foundation.cap.org v. # consultations in pathology practice: clinicians & patients jennifer l....

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Consultations in Pathology Practice: Clinicians & Patients

Jennifer L. Hunt, MD, MEdAssociate Chief of Pathology Massachusetts General HospitalAssociate Professor of PathologyHarvard Medical School

HARVARDMEDICAL SCHOOL

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Agenda

• Background• Direct Patient Consultations• Training program• Summary

PersonalizedMedicine

The task of science is to stake out the limits of the knowable, and to center consciousness within them

-Rudolph Virchow

The task of science is to stake out the limits of the knowable, and to center consciousness within them

-Rudolph Virchow


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Case Presentation

• 2009: 55 year old male• Presented with a new rapid onset neck mass

• CT scan showed multiple enlarged lymph nodes (largest 2.6 cm)

• FNA: squamous cell carcinoma

• Tonsil biopsy: squamous cell carcinoma


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Tonsil Tumor


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Case Presentation

• Tumor pathology• Predominantly non-keratinizing squamous cell

carcinoma of tonsil with metastases to neck

• HPV testing• p16 strongly positive

• HPV (high risk) in situ hybridization negative

• Reference lab HPV in situ negative

• HPV PCR negative

• HPV positive at outside facility

Our patient’s tumorNormal Control

PIK3CA mutation: E545KPIK3CA mutation: E545K


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Brain mets9/2010

Neck Dissection 12/2009

Recurrence11/2009

Diagnosis 3/2009

Diagnostic Timeline

Chemo/Rads

3/2009 11/2009 6/2010 9/2010 3/2011E

rbitu

xC

hem

oR

ads

MolecularTesting

Lung mets5/2010

PersonalizedHealthcareImpersonalHealthcare


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Direct Patient Consultation: Model

• Clinician sends patient to pathologist for consultation• Review the tumor morphologic features

• Go over staging parameters

• Review any molecular or ancillary testing

• Answer questions

• Discuss treatment options


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Direct Patient Consultation: Why?

• Education and information for patients• Informed patients participate in medical

decision making better

• Health literacy correlates with outcome


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• Better patient satisfaction• Patients like access to their healthcare team

• Advanced technology is a driver of satisfaction


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• Allows the pathologist to be an active participant in patient management• Personalized interactions are rewarding

• Valuable role to play in the house of medicine


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The Clinician Perspective

“As a medical oncologist, I can’t look at pathology slides and speak to what the slides are showing with any real understanding of what I’m looking at.”

Lori Wirth, MDMass General Hospital


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Direct Patient Consultation: Barriers

• Willingness: Pathologists and Clinicians• Some pathologists are uncomfortable with the

idea, while others are totally excited• Most clinicians are eager to try it.

• Logistics: Pathologists• Organization and billing issues

• Experience: Pathologists• Most pathologists haven’t seen patients since

medical school• Exception: Cytopathologists


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Willingness: CAPToday Article


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Willingness: CAPToday Article


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Logistics: Best Practices

• Optimize information flow and communication• Consultation questions and discussion

• Use good hand-off procedures and documentation• Letter or note in chart


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Logistics: The Billing Conundrum

• There is no perfect E & M code (without overstepping)

• Currently, billing for this may lead to clinician hesitation

• The real answer will come with healthcare reform• Creating a valuable new service for pathology


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Why Some Pathologists Hesitate

• “I went into pathology so I wouldn’t have to see patients”

• “I’m shy! I don’t want to see patients”

• “It isn’t paid!”

• “My clinicians don’t want me to see their patients”

• “I don’t have time!”

• “I haven’t seen patients since medical school XX years ago!”


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Standardized Patient Simulation

• An experiential training program for pathologists (sponsored by CAP Foundation and Transformation Program Office)• One-on-one direct interaction with a

standardized patient (actor)

• Standard case with advance preparation

• Immediate feedback from “patient” perspective


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Standardized Patient Simulation

• Event held at CAP ’10• 33 pathologists participated

• 30 did the pre- and post-surveys (91%)

• 24/30 were in practice for more than 10 years


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Where They Practiced

0

2

4

6

8

10

12

Academic CommunityHosp

PrivateGroup

Commerciallab


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How Often They See Patients

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2

4

6

8

10

12

14

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Never Once a year Once a month Once a week


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Comfort Level Consulting with Patients

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1

2

3

4

5

Average pre Average post


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Constructive Feedback from Patient

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5

10

15

20

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Excellent Good Fair OK Poor


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Constructive Feedback from Patient

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5

10

15

20

25

Excellent Good Fair OK Poor


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Improvement in Specific Skills

0 1 2 3 4 5

Treatment info

Relate as aclinician

Explain report

Post

Pre


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Quotes About the Experience

• “Reawakened my dormant clinician!”• “Training like this is vital for future

pathology services”• “I will speak to the clinicians I work with to

offer patient consultations”• “I will be more open to opportunities, even

in informal unpaid situations”


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Next Steps: Patient Consultation

• Science: A randomized controlled trial• Does patient consultation improve health

literacy, patient satisfaction and disease management (coping)

• Education: Standardized patient simulation• Offer again at CAP 11

• CAP Foundation fundraising campaign to expand the program to offer more broadly


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Summary

• Case Presentation• The Model: Direct Patient Consultations• Standardized Patient Simulation Training

Program

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