Thames Valley Cytology Society
Volume 4 Issue 2	June 2001
NAC Conference 2001 at Warwick University
Report by Marilyn Catlow
"To err is human" - Lessons in Litigation An Attorney's advert placed in a local paper shows how Pap smears have been singled out to solicit clients Dr Blair Holladay was our American visitor, and as such was well placed to speak on what is increasingly becoming a problem for us in the UK - litigation. In the US it is big business. Alongside a history of the American experience he gave a demonstration of the new method of incident management. The Multiple Slide Blinded rescreening Standard (described in SCAN, Aug 1999) could also serve indirectly to educate the courts, policy-makers and women about the uncertainty of our operational environment. The harmful effects of screening failures are more due to limitations inherent in screening tests, than to a violation of good standards of care by careless individuals.
	"Healthcare's Deadly Secret: Accidents Routinely Happen"

These are the kind of media headlines that we all dread to see. When the Wall Street Journal picked up on Pap misses in labs where individuals screened 150-200 slides per day, the customary $1-2 extra per cost of case in order to pay for litigation costs of the test, rose to $5 per case - the same for other years of bad exposure.

Public expectation is for 'zero error'.
The 'reasonable practitioner standard' (Bolam standard - UK) engages with a philosophy that does not accept the existence of zero error standard. However, it does invoke the discriminatory power of an expert witness.

This philosophy represents, in essence, "I'm an expert, and I know a negligently read slide when I see one".

Some expert witnesses are loose cannons for whom 'hired guns' might be an appropriate epithet. It is possible for an expert to choose to undermine medical history's most effective cancer screening test..

'Like a Tzar shooting a bear tied to a tree'

When an expert knows that the patient has cancer, the review of a slide becomes a treasure hunt - with retrospectively biased perception and biased time - it is clearly easy to go to a slide and find abnormal cells.

Dr Holladay's team's pilot studies indicated that 'flag-waving abnormalities' are generally not the case. He projected some examples of common 'flag-waving' culprits that have been paraded before the courts. As we saw, these tended to be immature or reactive metaplastic cells, or rare groups.

The most common genuine false negatives include cells

• that are obscured by blood
• that resemble histiocytes
• microbiopsies

The new method involves investigating the scene of the accident and asking what created the accident? Its philosophy is to be fair to both patient and provider, establishing what is below the standard of practice. It indicates what could be expected of a prudent competent practitioner under normal circumstances.

The environment for the blinded review should recreate normal conditions and it is imperative that adjudication is made by peers - cytotechs' interpretations by cytotechs; pathologists' interpretations by pathologists. The goal is to prevent opportunities for a 'treasure hunt' where currently more than 90 per cent of allegations are based on cytotech errors, and less than 10 per cent on pathologist errors.

Most of the time (75%), slides are not consistently interpreted as abnormal, and are representative of slides that would be 'thrown out' under proficiency testing or self assessment due to poor performance. The biggest culprit was overlooked HGSIL groups, and about 50% of cases coming for review are adenocarcinoma.

"The Multiple Slide Blinded Rescreening Standard" is reported in the August 1999 edition of SCAN by Dr R Marshall Austin.