Reforms, Errors, and Dermatopathology Malpractice: Then and Now: A Comprehensive Retrospective.
Journal
Advances in anatomic pathology
ISSN: 1533-4031
Titre abrégé: Adv Anat Pathol
Pays: United States
ID NLM: 9435676
Informations de publication
Date de publication:
01 Mar 2022
01 Mar 2022
Historique:
pubmed:
26
9
2021
medline:
11
2
2022
entrez:
25
9
2021
Statut:
ppublish
Résumé
Medical malpractice occurs when a hospital, doctor, or other health care professional, through a negligent act or omission, causes an injury to a patient. The negligence might be the result of errors in diagnosis, treatment, aftercare, or health management. To be considered medical malpractice under the law, the claim must violate the standard of care, the injury must be caused by the negligence and, last but most certainly not least, the injury must result in significant damages. This review is an overview of medicolegal issues specific to the practice of Dermatopathology with the caveat that most are likely pertinent to other specialties of pathology as well. The safety of patients remains the priority in pathology as it does in any medical undertaking, and this is no different in the practice of Dermatopathology. The review is broadly divided in 2 parts-we begin with an overview of tort reforms, advocated by physicians to reduce costs associated with malpractice defense. In the second part we address practical issues specific to the practice of pathology and dermatopathology. These include among others, errors-related to the biopsy type, inadequacy of clinical information regarding the lesion that is biopsied, role of interstate dermatopathology as well as examples of select entities commonly misdiagnosed in dermatopathology. In the last decade, artificial intelligence (AI) has moved to the forefront of technology. While research into the uses of AI in pathology is promising, the use of AI in diagnostic practice is still somewhat uncommon. Given that AI is not fully integrated routinely as a diagnostic adjunct, its' impact on pathology-specific medicolegal issues cannot, as yet at least, be defined. Restriction of medical malpractice is of particular relevance in the COVID-19 era, a period that is anything but normal. The response of states with specific pandemic-related guidelines is addressed with the caveat that this particular issue is only covered in select states. Furthermore, given that the COVID pandemic is only a year old, while it does not appear to have had an immediate impact on pathology-specific medicolegal matters, it is possible that the role of COVID on this issue, if any at all, will and can only be fully defined a few years down the line.
Identifiants
pubmed: 34561375
doi: 10.1097/PAP.0000000000000319
pii: 00125480-202203000-00002
doi:
Types de publication
Journal Article
Review
Langues
eng
Sous-ensembles de citation
IM
Pagination
81-96Informations de copyright
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Déclaration de conflit d'intérêts
The author has no funding or conflicts of interest to disclose.
Références
Mohr JC. American medical malpractice litigation in historical perspective. JAMA. 2000;283:1731–1737.
Pritchard DJ. A plaintiff’s attorney’s candid view of medical malpractice. Clin Perinatol. 2005;32:191–202.
Campbell MC, Lane LLP. Summary of medical malpractice law (Virginia). 2003. Available at: http://www.mcandl.com/viginia.html . Accessed September 21, 2020.
Studdert DM, Yang YT, Mello MM. Are damage caps regressive? A study of malpractice jury verdicts in California. Health Aff. 2004;23:54–67.
Center for Justice and Democracy. Medical malpractice insurer dumping states with severe “tort reforms”: more evidence that caps do not work. News release. September 26, 2003. Available at: http:/centerjd.org . Accessed September 21, 2020.
Norbut M. Three crisis states report improvement since tort reform. Am Med News. 2005;48:1.
Sorrel AL. Liability insurance rates mostly hold steady or drop this year. Am Med News. 2006;49:1.
Jacobson PD, Bloche MG. Improving relations between attorneys and physicians. JAMA. 2005;294:2083–2085.
Murray I. The Malpractice Economist: Liable to Suffer. New Haven: American Enterprise; 2003:501.
Rosenbaum S. The impact of United States law on medicine as a profession. JAMA. 2003;289:1546–1556.
Shapiro D. Essay. Beyond the blame: a no-fault approach to malpractice. New York Time , September 23, 2003. Available at: http:/www.nytimes.com . Accessed September 23, 2020.
Californians Allied for patient protection, the coalition to protect MICRA. About MICRA. 1975. Available at: http://www.micra.org/aboutMICRA.htm . Accessed July 28, 2020.
Ferrier Crystal. “The Collateral Source Rule: A Rule of Evidence and a Rule of Damages”. Georgia State College of Law Reading Room. 2004. Available at: https://readingroom.law.gsu.edu/cgi/viewcontent.cgi?article=1046&context=lib_student . Accessed December 11, 2020.
“Closing Arguments: Is Wisconsin’s collateral-source rule worth preserving?” Wisconsin Law Journal . The Daily Reporter Publishing Co. March 10, 2016. Available at: https://en.wikipedia.org/wiki/2011_Wisconsin_protests . Accessed December 11, 2020.
Campbell MC, Lane LLP. Summary of medical malpractice law (New Mexico), 1998. Available at: http://www.mcandl.com/viginia.html . Accessed September 21, 2020.
National Association of Mutual Insurance Companies (NAMIC). Joint and several liability reform states. 2004. Available at: http://www.namic.org . Accessed September 18, 2020.
Worsley B. The many facets of vicarious liability. Schweickert & Company. 2004. Available at: http://schweickert.cpm/p-vicarious.htm . Accessed September 10, 2020.
Sorrell AL. Court upholds doctors’ rights to pay only part of jury award. Am Med News. 2006;49:13.
Creswell J. So small a town, so many patent suits. The New York Times . September 24, 2006; Section 3:1.
Cass RA. Forum-shopper of the year. The Wall Street J . 2007;A13.
Prevatt HA, Sturgill TC, Austin JB, et al. Anatomy of a malpractice lawsuit. Surg Innov. 2007;14:62–64.
Yoon A, Baker T. Offer-of-judgement rules and civil litigation. 1984. Available at: http://www.utexas.edu/law/academics/centers/clbe/assets/YoonAlbert_paper_11.08.pdf . Accessed October 3, 2020.
Samanta A, Samanta J. Legal standard of care: a shift from the traditional Bolam test. Clin Med (Lond). 2003;3:443–446.
Kluft RP. The physician as perpetrator of abuse. Prim Care. 1993;20:459–480.
Struve CT. Improving the medical malpractice litigation process. Health Aff. 2004;23:33–41.
Norbut M. Physicians in 4 states score tort reform wins. Am Med News. 2005:5.
Darr K. Communication: the key to reducing malpractice claims. Hosp Top. 1991;75:46.
Liebman CB, Hyman CS. A mediation skills model to manage disclosure of errors and adverse events to patients. Health Aff. 2004;23:22–32.
Campbell MC, Lane LLP. Summary of medical malpractice law. August 15, 1998. Available at: http://www.mcandl.com/viginia.html . Accessed September 11, 2020.
Robert Wood Johnson Foundation. A plan for voluntary mediation as alternative for malpractice claims doesn’t make it to the demonstration phase. 2002. Available at: http://www.rwjf.org/reports/grr/033629.htm . Accessed August 10, 2020.
Tongue JR, Epps HR, Forese LL. Communication skills. Instr Course Lect. 2005;54:3–9.
Metzloff TB. Researching litigation: the medical malpractice example. Law Contemp Probl. 1988;51:199–241.
Medical Liability. Florida voters speak, but the courts won’t listen. Am Med News. 2006:23.
Herman T. How to lower your tax-bill this year: more people get hit with stiff penalties for delaying tactics or frivolity. The Wall Street J . 2006:D1.
John Edwards on Government Reform. On the Issue. 2003. Available at: http://ontheissues.org/2004/John_Edwards_Government_Reform.htm . Accessed August 29, 2020.
Nelson KB. Can we prevent cerebral palsy. N Engl J Med. 2003;349:1765–1769.
Larson A. New Mexico statute of limitations for civil and personal injury actions: an overview. Expert Law. 2004. Available at: http://www.expertlaw.com/library/limitations_by_state_New_mexico.htm . Accessed August 29, 2020.
Massey B. Medical malpractice suit rules change for kids. The Aberquerque J. 2004. Available at: http://www.abqjournal.com . Accessed August 29, 2020.
Landro L. Doctors learn to say “I’m sorry”. The Wall Street J . 2007:PgD5.
Allen TC, Stafford M, Liang BA. Pathology and medical malpractice: academic and trainee emperical review of cases by state of Texas physicians. Am J Clin Pathol. 2014;141:501–509.
Heher YK, Dintzis SM. Disclosure of harmful medical error to patients: a review with recommendations for pathologists. Adv Anat Pathol. 2014;25:124–130.
Cardona DM, Black-Schaffer S, Shamanski F, et al. Medicares new quality payment program has started—are you ready. Arch Path Lab Med. 2017;141:741–745.
South Carolina Reforms. American tort reform organization. 2005. Available at: http://www.atra.org/states/SC . Accessed August 5, 2020.
Schaffer A. Medical malpractice in the time of COVID-19. Available at: https://www.rmf.harvard.edu/Blog/2020/March/MPL-In-The-Time-of-COVID19 . Accessed October 5, 2020.
Freckelton I. COVID-19, negligence and occupational health and safety: ethical and legal issues for hospitals and health centers. J Law Med. 2020;27:590–600.
Kelly AM. COVID-19 and medical litigation: more than just the obvious. Emerg Med Australas. 2020;32:703–705.
Duignan K, Bradbury C. Covid-19 and medical negligence litigation: immunity for healthcare professionals? Med Leg J. 2020;88:31–34.
Waterman AD, Garbutt J, Hazel E, et al. The emotional impact of medical errors on practicing physicians in the United States and Canada. Jt Comm J Qual Patient Saf. 2007;33:467–476.
Mello MM, Chandra A, Gawande AA, et al. National costs of the medical liability system. Health Aff. 2010;29:1569–1577.
Studdert DM, Mello MM, Sage WM, et al. Defensive medicine among high-risk specialist physicians in a volatile malpractice environment. JAMA. 2005;293:2609–2617.
Mello MM, Studdert DM, Brennan TA. The new medical malpractice crisis. N Eng J Med. 2003;348:2281–2284.
Kassirer JP, Cecil JS. Inconsistency in evidentiary standards for medical testimony. Disorder in the courts. JAMA. 2002;288:1382–1387.
Foucar E. Pathology expert witness testimony and pathology practice. A tale of 2 standards. Arch Pathol Lab Med. 2005;129:1268–1276.
US Supreme Court, 509 US 579 (1993). Daubert v Merrell Dow Pharmaceuticals Inc. 1993. Available at: http://supct.law.cornell.edu . Accessed December 5, 2020.
Cho A. Fingerprinting doesn’t hold up as a science in court. Science. 2002;297:418.
Faigman DL. Is science different for lawyers. Science. 2002;297:339–340.
Sedgwick P, Greenwood N, Sedgwick P, et al. Understanding the Hawthorne effect. BMJ. 2015;351:h4672.
Chen LF, Vander Weg MW, Hofmann DA, et al. The Hawthorne effect in infection prevention and epidemiology. Infect Control Hosp Epidemiol. 2015;36:1444–1450.
Ackerman AB. A trial in Philadelphia and matters that transcend it. Dermatopathol Pract Concept. 2000;6:236–250.
Cooper K. Errors and error rates in surgical pathology: an association of Directors of Anatomic and Surgical pathology Survey. Arch Pathol Lab Med. 2006;130:607–609.
Frable WJ. Surgical pathology-second reviews, institutional reviews, audits and correlations: what’s out there? Error or diagnostic variation. Arch Pathol Lab Med. 2006;130:620–625.
Troxel DB. Medicolegal aspects of error in pathology. Arch Pathol Lab Med. 2006;130:617–619.
Heher YK, Dintzis SM. Disclosure of harmful error to patient: a review with recommendations for pathologists. Adv Anat Pathol. 2018;25:124–130.
Wick MR, Foucar E. Evidence-based medicine and tort law. Semin Diagn Pathol. 2005;22:167–176.
Crowson AN. Medicolegal aspects of neoplastic dermatology. Mod Pathol. 2006;19:S148–S154.
Epstein JI. Pathologists and the judicial process: how to avoid it. Am J Surg Pathol. 2001;25:527–537.
Gittler GJ, Goldstein EJ. The elements of medical malpractice: an overview. Clin Infect Dis. 1996;23:1152–1155.
Comfere NI, Peters MS, Jenkins S, et al. Dermatopathologists’ concerns and challenges with clinical information in the skin biopsy requisition form: a mixed-methods study. J Cutan Pathol. 2015;42:333–345.
Romano RC, Novotny PJ, Sloan JA, et al. Measures of completeness and accuracy of clinical information in skin biopsy requisition forms: an analysis of 249 cases. Am J Clin Pathol. 2016;146:727–735.
Fernandez EM, Helm T, Ioffreda M, et al. The vanishing biopsy: the trend toward smaller specimens. Cutis. 2005;76:335.
Stuart LN, Rodriguez AS, Gardner JM, et al. Utility of additional tissue sections in dermatopathology: diagnostic, clinical and financial implications. J Cutan Pathol. 2014;41:81–87.
Dyson SW, Bass J, Pomeranz J, et al. Impact of thorough block sampling in the histologic evaluation of melanomas. Arch Dermatol. 2005;141:734–736.
Steindel SJ, Jones BA, Howanitz PJ. Timeliness of automated routine laboratory tests: a College of American Pathologists Q-Probes study of 653 institutions. Clin Chim Acta. 1996;251:25–40.
Fox BC, Siegel ML, Weinstein RA. “Curbside” consultation and informal communication in medical practice: a medicolegal perspective. Clin Infect Dis. 1996;23:616–622.
Olsen TG, Feeser TA, Jenkins PL. Interstate dermatopathology interpretations—50 separate licenses? J Am Acad Dermatol. 2004;51:454–457.
Marsch A, High WA. Teledermatology, teledermatopathology, interstate dermatopathology and the law. Semin Cutan Med Surg. 2013;32:224–229.
Marsch AF, Feinberg JS. State restrictions on the interstate practice of dermatopathology are unconstitutional: the tissue is the issue. J Cutan Pathol. 2015;42:669–673.
Chuchvara N, Patel R, Srivastava R, et al. The growth of teledermatology: expanding to reach the underserved. J Am Acad Dermatol. 2020;82:1025–1033.
Hiemenz MC, Leung ST, Park JY. Crossing boundaries: a comprehensive survey of medical licensing laws and guidelines regulating the interstate practice of pathology. Am J Surg Pathol. 2014;38:e1.
Brauer JA, Shin DB, Troxel AB, et al. Characteristics of dermatologists who read dermatopathology slides. J Cutan Pathol. 2007;34:687–692.
Giambrone D, Rao BK, Esfahani A, et al. Obstacles hindering the mainstream practice of teledermatopathology. J Am Acad Dermatol. 2014;71:772.
Ackerman AB. Dermatologist ≠ dermatopathologist: no place in a profession for pretenders. J Am Acad Dermatol. 2005;53:698–699.
Glusac EJ. Under the microscope: doctors, lawyers, and melanocytic neoplasms. J Cutan Pathol. 2003;30:287–293.
Grant-Kels JM. The whys and wherefores of who reads dermatopathology slides. J Am Acad Dermatol. 2005;53:703–704.
Read S, Hill HF III. Dermatology’s malpractice experience: clinical settings for risk management. J Am Acad Dermatol. 2005;53:134–137.
Cocks M, Gru AA. Quality assurance in dermatopathology: a review of report amendments. J Cutan Pathol. 2021;48:34–40.
Comfere NI, Sokumbi O, Montori VM, et al. Provider-to-provider communication in dermatology and implications of missing clinical information in skin biopsy requisition forms: a systematic review. Int J Dermatol. 2014;53:549–557.
White WL, Stavola JM. The dark side of photomicrographs in pathology reports: liability and practical concerns hidden from view. J Am Acad Dermatol. 2006;54:353–356.
High WA, Stewart D, Wilbers CR, et al. Completely regressed primary cutaneous malignant melanoma with nodal and/or visceral metastases: a report of 5 cases and assessment of the literature and diagnostic criteria. J Am Acad Dermatol. 2005;53:89–100.
King R, Hayzen BA, Page RN, et al. Recurrent nevus phenomenon: a clinicopathologic study of 357 cases and histologic comparison with melanoma with regression. Mod Pathol. 2009;22:611–617.
Lydiatt DD. Medical malpractice and cancer of the skin. Am J Surg. 2004;187:688–694.
Marsch A, High WA. Medicolegal issues with regard to melanoma and pigmented lesions in dermatopathology. Dermatol Clin. 2012;30:593–615.
Massi G. Melanocytic nevi simulant of melanoma with medicolegal relevance. Virchows Archiv. 2007;451:623–647.
Trotter MJ, Bruecks AK. Interpretation of skin biopsies by general pathologists: diagnostic discrepancy rate measured by blinded review. Arch Pathol Lab Med. 2003;127:1489–1492.
Troxel DB, Sabella JD. Problem areas in pathology practice. Uncovered by a review of malpractice claims. Am J Surg Pathol. 1994;18:821–831.
Ian Tomlison Pathologist struck off. 2012. Available at: http://www.bbc.co.uk/news/uk-19355106 . Accessed December 7, 2020.
Hirschowitz L, Wells M, Lowe J. Double reporting in histopathology. The Royal College of Pathologists, February 2013. Available at: http://www.rcpath.org/Resources/RCPath/Migrated%20Resources/Documents/G/G128_Doublereporting_Feb13.pdf . Accessed December 7, 2020.
Smith KJ, Barrett TL, Skelton HG. Spindle cell and epithelioid cell nevi with atypia and metastasis (malignant spitz nevus). Am J Surg Pathol. 1989;13:931–939.
Tronnier M, Wolff HH. UV-irradiated melanocytic nevi simulating melanoma in situ. Am J Dermatopathol. 1995;17:1–6.
Seo H, Hirai H, Aoyama T, et al. Undifferentiated intimal sarcoma mimicking a mycotic aneurysm. Vasa. 2020;49:243–246.
Hart SN, Flotte W, Norgan AP, et al. Classification of melanocytic lesions in selected and whole-slide images via conventional neural networks. J Pathol Inform. 2019;10:5.
Wells A, Patel S, Lee JB, et al. Artificial intelligence in dermatopathology: diagnosis, education and research. J Cutan pathol. 2021;48:1061–1068.
Crowley RS, Legowski E, Medvedeva O, et al. Effect of a limited-enforcement intelligent tutoring system in dermatopathology on student errors, goals and solution paths. Artif Intell Med. 2009;47:175–197.
Nagarajan P. Differentiating keratoacanthoma from squamous cell carcinoma—in quest of the holy grail. J Cutan Pathol. 2020;47:418–420.
Lohman ME, Grekin RC, North JP, et al. Impact of second-opinion dermatopathology reviews on surgical management of malignant neoplasms. J Amer Acad Dermatol. 2021;12:S0190–S9622.
Meier FA, Varney RC, Zarbo RJ. Study of amended reports to evaluate and improve surgical pathology processes. Adv Anant pathol. 2011;18:406–413.
Piepkorn MW, Longton GM, Reisch LM, et al. Assessment of second-opinion strategies for diagnoses of cutaneous melanocytic lesions. JAMA Netw Open. 2019;2:e1912597.
Sheikh UA, Sufficool KE, Buchanan P, et al. Dermatopathologist assessment of “pathologist-to-dermatologist” communication for dermatopathology services. J Cutan pathol. 2020;47:328–338.