Agent/Broker Portal
Forgot your User ID
or Password?
Sign Up Now
Contact Us: 844.466.7225

Avoid Ambiguity in Pathology Reports to Improve Communication

March 26, 2021

A pathologist’s main objectives in writing a pathology report are to communicate the diagnosis and create a permanent record.1 The entire purpose of specimen procurement and pathology consultation may be defeated if the pathology report is inaccurate, incomplete, difficult to read, or difficult to understand.2

NORCAL Group Risk Management Department Inquiry

More Information About Communicating Critical Findings along the Continuum of Care

Overview: Healthcare Communication: Case Studies and Best Practices for Communicating Critical Findings

Part 1: From Radiology to ED

Part 2: From Anatomic Pathologist to Ordering and Primary Care Physician

Part 3: From Primary Care Physician to Patient

A policyholder called the NORCAL Risk Management department. He had heard from colleagues that for liability risk management purposes it was better for a pathologist to use “consistent with” as opposed to “suggestive of” when describing a diagnosis in a pathology report.

Discussion

Pathologists commonly use ambiguous phrases in the diagnosis section of pathology reports, including “consistent with,” “worrisome for,” “cannot rule out,” “suspicious for,” “favor,” “indefinite for,” “compatible with,” “indicative of,” “not excluded,” “cannot exclude,” “not ruled out,” “not definite for,” “not specific for,” “indeterminate,” and “not identified.”3,4 A desire to avoid legal liability is one of the various reasons a pathologist may use ambiguous terminology in a report. But more often, ambiguous terminology is used because absolute diagnostic certainty is not attainable so the pathologist is using the descriptors to accurately reflect the level of uncertainty in a diagnosis.4

Many pathologists use a particular ambiguous term to express a specific level of uncertainty (e.g., a 50-60% probability of malignancy is denoted as “suspicious for” malignancy, a 40-50% probability is “indicative of” and a 20-30% probability is “cannot rule out.”) Unfortunately, because there is no consistency in the use and definition of these terms — even among pathologists — the person using the report for treatment purposes may believe there is more or less of a probability of the diagnosed condition than the pathologist intended.4 Consequently, a pathologist’s careful choice of a particular ambiguous term can lead to treatment delay, over-treatment, and patient misunderstanding.

When treatment delay or unnecessary treatment results in malpractice litigation, a pathologist involved in the treatment who submitted an ambiguous diagnosis will inevitably be named as a defendant. Whether the plaintiff will dismiss the pathologist from the case will depend on many different issues. However, a pathologist who expresses a diagnosis in ambiguous terms for the sole purpose of avoiding liability will likely have difficulty arguing doing so met the standard of care, particularly if the ambiguity resulted in the misunderstanding of the diagnosis and caused the patient injury.

Medical Liability Risk Management Recommendations

Ambiguity in pathology reports can be problematic for various reasons, although it is generally understood that various factors (e.g., complexity of the specimen, insufficient specimen, inconclusive morphologic criteria) may make the use of ambiguous terms necessary in limited circumstances.3

Consider using the following strategies when composing pathology reports:1,2,5

  • Use words and terms in reports that can be easily understood by non-pathologists — the person reading the report will most likely not be a pathologist.
  • Avoid ambiguous and equivocal terminology.
    • If the diagnosis is uncertain, explain the cause of uncertainty and recommend strategies for greater clarity (e.g., request addition clinical information or better quality/larger samples).
  • Obtain a second opinion if the diagnosis isn’t clear.
    • Document your thought process.
    • Include differential diagnoses in the report, if appropriate.
    • Do not add uncertainty to a diagnosis for the purpose of avoiding liability.
  • Use style and word order that makes the diagnoses easy to understand.
    • Prioritize essential information at the beginning of the report.
  • Use headlines to emphasize key findings.
  • Indicate whether the report is final or pending further testing or opinions.
  • Review the final report for accuracy before sending it.
This content originally appeared as part of the March 2017 release of the NORCAL Group Risk Management publication, Claims Rx, “Communicating Critical Findings — A Three-Part Series, Part 2: Anatomic Pathologist to Ordering and Primary Care Physician.” This release and many others are available in the Claims Rx Directory for download. Policyholders will also find instructions for obtaining CME credit for select releases.

References

1. Raouf E. Nakhleh (ed.) Error Reduction and Prevention in Surgical Pathology. Springer Science+Business Media. New York. 2015. “Chapter 11. The Complete Surgical Pathology Report.” (not available online at the time of publication)

2. Raouf E. Nakhleh (ed.) Error Reduction and Prevention in Surgical Pathology. Springer Science+Business Media. New York. 2015. “Chapter 12. Communicating Effectively in Surgical Pathology.” (not available online at the time of publication)

3. Richard L Attanoos, A. D. Bull, et al. “Phraseology in Pathology Reports. A Comparative Study of Interpretation Among Pathologists and Surgeons.” Journal of Clinical Pathology. 1996;49:79-81. DOI: 10.1136/jcp.49.1.79

4. Sarah W. Lindley, Elizabeth M. Gillies, et al. “Communicating Diagnostic Uncertainty in Surgical Pathology Reports: Disparities Between Sender and Receiver.” Pathology – Research and Practice. 2014;210:628–633. DOI: 10.1016/j.prp.2014.04.006

5. Michael O. Idowu, Austin Wiles, et al. “Equivocal or Ambiguous Terminologies in Pathology: Focus of Continuous Quality Improvement?American Journal of Clinical Pathology. 2013;37:1722–1727. DOI: 10.1097/pas.0b013e318297304f

Filed under: Patient Care

 Topics 

 Specialties 

Interested in NORCAL Group?

Contact Your Agent/Broker or call 844.4NORCAL today