g w i t h f a t ig u e
Fatigue adversely affects our ability to think and
perform tasks, as well as communication and social
skills.22 In other words, we do less well and make less
effective interpersonal interactions when we are tired.
Recognizing tiredness is key to this – reviewing a
problem slide in the morning will often reveal features
that had not been spotted or the significance of which
had been overlooked when we looked at it last thing the
night before. Fatigue is a factor in adverse incidents
in transportation,50 aviation51–52 and medicine.53–55
Dealing with the effects of fatigue has been a driver for
trainee duty roster design in the UK health service,
although less obviously for senior staff. The literature on
fatigue, however, tends to be centred on sleep depriva-
tion (e.g. the Queensland Government’s recent publica-
tion56). Histopathologists will recognize tiredness as a
limiting factor in reporting, and this may accord with
workload. In histopathology, the nature of the work
with intense concentration during microscopy, sustain-
ing this effort over protracted periods and environmen-
tal factors such as heat or noise are possibly the most
probable influential factors. As with acute stress, the
non-technical skills for fatigue management include
identifying the symptoms in self and others and apply-
ing coping strategies to avoid causes or to reduce effects.
While there appears to have been very little research
in histopathology into these non-technical skills, the
following scenarios are presented to indicate why it
seems to be an important component of safe and
effective practice.
 2011 Blackwell Publishing Ltd, Histopathology, 59, 359–367.
Histopathology non-technical skills 363
Scenario 1
A frozen section arrives in the department. No one is
expecting it. You are busy reporting a series of
diagnostic biopsies when this happens but immediately
stop to attend to the frozen section. The details on the
request form and the specimen container match. You
proceed to examine, describe and block the material
and the sections are duly cut and stained. The clinical
history is of a 60-year-old woman with a small nodule
which has been found on the gall bladder while a
routine cholecystectomy is being carried out. You look
at the sections and find rather crushed nuclei with a
roughly glandular appearance embedded in smooth
muscle. You cannot see the architecture clearly on
the first set of sections or on the deeper levels into the
block. You are not sure if this is a Rockitansky–Aschoff
sinus or a deposit of adenocarcinoma. You call the
surgeon in theatre and tell him this. ‘Ah’, he says, ‘well
now. We have a similar-looking thing on a loop of
small bowel’. You ask him to send this saying that if it
is the same, then what you are looking at now may be
more likely to be adenocarcinoma. ‘Well’, he says,
‘there is some thickening at the neck of the gall bladder
and she is cholestatic’. When you look at the second
sample, this too contains glandular tissue but this time
you can see irregular profiles, solid nests and consid-
erable nuclear aberration. You call the surgeon again,
this time saying you think this is metastatic carcinoma.
The surgeon is happy with this and says that he will
stent the common duct and terminate the procedure.
This scenario demonstrates that the histopathologist
is aware of the clinical urgency of the situation and
immediately reprioritizes work to carry out the frozen
section, the outcome of which ultimately changes the
outcome of the surgical operation. The pathologist
makes clear decisions about concerns aroused by the
appearances of the material and asks the surgeon for
more information and clarification of the intra-opera-
tive findings. This indicates the value of clear commu-
nication between the two who are working together to
ensure an outcome that is appropriate to the clinical
circumstances. There is mutual respect for the other’s
position – the surgeon does not expect the pathologist to
deliver a diagnosis on crushed and potentially mislead-
ing material and helpfully provides more while the
pathologist does not complain that he has been sent
poor-quality material. These behaviours show that both
are capable of good team working to the patient’s
benefit. This is a potentially difficult or stressful situation
for both, as there is an unexpected finding at laparotomy
and the first attempt at resolving the issue is not
entirely enlightening. They deal with this carefully and
364 P W Johnston et al.
professionally, demonstrating not only their clinical
expertise but also their non-technical skills.
Scenario 2
Your three double trays of slides from yesterday’s cut
have appeared from the laboratory. You are aware,
however, that the multidisciplinary team meeting
(MDT) is in 15 min and one case you still have to
review is missing. The telephone has rung incessantly
all morning; the secretary has a day off; and then the
trainee comes in from a coffee break and says she
wants to check some cases now because she needs to be
away by 5 PM. The temptation may well be that you do
not respond to this request with the usual smiling
positive endorsement but, resisting this, you explain
that right now you have to prioritize the MDT meeting
and must get hold of the slides to examine before it. She
says she’ll find them. You also want to look at a couple
of cases that have just come from the laboratory to see
if, as you suspected yesterday, you will have to ask for
immunocytochemical (ICC) investigations which you
would like to get under way as soon as possible. You
pick out a couple of needles cores with ‘urgent, please
phone’ on the request forms. One shows a high-grade
lymphoma and the other looks like metastatic carci-
noma. You start to sort out the ICC orders to classify
both lesions and, as you are doing this, the trainee
comes in with the missing slides. ‘Where do you want
me to put these?’, she asks. Trying to remember where
the rest of the MTD slides are, you stand up, look
around and point to the pile on the shelf. The telephone
rings and this is the oncologist wanting to know about
one of the needle cores. You grab the slide and put it on
the stage, saying ‘this is a high-grade lymphoma – I am
just getting the ICC on the way as we speak’. You finish
the ICC orders and go to the MDT. The next day, ICC
slides arrive. There is a lymphoma panel on a meta-
static carcinoma and a variety of cytokeratins on the
lymphoma. Then it hits you. ‘Which slide did I look at
when I spoke to the oncologist?’
The trainee came in from a coffee break and noticed
the situation into which she had just ambled, recog-
nizing the signals of someone just coping with pressure,
hanging on to control and a great deal to do in a short
time. Situation awareness is about seeing what is going
on around us and noticing that those with whom we
are working are absorbed, distracted or otherwise
stressed, giving out non-verbal messages indicating
that interruption had better be for a good reason. The
trainee is able to deal positively with this and takes on
a task she can do easily to help her senior colleague.
She then unwittingly breaks the concentration of the
senior by asking where to put the slides. The senior
does not cope well with the stress of this situation and
has to look to see where he put the stack of cases for
the MDT. He has not prioritized his activities (a
leadership skill) and thus has no clear course to follow.
He then lacks situation awareness and carries on
where he left off, but without checking to ensure that
he is looking at the right slide. Communication then
fails as the wrong information is conveyed to the
laboratory about which immunocytochemical stains
to prepare on which case, and he delivers incorrect
information to the oncologist because he is unwittingly
looking at the wrong slide. His leadership and decision-
making under these circumstances are questionable: he
might better have said to the oncologist that the cases
had just come through, give him 5 min to look at them
and he would call back, thus buying time to cope with
the stress, fulfil his role in the team and make the
correct diagnostic decisions.
Scenario 3
The breast MDT takes place on a hot afternoon in a
small room, in half light, crammed with people, with
52 patients on the list. The 32nd patient is screening
detected and the lesion impalpable. The radiologist is
uncertain about the interpretation of the imaging and
suggests a magnetic resonance imaging scan. The fine
needle aspiration has been reported as suspicious of a
lymphoma and the core biopsy looks like a low-grade
lymphoma but you, as the histopathologist, know that
classification of these on small cores is perilous. The
surgeon is flicking a pen around and appears fidgety.
You suggest that for accurate diagnosis the lesion
should be excised and ask the radiologist if she could
put a wire in it for a wide local excision. The radiologist
says this is possible. The surgeon is pleased with this
suggestion and asks the coordinator to organize a
theatre date for the patient.
In this scenario, the pathologist demonstrates a
number of non-technical skills. She deals with a phys-
ically stressful environment (hot room, long meeting,
dark), is aware of the surgeon’s difficulty with the patient
(situation awareness) and shows leadership in finding a
solution that is acceptable to the multi-disciplinary
team. She displays good communication skills in recog-
nizing the surgeon’s non-verbal signals of disquiet and
acts effectively in the patient’s best interest.
Discussion
The literature cited in the Introduction to this paper
illustrates the generic nature of non-technical skills and
 2011 Blackwell Publishing Ltd, Histopathology, 59, 359–367.

their application in everyday work. The definitions
relate the aspects of non-technical skills to the envi-
ronments in which histopathologists practise and the
scenarios give examples of how good practice employs
these skills to advantage. In safety-conscious cultures
such as health care, much time is spent ensuring that
processes are ‘fit for purpose’, constructing governance
structures to police them and worrying about outcomes
of inspections. Large sums are devoted to training staff
in pathology departments as well as wards and clinics
across a range of skill areas, and many of these attempt
to develop an awareness of issues that staff will rarely
encounter. However, all pathologists use aspects of the
non-technical skills repertoire every day. This is true of
most health-care workers and is certainly so for all but
the most isolated practitioner. Given the evidence from
anaesthesia27,28,31 and surgery,35,36,48 the relevance
of non-technical skills to medical mishap is clear. In
histopathology, there is considerable interest in dis-
crepancy rates of interobserver variation (the science of
kappa statistics in reporting, for instance) and ‘accept-
able’ rates of mistakes.1–4 The work in this area
concentrates on the diagnostic skill development (or
implies its lack) in reporting histopathologists, but little
attention is paid to the human factors that underlie
most adverse incidents.
Human error plays a role in a proportion of
occasions when histopathology reports are incorrect.
Failures in the domains of the non-technical skills
certainly become evident when services or departments
encounter performance difficulties. These situations
are complex and pose ‘wicked’ problems57 which
expose issues for management that demand leadership
that is equipped to deal with such situations.45,58
Histopathology is, to a large extent, problem-solving in
nature and categorizing, defining and ascribing disease
processes in fields where most would agree with the
solution reached. This can be termed consensus, but
Rittell and Webber57 have defined such problems as
‘tame’. Dealing with problems that are complex and
have no immediate solution (‘wicked’ problems57) is a
challenge, as there is no easy fix that resolves them. All
histopathologists come across clinical diagnostic cases
in this category, and they interest and stretch the
diagnostician with challenge and sometimes defeat.
More commonly, this category of difficulty is encoun-
tered when facing organizational or financial chal-
lenge. What do we do to equip trainees to handle these
situations?
Apart from Foucar’s analysis,59 little literature exists
describing histopathological decision-making. Con-
versely, the perceptual processing that contributes to
the decision-making process has been studied,60–62
 2011 Blackwell Publishing Ltd, Histopathology, 59, 359–367.
Histopathology non-technical skills 365
concluding that understanding that process will pro-
vide insights valuable to training, studying diagnosis
and ‘error’, however that is defined in the context of the
variability of the interpretative opinion captured in a
histopathology report. Psychologists study expert deci-
sion-makers in their natural environment, e.g. the
operating theatre, to dissect their cognitive processes in
order to understand the basis of their expertise. This
has been labelled ‘naturalistic decision making’.63
Affect is also likely to influence the decision-making
processes that apply in the diagnostic histopathology
setting. Observations would suggest that both inciden-
tal affect (emotions the decision-maker brings to a
situation along with him or her – their own ‘baggage’)
and integral affect (the emotional response the person
has to the decision-making process on the given
task) both influence the decision-making process in
experts.64
The UK Royal College of Pathologists, in common
with other UK medical Royal Colleges, has recently
revised its speciality training programme.65 This has
incorporated generic aspects of training for leadership
and maintains the relevance of communication skills
to clinical function. Pathology curricula about lead-
ership are more about managerial or organizational
function66 rather than developing leadership skills.
The non-technical skills needed by histopathologists
remain embedded in the curriculum as they do in
practice, but are not highlighted as areas that might
be developed. Anaesthesia28,32,33 and surgery67 have
grasped the value of defining elements of non-techni-
cal skills that are specifically relevant to sensitive
areas of speciality practice and devising programmes
to help develop the necessary skills in the relevant
doctors. There is emphasis in simulations of high-risk
procedures such as challenging intra-operative situa-
tions on the non-technical aspects of practice to help
people work together to improve patient safety and
outcomes.
The evidence and literature presented here set
questions for histopathologists regarding how the
non-technical aspects of diagnostic work are dealt
with, how well the human components of working
environments are handled, how well colleagues work
together and how much better these might be
addressed if we really knew what we were doing. This
is the challenge we pose.
Acknowledgements
The authors are grateful to Dr Mary McKean for her
helpful comments and for colleagues who encouraged
this work.
366 P W Johnston et al.
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