Moral Distress in Academic Medicine: My Brother’s Keeper?

As a member of the hospital ethics committee, I’ve become the go–to person for any ethical issues that arise in our Department. Being a pathologist who is interested in ethics, I’m a rare bird. In this role, I get the occasional curbside consult when anyone has a question or concern. Shortly after an ethics lecture to our trainees, one of the junior residents approached me and asked to speak privately. We headed to the cafeteria and found a private table where we could talk. She hesitated, running her fingers through her hair and gazing around the room before speaking.

She told me that the trainees were concerned because they had noticed that the pathologists at another institution were not grading one type of cancer the way that they had learned to do this at our hospital. This type of cancer grading is a surrogate for aggressiveness, and, while somewhat flawed, it often determines the staging and adjuvant therapy that the patient will receive. The resident argued that at this hospital, patients were getting assigned cancer grades that were higher than the ones they would receive at our institution. Therefore, a cancer presenting at the other hospital would be considered more aggressive by the clinicians treating the patient.

The resident and many of her colleagues had tried to broach this subject with the pathologists. Many had been brave enough to voice their confusion and concern over the practices. Their efforts, she explained, had been rebuffed. The pathologists assured the residents that they were grading their cases correctly and cited a reference that they used for this purpose. Due to the hierarchical nature of medicine, it is understandably difficult for trainees to confront attending physicians when they have concerns about their clinical cases and diagnostic acumen. Residents and fellows often do not express their concerns for fear of overstepping their roles. In spite of this, many trainees felt that their concerns for the patient made them set aside their own best interest and they spoke up. Moral distress and genuine concern trumped self–interest in this case, which was admirable.

At the time of our meeting, I wondered what I could do to help. I am a hematopathologist who specializes in diagnosing leukemias and lymphomas. I know very little about solid tumor diagnosis and treatment. I have not looked at many solid tumors since I was a trainee six years ago. I do not read the literature in that area and I’m not up–to–date on any controversies regarding grading. In summary, I am far from an expert.

However, the problem, on a broader scale, was familiar. As pathologists, we may disagree with or question the diagnoses of our colleagues. What is the appropriate course of action when this occurs? This question is an interesting and infinitely complex issue in the realm of pathological diagnosis. If you aren’t a pathologist or a physician, it may be difficult to grasp why there isn’t a right answer in every case. Diagnosing cancer, in many ways, is truly an art as much as a science. Many intersecting variables are at play, including the size and quality of the sample, the experience and training of the pathologist, and the clinical information available at the time of the diagnosis. Some areas are fraught with subjectivity and inter–observer reliability. Some pathologists are more skilled than others. These are realities that no one wishes to freely admit.

It is important, however, to differentiate between systematic and random errors. There are many errors that are difficult to predict or avoid. However, systematic errors are the ones that we most want to uncover as they can be fixed with education and awareness. This case appeared to represent a systematic error in which the pathologists at the other hospital were all performing grading in a way that differed from usual practice.

I wondered if it would be overstepping my role to speak to the pathologists. I ran the situation by some of the senior pathologists that I know. Many understood my concern but subtly discouraged any action. Many felt...