"Also in August, the Ontario government announced it would compensate victims of pathologist Dr. Charles Smith, who worked at Toronto's renowned Hospital for Sick Children from 1981 to 2005. Smith served as an expert witness in dozens of suspicious child deaths. In the end, his faulty testimony would help convict innocent people of murder............
But public trust in them has been seriously jarred in the wake of a series of controversies that make it seem as if the state of pathology is coming undone.
Judicial and public investigations have been held into misdiagnoses and errors in pathology in four provinces, the most recent involving two women in Windsor who had cancer-free breasts removed.
Their professional organization says pathologists have among the lowest error rates in medicine and that the overall quality of pathology diagnoses in Canada is high.
But, the controversies have exposed vulnerabilities in a world of medicine hidden from most patients. "There are so many gaps in the system that it's actually surprising that there are not more disasters," says Vancouver pathologist Dr. Diponkar Banerjee."
REPORTER SHARON KIRKEY; POSTMEDIA NEWS;
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BACKGROUND: The inquiry focused largely on the flawed work of Dr. Smith — formerly the province's chief pediatric pathologist and a self-styled member of the prosecution team — whose "errors" led to innocent people being branded as child murderers. The 1,000-page report by Justice Stephen Goudge slammed Dr. Smith, along with Ontario's former chief coroner and his deputy, for their roles in wrongful prosecutions and asked the province to consider compensation. The provincial coroner's office found evidence of errors in 20 of 45 autopsies Dr. Smith did over a 10-year period starting in the early 1990s. Thirteen resulted in criminal charges. William Mullins-Johnson, who was among those cases, spent 12 years in prison for the rape and murder of his four-year-old niece, whose death was later attributed to natural causes. In another case, Dr. Smith concluded a mother had stabbed her seven-year-old girl to death when it turned out to have been a dog mauling. The inquiry heard that Dr. Smith's failings included hanging on to crucial evidence, "losing" evidence which showed his opinion was wrong and may have assisted the accused person, mistating evidence, chronic tardiness, and the catastrophic misinterpretation of findings. The cases, along with other heart-rending stories of wrongful prosecutions based in part on Smith's testimony, also raised a host of issues about the pathology system and the reliance of the courts on expert evidence."
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"Two trays draped in blue surgical towels are carried into the fourth-floor autopsy conference room in one of Canada's largest hospitals,"the Postmedia story by reporter Sharon Kirkey published on October 16, 2010 under the heading, "Pathologists work on the thin edge between death and life," begins.
The air is cold. Pathologist Jagdish Butany folds back the towels, exposing the greyish-pink internal organs taken from a man who had been admitted to hospital with overwhelming abdominal pain," the story continues.
"An X-ray had shown free air in his abdomen, suggesting a perforated bowel. He died the day after surgeons took out part of the damaged organ.
His heart is oddly thick in places. His lungs, cut front to back in the shape of a butterfly, show an abnormal mass, and the pleura, the surface, is slightly puckered. The man's aorta is so thin in spots there is almost nothing left of it.
It is morning autopsy rounds at the Toronto General Hospital. Half a dozen residents pull on gloves — young doctors in training for a field of medicine the public has largely ignored, until recently.
Butany gently pushes the residents to decide, based on the look and feel of the organs laid out before them: Did the ulcerated bowel kill this man, or was it something else?
Butany and his trainees are not the only pathologists working on this particular day.
In an operating room two floors below them, a surgeon cuts into the body of a living patient. He removes a tumour from the colon and the surrounding tissue. The tissue is rushed to the surgical pathology lab, where it's flash-frozen, sliced into thin layers, stained and mounted on slides. Two pathologists peer through a multi-headed microscope while the surgeon waits in the operating room for their call. Does he have it all? Are the margins clear, meaning there's no cancer at the edges of the tissue? Does the surgeon have to go back in for more?
Pathologists do far more than just determine how we die. They play a vital role in keeping the living alive.
But public trust in them has been seriously jarred in the wake of a series of controversies that make it seem as if the state of pathology is coming undone.
Judicial and public investigations have been held into misdiagnoses and errors in pathology in four provinces, the most recent involving two women in Windsor who had cancer-free breasts removed.
Their professional organization says pathologists have among the lowest error rates in medicine and that the overall quality of pathology diagnoses in Canada is high.
But, the controversies have exposed vulnerabilities in a world of medicine hidden from most patients. "There are so many gaps in the system that it's actually surprising that there are not more disasters," says Vancouver pathologist Dr. Diponkar Banerjee.
Canada's population is aging, and an aging population means a growing burden of cancer. An estimated 173,800 cancers will be detected in Canada this year alone through the work of pathologists — doctors who also diagnose infections, heart attacks, immune disorders, blood disorders, diabetes, brain cysts and a host of other diseases. Their workloads are increasing, and the complexity of their cases keeps growing. It's no longer enough to say cancer, yes or no. Today, a pathology report can run pages long and contain 30 or more discreet bits of critical information about a tumour — does it have receptors for hormones? If so, which ones? — that drives all decisions for treatment.
But pathologists say they are working at an unsustainable pace, with no ability to control their workloads. The number of doctors ordering tests and performing biopsies is increasing faster than the pathologists who can handle them. "Turnaround time" is the new buzzword. Cases are being moved through laboratories as quickly as possible. But Canada, unlike the U.S., Britain and Australia, has no national body to oversee quality assurance for pathologists, and no universal standards that apply to labs across the country.
"If you get a breast biopsy in St. John's or Toronto or Victoria, you should get the same diagnosis — the same quality of diagnosis," says Butany, a cardiovascular pathologist and director of autopsy services at the University Health Network and Toronto General Hospital.
"You have national standards for how much milk you can put in a carton, and what chemicals you can put into it. But there are no national standards for immunohistochemistry for your breast biopsy. How can that make any sense? It doesn't."
Later this fall, pathologists from across the country will gather in Ottawa for a national conference on surgical pathology chaired by the Royal College of Physicians and Surgeons of Canada.
Meanwhile, the Canadian Association of Pathologists has developed national quality assurance guidelines for immunohistochemistry — specialized cancer testing that was at the heart of faulty breast-cancer testing scandals in Newfoundland and Quebec. The organization wants funding from the federal government for national standards and is developing guidelines for investigating laboratory "irregularities." But the voluntary association has no power to enforce them.
Pathologists suffer from an image problem. One pathologist, writing recently in the British Medical Journal, says the reaction she gets at parties when she tells strangers what she does for a living is either "morbid fascination" or "politely concealed revulsion." Surveys have found that most people think pathologists only determine cause of death. Less than one-third realize that a pathologist's diagnosis is frequently the foundation upon which other doctors rely for deciding how to treat a patient — some 70 per cent of all decisions made in medicine are based on a lab test of one kind or another — and that lives can be at stake.
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Dr. Bruce Burns opens the specimen jar, and the sharp smell of formalin rises. A uterus floats in the solution. "These little lumps are called fibroids," Burns says, pointing to tiny growths on the uterus.
"A simple uterus like this might generate 10 slides. A complicated cancer case might generate dozens."
Burns, a professor of pathology at the University of Ottawa and The Ottawa Hospital, has been practising for 30 years. He's calm and chooses his words carefully. He's used to staying focused. He holds two age-group course records for the Subaru Ironman Canada competition; until this year, he held a third.
He handles between 4,000 and 5,000 cases a year. His specialties are skin diseases and lymphomas, from non-Hodgkin to Burkitt's — the Ferrari, he says, of malignancies. "It is the fastest growing tumour in man."
Burns consults on about 300 other doctor's cases a year and has been called in as an expert reviewer in pathology investigations in Canada.
Not a day goes by when he doesn't show at least two of his own cases to a colleague.
"The pathologist who thinks he or she knows everything, can diagnose everything, who doesn't need to ask for help . . . that is hubris in the extreme. Nobody's like that anymore."
The most difficult part of his job, Burns says, is making mistakes. "I hate it.
"I do everything I can to avoid it, but it happens. And it just kills you. But you are going to get the message from any pathologist you talk to. We make mistakes. We try not to, but we do. It's a fact of life and it isn't going to go away."
- In August, investigators probing pathology and surgery errors in Windsor called on the Ontario government to implement a provincewide quality assurance system for pathology. Their review of more than 6,000 pathology cases of a now-suspended doctor raised "significant concerns" about her work, though her "clinically significant" error rate of less than one per cent appeared within the accepted norm. Still investigators identified cases where two different diagnoses were recorded, where surgeons operated without waiting for the results of a second review and an "alarming lack of respect" between medical leaders, senior managers and the hospital board of directors.
- Also in August, the Ontario government announced it would compensate victims of pathologist Dr. Charles Smith, who worked at Toronto's renowned Hospital for Sick Children from 1981 to 2005. Smith served as an expert witness in dozens of suspicious child deaths. In the end, his faulty testimony would help convict innocent people of murder.
- Last year in Quebec, 2,856 breast cancer pathology test samples had to be re-tested after an investigation revealed lab tests for hormone and protein markers that help determine treatment were flawed. In all, 87 women received the wrong test result. Five have since died.
- In Newfoundland, more than 400 breast-cancer patients received inaccurate results from hormone-receptor testing conducted by a St. John's lab between 1995 and 2007. More than 100 women who received the wrong result have since died. An inquiry ruled that quality controls at the St. John's lab were "so deficient as to be practically non-existent."
- In 2008, the Winnipeg Free Press reported that a senior pathologist at Winnipeg's St. Boniface Hospital had retired for "personal reasons" after an investigation into his work revealed that he had failed to diagnose cancer in two patients. One had colon cancer, the other, thyroid cancer.
- In 2007, a foreign-trained New Brunswick pathologist in his 70s was suspended after an audit of 227 biopsy reports found 40 were incomplete. Seven were incorrect, meaning they indicated the people had no cancer when, in fact, they did. A public inquiry into the pathologist's work said he should have been fired two years before he was suspended because of problems with his work.
- In April 2007, a family doctor did a biopsy of a small black lesion on Nick Bala's right shin. The specimen was sent to a pathologist at a commercial lab in Toronto, who diagnosed the lesion as benign. In fact, it was melanoma. In September 2008, Bala, a law professor in Kingston, Ont., discovered a lump in his groin that turned out to be metastatic melanoma that had spread to the lymph nodes in his groin. It later spread to his liver. If his condition had been properly diagnosed in 2007, the condition could have been treated with a minor procedure. Instead, Bala had almost two years of gruelling cancer treatment, and his present prognosis is "guarded." Bala observes: "I have to remain optimistic, but the survival rates for fourth-stage melanoma are challenging." In February 2009 Bala, worried that others might also have been misdiagnosed, wrote to the College of Physicians and Surgeons of Ontario seeking a review of the work of the now retired pathologist. The college's complaint committee decided that, given that the pathologist is no longer practising, "the risk of harm to the public by any future similar error" is "nil."
Meanwhile, a second Kingston man says the same pathologist misdiagnosed his cancer three years ago.
Bala appealed the college's decision to the Ontario Health Professions Review and Appeal Board. In June, the review board concluded that, if the allegation of a second misdiagnosis is confirmed, the college should "immediately undertake" a review of the now retired pathologist's practice, especially in light "of the tragic and highly public cases of pathology errors in Ontario and Canada."
Each crisis builds on the one before.
"There is this general feeling now that all of pathology is in this state of ruin and that patients are in danger, which is very far from the truth. Most pathologists practice at a very high level," says Dr. Laurette Geldenhuys, president of the Canadian Association of Pathologists.
"It doesn't mean that we should accept the situation and do nothing at all," she said. "We need to reduce the error rate to as close to zero as we possibly can."
According to a report published in September by the Pennsylvania Patient Safety Authority, a 2008 review of diagnostic errors studies showed error rates are generally the lowest — less than five per cent — for pathology, radiology and other specialties that rely heavily on visual pattern recognition.
Error rates range from up to 10 to 15 per cent in most other fields of medicine. The rate of diagnostic errors in emergency departments, for example, is reported to be from less than one per cent, to 12 per cent.
"But the thing about pathology is that our mistakes are sitting there in the slide drawer, or the library, forever," says the Ottawa Hospital's Burns. "You can't say that in clinical medicine."
A doctor can miss a diagnosis based on a physical examination of a patient, "and then someone in the future might palpate the abdomen and say, 'How could you have missed this?,'" Burns says.
"The reply is, 'It wasn't there.' Who's to know?"
A pathologist's assistant comes into the room carrying a "rush GI" — a woman with a mass on her colon that is suspicious on colonoscopy for cancer — as well as tissue from a lung nodule.
"Oh My God, just look at how small the fragments are," Burns says. Needle biopsies are popular, because they're less invasive than surgery and doctors don't have to book scarce operating room time. But sometimes, "you just don't have enough tissue to work with," Burns says. "Sometimes our report just indicates that we have no idea what this is, you need to get more tissue. 'Insufficient for diagnosis' is not an infrequent diagnosis. You'd be reckless in saying, 'I think it's cancer.'
"Well, is it or not?"
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The call came on a late Friday afternoon. Would Butany autopsy a patient who had just died at another hospital? No one there would do it.
The patient had died unexpectedly from a mysterious pneumonia like illness that would turn out to be severe acute respiratory syndrome, or SARS — the infection that claimed the lives of 44 in the Toronto area in 2003.
Because the bug was unknown, Butany and his team extracted tissue from virtually every organ. "The lung was the big thing", he says. It looked brown instead of pink, almost black, because of the blood and infection. "The trachea was next, then we took heart and other tissues."
The next morning Butany awoke to the headline in the National Post: "Alert issued after 2 die in pneumonia outbreak: Toronto family: Doctors suspect link to Asian epidemic that has hit hundreds."
One of the dead was the patient his team had just autopsied.
Butany's phone rang at home. "They told me I had nothing to worry about, that I wouldn't get it, that my family wouldn't get it," he says.
"I said, 'Now you tell me this?'"
The samples taken from Butany's autopsy would help scientists sequence the SARS genome.
Today, his in-basket is filled with specimen jars and requisition forms from some two dozen cases. Butany, a past president of the Canadian Association of Pathologist, specializes in cardiac pathology — diseases of the heart and blood vessels.
He frequently has to base his diagnoses on specimen samples a mere one to two millimetres square.
"Other times you're downstairs on the second floor next to the operating rooms and the surgeon has sent a piece of tissue and needs a diagnosis. If I tell him it's a malignant tumour of the heart, which are exquisitely rare, he's either going to have to close down and the patient is almost on a death watch, or he's going to try to get as much out as he can because I said it's malignant.
"God forbid that I'm wrong."
A pathologist, he says, "is everyone's friend and everyone's enemy.
"At times you'll think I'm the world's biggest son of a bitch . . . If you thought it was inflammation of the gallbladder and I saw a tumour there . . . I've had patients walk in unannounced and say they want to talk. They want to know, 'Are you sure of the diagnosis? Can we send it to anyone else? Explain to me what this is and what it means to my future.' And I'm always honest."
The autopsy of the man who died after being admitted for abdominal pain revealed the man had a seriously diseased aorta with numerous aneurysms — thinning in the walls — that caused the artery to swell to several times its normal size. One of them ruptured; the man bled into his abdomen and died because of it.
The man also had undiagnosed lung cancer that had spread into his abdomen.
"If you don't do the autopsy you would never know why he died. This tells the family, he didn't die because of the surgery. He died because something else happened."
Butany suddenly leans against the wall in the pathology lab. He has been experiencing shortness of breath for the past year that no doctor has yet been able to explain. "There are too many of us who are over 50, 60, or 70," he says.
"The part nobody wants to talk about is that we have been our own worst enemies. We've stayed in the background. Let me do my work, let me sign out my cases, let me go home. If it has to be eight at night, I'll work until eight at night."
Like that weakened aorta, the profession is being stretched too thin."
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The story can be found at:
http://www.canada.com/health/Pathologists+work+thin+edge+between+death+life/3680244/story.html
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PUBLISHER'S NOTE: The Toronto Star, my previous employer for more than twenty incredible years, has put considerable effort into exposing the harm caused by Dr. Charles Smith and his protectors - and into pushing for reform of Ontario's forensic pediatric pathology system. The Star has a "topic" section which focuses on recent stories related to Dr. Charles Smith. It can be accessed at:
http://www.thestar.com/topic/charlessmith
For a breakdown of some of the cases, issues and controversies this Blog is currently following, please turn to:
http://smithforensic.blogspot.com/2010/08/new-feature-cases-issues-and_15.html
Harold Levy: Publisher; The Charles Smith Blog; hlevy15@gmail.com
