Sir William Osler famously said,
"As is our pathology so is our practice... what the
pathologist thinks today, the physician does tomorrow."
If Dr Osler — a pathologist himself — was
right, then Canada's entire medical system is in deep
trouble, says Canadian Association of Pathologists president
Dr Jagdish Butany.
"Over the last 20-plus years, we
have not paid enough attention to laboratories and pathology
and pathologists," he says. "[The healthcare system
has] relegated pathologists to the basement and given
them that same priority."
The result of that chronic disregard
is now becoming readily apparent: Canadian pathology
is in crisis.
SYSTEMIC
PROBLEMS
Three major ongoing scandals in Ontario, Newfoundland
and Labrador and New Brunswick — which have collectively
been linked to hundreds of deaths, tens of thousands
of suspect test results and dozens of questionable imprisonments
— and their requisite high-profile public inquiries,
have highlighted the pathology system's serious failings.
As a result, an expert panel of
leading medical authorities are now in the process of
setting up a comprehensive review of the current deficiencies
in pathology in Canada. The details of the review haven't
been finalized yet, says Royal College of Physicians
and Surgeons of Canada CEO Dr Andrew Padmos, but the
report will have another goal as well: to restore the
public's severely shaken confidence.
The three scandals have done grievous
damage to the profession's reputation. "They've given
us a black eye," Dr Butany admitted to the National
Post last month as he and Dr Padmos dutifully denied
a crisis exists and reassured reporters across the country
that Canadian pathology is indeed trustworthy and can
be repaired.
In conversation, however, cracks
appeared in the veneer of their everything's-under-control
exhortations. After explaining that Canadian health
human resources problems are having a particularly acute
effect on the field of pathology — "We are concerned
the problem is going to become worse and more widespread
and we don't have in place an effective pan-Canadian
action to stop it" — Dr Padmos quickly sought to
quell any possible anxiety. "Is it an absolute knockdown
crisis? Of course not. What they need is some hope and
some planning."
The shortage of pathologists and
lab technologists is already putting pressure on the
system. "People are working too long hours, or past
your threescore and ten, even," says Dr Butany, "so
that makes for an increasing potential for mistakes.
You don't have time to critically analyse previous work,
to sit back and think."
But the real culprit in all three
scandals appears to be a lackadaisical approach to quality
assurance and training.
ONTARIO
Dr Charles Smith was once considered the epitome of
expertise when it came to pediatric forensic pathology.
If a child died under suspicious circumstances in Ontario,
all eyes turned to Dr Smith. If Dr Smith served as an
expert witness in a homicide case, people listened.
But that trust was misplaced. Dr
Smith is now at the centre of a public inquiry into
the entire field of pediatric forensic pathology in
the province. Many child murder convictions that Dr
Smith helped resolve have been thrown into question
and the provincial Chief Coroner's office is now suggesting
a total of 142 cases be reviewed.
Although Dr Smith made a dramatic
apology to his victims at the inquiry, he wasn't actually
on trial. In fact, there's one thing he and his victims
seem to be able to agree on: the balance of the blame
should go to the pediatric forensic pathology system
itself and the lack of oversight, training and quality
assurance.
The inquiry's closing arguments
wrapped up April 1. Justice Stephen Goudge is due to
submit his final report and recommendations to the government
by September 30.
NEWFOUNDLAND
AND LABRADOR
In a strange twist of fate, the Ontario inquiry has
come to a head at almost exactly the same time another
inquiry, this one potentially just as broad as the Ontario
one, is just getting underway in Newfoundland and Labrador.
This inquiry, headed by Justice Margaret Cameron, is
looking at how 383 women were given incorrect estrogen
and progesterone hormone receptor breast cancer test
results (which determine whether the patient should
receive tamoxifen) over an eight-year period from 1997
to 2005. Over a hundred of those women are now dead.
Again, the absence of standardized
quality assurance — a problem that still persists
today, says Dr Padmos — appears to have contributed
significantly to the errors. There have also been suggestions
that a St John's lab may have misinterpreted the results
of a now-outmoded method of immunohistochemical testing
on biopsy tissue; a 2003 internal memo by pathologist
Gershon Ejeckam called the lab's technique "unreliable
and erratic" and said diagnoses based on those tests
"will surely jeopardize patient care."
Amidst allegations of a politically
motivated coverup, some have called for Health Minister
Ross Wiseman's resignation. The inquiry's final report
is due no later than July 30.
NEW
BRUNSWICK
The New Brunswick investigation is slightly different
from those in Ontario and Newfoundland in that it focuses
more specifically on the work of one pathologist, Dr
Rajgopal Menon of Miramichi, who was found to have a
misdiagnosis rate of 3% and an incomplete diagnosis
rate of 18% in a recent audit. Another report released
late last month said Dr Menon's "vision seemed to be
failing," his hands were shaky and his work "fails to
meet the current standards of surgical pathology."
Already, Dr Menon's lawyer, Mel
Norton, has employed the same tactics that Dr Smith's
have in Ontario, blaming the pathology system and the
lack of oversight. "[It's] too convenient just to aim
the gun at one person," he told the Telegraph-Journal
in February.
The government has ordered reviews
of all 24,000 of Dr Menon's cases, from 1995 until 2007,
and the RCMP has also been asked to consider charges
of criminal negligence against Dr Menon.
Retired judge and former provincial
Tory health minister Paul Creaghan, who is heading the
inquiry, is due to submit his final report by August
22.
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