{"id":2481,"date":"2025-07-12T16:34:44","date_gmt":"2025-07-12T20:34:44","guid":{"rendered":"https:\/\/wordpress.forensicpath.us\/?p=2481"},"modified":"2025-12-10T09:36:25","modified_gmt":"2025-12-10T14:36:25","slug":"private-consultation-in-forensic-pathology-11-on-making-mistakes","status":"publish","type":"post","link":"https:\/\/wordpress.forensicpath.us\/index.php\/2025\/07\/12\/private-consultation-in-forensic-pathology-11-on-making-mistakes\/","title":{"rendered":"Private consultation in forensic pathology 11 — on making mistakes"},"content":{"rendered":"

A little while ago, I had a very humbling experience. I had a case of a newborn infant who died at home. At autopsy he had a necrotic and congested liver as well as a sizeable atrial septal defect. I became convinced that the liver showed fulminant congestive hepatopathy, and decided that that ASD was the cause. Admittedly, ASDs are rarely clinically significant very early in life, but they can<\/strong><\/em> result in fulminant congestive heart failure with congestive hepatopathy. I thought I had brought all the findings together quite nicely.<\/p>\n

The case went to peer review, and I had missed an important finding — viral inclusions the liver. This was not congestive hepatopathy, it was TORCH due to Herpes. When my colleagues looked at the slide in peer review, they picked up on the inclusions right away. Of course, as always happens when you are looking at these kinds of things, once they are pointed out, you see them all over the place.\u00a0 \u00a0I blew it.<\/p>\n

I had to ask myself how I could have made this mistake. It was not a matter of knowledge — I’ve been looking at viral inclusions for 40 years and certainly know what they look like. At this point I don’t remember looking at the slides originally, so I don’t know if I looked at them too quickly, jumped on the lower power fulminant hemorrhagic pattern rather than more carefully looking at the higher power views, if I was distracted, tired, rushed, or what. I do know that I did this case during a period where I was distracted and fatigued in the general sense. My wife had fallen ill near to death, was bed bound and invalid, and I was spending a lot of effort focusing on her needs (she’s much better now, by the way, thanks to God). But, whatever. I made a rookie mistake.<\/p>\n

I make a fair number of mistakes, truth be told, though (again, thanks to God) the vast majority are not significant. I am, unfortunately, a horrible proofreader, and I base my reports on a template. It is not too uncommon for me to have accidentally left in “something” in my report that does not apply to a specific case.\u00a0 It’s usually a template based negative finding that is relatively insignificant, such as “The appendix is unremarkable” in a case where the appendix was not present (i.e. I forgot to edit “unremarkable” to “not noted.” ) I see this a lot in reviewing cases as a consultant as well. It sometimes makes the news when an office decides to hang a pathologist out to dry.\u00a0 That’s not an error of knowledge, that’s an error of proofreading and using a template (which almost everybody does). I remember a case from the 1990s where a pathologist noted that a male decedent had a normal uterus and ovaries. Those who were attacking the pathologist in the press ridiculed him as not knowing that a man didn’t have a uterus. Of course that wasn’t the case — he was using a templated report and made a copyediting mistake.<\/p>\n

For those kinds of errors, my only solace is a couple of studies I’ve read that suggested that the probability of making that kind of proofreading error is highly correlated with one’s knowledge of the subject. The reason is that we tend to read what we *think* we are saying instead of what we *actually* write. It’s a function of how we read — by reading phrases and sentences as units rather than individual words.\u00a0 It’s worse for me because I was trained in elementary school in “speed reading,” and tend not to read individual words at all, most of the time.\u00a0 I have the advantage of being able to read and enjoy a 400 page novel in an afternoon, but it also means that I simply don’t read every word.<\/p>\n

But whatever. This was not that kind of mistake. This was a basic perceptual error. No matter how good or experienced one is, one will make errors. And in our jobs, there are consequences to error. So, I have three points to make about it, since it is, unfortunately, part of my practice.<\/p>\n

First we should be quick to acknowledge error. Second, we should be quick to accept reasonable consequences for the error. Third, we should welcome review.<\/p>\n

Acknowledging error is a basic part of professionalism, and as a Christian, it is a fundamental part of my world view<\/a>. My profession is my calling and my ministry. Any failure to achieve perfection is a sin. Most people think of sin as doing something mean, dishonest, cruel, spiteful, or involving some sort of malignant motivation. All of those are sins, of course. But sin, at its core, is simply failure to do what is right in any situation. Failure to achieve perfection, even with good intent, is a sin.<\/p>\n

This is the lesson of the story of Uzzah and the Ark of the Covenant.\u00a0 For those of you who don’t remember (or never knew), in two passages of the Old Testament (or in the Jewish classification, both in the Prophets and the Writings) — 2 Samuel 6:3-8 and 1 Chronicles 13:7-11– there is a story where King David attempted to move the Ark of the Covenant to Jerusalem. As he was moving the Ark, the oxen pulling the cart stumbled and the Ark started to tilt. Uzzah, a member of David’s army, raised his hand to stabilize it. God had said that anybody who touched the Ark would die, and Uzzah was struck dead on the spot. David was angry at God for this — he didn’t think it was fair.<\/p>\n

David didn’t understand, I think, the impassable nature of sin and God’s judgment. God’s laws of behavior are like His physical laws — they are about actions and consequences, not motive. A law of God is not negated by intent any more than gravity disappears because one did not intend to fall out of a window. I won’t discuss that at length here, but did so in my post on worldview and faith<\/a> .<\/p>\n

So, not performing your job to the best of your ability is a sin and, moreover,\u00a0 making an error even if you are doing your best is a sin.\u00a0 But Christians like me have a guide to approaching it — confession and repentance.\u00a0 Confession is obvious.\u00a0 We should not hide our imperfections, but we should be open about them and constantly try to do better.\u00a0 \u00a0As the writer of 1 John noted “If we say we have no sin, we deceive ourselves, and\u00a0the truth is not in us.<\/span>\u00a0If we confess our sins, he is\u00a0faithful and just to forgive us our sins and\u00a0to cleanse us from all unrighteousness.<\/span> \u00a0<\/sup>If we say we have not sinned,\u00a0we make him a liar, and\u00a0his word is not in us.<\/span>”\u00a0 <\/em>And as Paul noted in 2 Corinthians “But he said to me, \u201cMy grace is sufficient for you, for my power is made perfect in weakness.\u201d Therefore I will boast all the more gladly of my weaknesses, so that the power of Christ may rest upon me.”\u00a0 \u00a0\u00a0<\/em>The writers of the Old Testament agree.<\/p>\n

Of course, we don’t like to admit we are wrong.\u00a0 But hiding one’s errors just makes the consequences worse.\u00a0 In the secular world, the trope is that “The cover up is worse than the crime.”\u00a0 That’s true in every realm.\u00a0 Repentance means looking for causes and making corrections.\u00a0 In quality terms, of course, one looks for “root causes” and takes “corrective actions.”\u00a0 In God’s word, it’s the same, but uses different terms of art.<\/p>\n

Back when I was a teenager, I had a summer job doing handyman work.\u00a0 One day a homeowner came to our team leader complaining about how a job was done.\u00a0 It was clear the customer had a valid complaint.\u00a0 The team leader became enraged.\u00a0 He said “This is completely unacceptable.\u00a0 I apologize to you about this.\u00a0 We will make it right.\u00a0 Not only that, this kind of work will not be allowed on my team.\u00a0 Rest assured that [the guy] will be fired and will never work in this town again!”\u00a0 \u00a0The woman looked shocked.\u00a0 She said “No, wait.\u00a0 Look, he probably did his best.\u00a0 Just fix it.\u00a0 There’s no reason to fire anybody.”\u00a0 The team leader said “Well, if you are sure…”\u00a0 She replied “No, really.\u00a0 It’s fine.”\u00a0 Satisfied, she walked away.<\/p>\n

I talked to my boss about it shortly afterwards.\u00a0 He said that when you are in a situation like that, there are always two sides of the conversation.\u00a0 There’s one side that tries to minimize the problem and says that things are not so bad.\u00a0 The other side says that it’s horrible and the worst thing in the world.\u00a0 When a customer comes in, and it’s a valid complaint, you basically only get to choose which side of the conversation you are on.\u00a0 If you choose the angry side, the customer will reflexively choose the mitigating side.\u00a0 That means the customer not only gets the problem fixed, but walks away feeling good about himself or herself because they had the opportunity to be gracious and forgiving.\u00a0 \u00a0Everybody’s happy.<\/p>\n

I don’t know if that would work as well today. Outrage and exaggerated victimization are considered virtues by so many — with the associated demand for hateful and draconian consequences for those who offend — but for most of my life I’ve found that giving the aggrieved party the opportunity to be gracious worked fairly well.\u00a0 Not always, of course, but as an initial tactic it’s been useful.\u00a0 In contrast, denial and stonewalling when you are clearly in the wrong often makes things much worse. As the writer of Proverbs notes “Whoever conceals his transgressions will not prosper, but he who confesses and forsakes them will obtain mercy.”<\/em><\/p>\n

A corollary of this point is that we should be quick to amend a report.\u00a0 I have no problem doing that.\u00a0 I don’t know why, but a lot of pathologists seem driven to go to great lengths to avoid an amendment.\u00a0 It’s no big deal to me.\u00a0 I probably amend a report for my autopsy work every three months or so.\u00a0 In fact I amended a report this morning — I had misread part of the clinical summary and wrote that the decedent went to one hospital, when in fact he had gone to a different one.\u00a0 Many pathologists would say that this is not big enough of an error to make an amendment to an autopsy report, but one of the people reading the report noticed it and mentioned it.\u00a0 It was important to him,\u00a0 which means it’s worth fixing.\u00a0 And, when fixed quickly (I amended the report two days after publishing it), the problem is solved without repercussions.<\/p>\n

Second, we have to recognize that error can *and should* have consequences.\u00a0 \u00a0These can usually be minimized by rapid acknowledgement and honest efforts at correction, mitigation, and changing how you do things.\u00a0 But error will out.\u00a0 As the author of Proverbs writes “Blows and wounds scrub away evil, and beatings purge the inmost being.”\u00a0 \u00a0<\/em>This does not mean that all<\/strong><\/em> consequences are just, nor does it mean that we cannot object to unjust consequences.\u00a0 Nonetheless, as Proverbs also states “Accept correction, and you will find life; reject correction, and you will miss the road.”\u00a0\u00a0<\/em>Or, as the Psalmist wrote “<\/em>Blessed is the man whom you discipline, O Lord, and whom you teach out of your law.”<\/em>\u00a0 In the best case, that discipline is corrective, and organizations should focus on correction rather than painful punishment.\u00a0 We should welcome those corrections and use them to learn and change course.\u00a0 Once again, it has been my experience that the most painful consequences I have had came from trying to avoid appropriate consequences, and that avoidance was the real problem.<\/p>\n

The purpose of consequences is, or at least should be, correction.\u00a0 Accepting it can be hard. It means you accept responsibility *and* embrace corrective actions to minimize the likelihood that you will do it again. I see a lot of people “accepting responsibility” who are then horrified and offended when consequences follow.\u00a0 They are part of the same package.<\/p>\n

In this context it mean error analysis, retraining, etc.\u00a0 As Peter said in Acts, “Repent therefore, and turn back, that your sins may be blotted out,…<\/em>”\u00a0 People think this applies only to “moral” issues, but it applies to all error.\u00a0 Learning from errors is exactly that — a learning experience.\u00a0 While one can attempt to reduce errors it is unlikely that one will become perfect, but each error becomes another learning opportunity.\u00a0 As Jesus told us, “Pay attention to yourselves! If your brother sins, rebuke him, and if he repents, forgive him, and if he sins against you seven times in the day, and turns to you seven times, saying, \u2018I repent,\u2019 you must forgive him.\u201d\u00a0 \u00a0<\/em>We will continue to make errors, but each time we do, we can improve.\u00a0 We have to face our errors straight on, try to figure out why we made them, and learn to do better.\u00a0 As the writer of Proverbs notes about his teachings, “Let the wise listen and add to their learning, and let the discerning get guidance.”<\/em><\/p>\n

Finally, the fact that we are doomed to make mistakes means that we should welcome peer review and timely intervention.\u00a0 The usefulness of peer review is beyond question.\u00a0 I recently read a study about the use of AI in medical diagnosis.\u00a0 It pitted individual human physicians against an AI “panel” made up of multiple AI “personalities” that were very different, and even antagonistic each other.\u00a0 The panel outperformed the individuals by a huge margin.\u00a0 I don’t think it was all that convincing an argument for AI, since the way they provided information to the human physicians was very formalized and unlike real practice.\u00a0 But it’s a nice demonstration of the value of bringing different viewpoints to a case.\u00a0 Peer review has been invaluable to me.\u00a0 At the office where I do locum tenens, they have a weekly peer review session for difficult cases.\u00a0 It’s always fascinating, and the discussions often provide approaches that I did not consider. Almost every study I’ve seen indicates that diagnoses made with the help of a team ends up with lower error rates.\u00a0 Plus, peer review means on an ongoing basis means that you will catch errors and weaknesses before they end up happening on a high profile case, or, even better, before the case is signed out at all.\u00a0 It’s invaluable.<\/p>\n

Most of the above is oriented for casework in an office, e.g. full time ME work or locum tenens.\u00a0 What about consultation work?\u00a0 The same principles apply,\u00a0 First, in consultation work, we often don’t get all the data. Every report I write has a disclaimer that I might change my diagnosis with new data.\u00a0 I have not suffered from this, but I have seen colleagues who were completely sandbagged by counsel, being given only biased and selected records to review.\u00a0 I recently testified in a trial where the question was one of abuse.\u00a0 I was given 15 years of medical records in which there was an obvious pattern of recurring injuries, etc. characteristic of abusive injury. Counsel for the opposing side gave their expert only the records from the terminal admission, and thus the expert knew nothing of the years leading up to this.\u00a0 If something comes up, I am quick to respond if I need to change something.\u00a0 \u00a0This is particularly true in torts where there may be a series of reports and rebuttals from experts.\u00a0 If an expert from an opposing side brings up a valid point, don’t ignore or dismiss it just because they are on the opposite side.\u00a0 If they are right, they are right.<\/p>\n

If you are on the stand, it’s even more important to be straight up about uncertainty and error.\u00a0 In my personal experience, juries are fairly forgiving of honest mistakes, but they hate it when you try to bullshit your way through and cover up an error.\u00a0 Plus, if opposing counsel is good, they will rip you apart.<\/p>\n

A couple of years ago, I testified on a case I did in my regular job.\u00a0 The defense decided to make a big deal about a single hair fiber that was stuck in dried blood on the hand of the decedent.\u00a0 They were making the assertion that the “real” assailant was someone else, and that he would have been discovered if only I had saved that hair as trace evidence.\u00a0 Of course at autopsy, I didn’t even see the thing.\u00a0 It was obvious in the close up photos of the hand (that we take in all cases), but I just didn’t see it at the time.\u00a0 And, frankly, even if I had, I probably wouldn’t have saved it.\u00a0 There’s a lot of little bits of debris on a body found laying on a rug, and I almost never collect all of it.\u00a0 We do fingernail clippings, etc., but we don’t save all the flakes of blood that come off the skin.<\/p>\n

So, at trial, it came up.\u00a0 “What is this?”<\/p>\n

“This is a picture of the decedent’s hand before being washed.”<\/p>\n

“And what is this on the thumb?”<\/p>\n

“It’s a hair in the dried blood.”<\/p>\n

“Did you submit this hair as trace evidence?”<\/p>\n

“No.”<\/p>\n

“Why not?”<\/p>\n

“I didn’t notice it.”<\/p>\n

“You didn’t look?”<\/p>\n

“I looked, I just didn’t see it.”<\/p>\n

And that’s it.\u00a0 From that point on, counsel didn’t have anywhere to go without looking like a jerk.\u00a0 If I had tried to come up with some BS thing to pretend that I had seen it but there was some important reason not to collect it, I would have sounded foolish.\u00a0 Instead, I sounded human.\u00a0 Many years ago, I had a trial in which counsel spent an hour attacking my competence, integrity, etc.\u00a0 After my cross examination, the judge called a break.\u00a0 One of the paralegals heard the jurors talking as they waited for the elevator.\u00a0 They thought the lawyer had been such as ass and treated me so badly that they were considering voting for conviction just to teach the lawyer a lesson.\u00a0 I can tell you that had I responded to his attacks with dissimulation or anger their attitude would have been different.<\/p>\n

Errors are not good.\u00a0 We should try to minimize them as much as possible.\u00a0 But we shouldn’t be afraid of them.\u00a0 No pain, no gain.<\/p>\n","protected":false},"excerpt":{"rendered":"

A little while ago, I had a very humbling experience. I had a case of a newborn infant who died…<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[148,1],"tags":[145],"class_list":["post-2481","post","type-post","status-publish","format-standard","hentry","category-private-consultation","category-uncategorized","tag-error"],"_links":{"self":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts\/2481","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/comments?post=2481"}],"version-history":[{"count":18,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts\/2481\/revisions"}],"predecessor-version":[{"id":2540,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/posts\/2481\/revisions\/2540"}],"wp:attachment":[{"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/media?parent=2481"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/categories?post=2481"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/wordpress.forensicpath.us\/index.php\/wp-json\/wp\/v2\/tags?post=2481"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}