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  A meeting of minds on patient consults

 

CAP Today

 

 

 

January 2011
Feature Story

Karen Titus

What turns an idea into a practice?

In medicine, there’s no shortage of signings on and signings off, memos and meetings, conference tables and huddled conferences in hallways, followed by more of the same, before the emergence of a pilot study, perhaps a practice guideline, and pleas to colleagues to change their ways, please.

But surely the first steps toward praxis include simply talking about the idea. It begins not with brass cannons, but with the burble of conversation, letting things take shape by talking aloud. That, at least, is what a few pathologists are doing as they consider how and why they might meet with patients.

They are sharing thoughts, not studies. They are not turning their backs on evidence-based medicine; rather, they might be tugging a thread of common sense through the medical discourse.

Jeffrey Myers, MD, of the University of Michigan, Ann Arbor, speaks in swift, funny, highly quot­able sentences that represent the tail end of long, semiphilosophic thoughts. In this he is matched by a colleague at Massachusetts General Hospital, Gregory Lauwers, MD, whose right to a philoso­phic outlook is impeccable: He was trained in France and thus comes by his Gallic logic naturally.

The two have embarked on a serious, if ever so slightly desultory, conversation about how they might interact with patients at their own institutions, sparked, in part, by their own limited patient consults.

Dr. Myers, the A. James French professor and director, Division of Anatomic Pathology at Michigan, thinks there might be a way to improve the way he delivers results to patients. His one-patient proof of principle came about at the request of a surgical colleague, who entered the gross room and asked if he could provide the patient (at the patient’s request) with a picture of her resected tumor. Absolutely, Dr. Myers replied. When he thought about it further, he wondered if delivering the picture himself might be meaningful, giving the patient an opportunity to ask questions about the pathology.

Quickly, a resident took a “nice” photograph of the specimen, made an 8∞10 glossy print, placed it in a blue University of Michigan folder (along with a pen inscribed with the words “University of Michigan Pathology Department”), and walked it up to the patient.

And the ensuing, face-to-face discussion? “Turns out the patient was asleep,” says Dr. Myers, who gave the folder and his card to the nurse with a request to give it to the patient, along with making it known he’d be delighted to discuss the results with the patient. “I didn’t get the conversation I imagined,” he says.

Still, even the conjectured talk was enough to launch his thoughts. Why should this be by special request, he wondered.

To demonstrate the potential value of his semicompleted mission, he notes that the next time he saw the surgeon, she told him, “Wow, we have a patient for life.” The patient, who was not from Ann Arbor, told her caregivers, “I’m going to go home and tell all of my friends to get their care from the University of Michigan.” While this isn’t a strict cause-effect vector, Dr. Myers says he realized, as the surgeon shared this story with him, that providing the photo impressed the patient; that she was grateful for it; and that his doing so, along with other aspects of her care, may have created a loyal patient.

Though providing the photo was a new step for Dr. Myers, he recognizes there’s a nothing-new-under-the-sun aspect to patient consults. Mayo Clinic—where he practiced before coming to Michigan—did them years ago, when, he says, it was common for pathologists to show patients and their families the specimen itself and to discuss the findings with them. The practice was dwindling, he says, when he left Mayo Clinic in 2005, though it still happened irregularly. “You’d get a phone call, they’d say the patient and the family are coming down to look at the resected fill-in-the-blank. It was encased in formalin in a plastic bag.” Seeing the specimen itself wasn’t strictly the point. It was mainly an excuse for patients to ask questions, much as going to a Cubs game is often an excuse to sit in the bleachers and drink Old Style.

That one-off patient experience also led to his conversations with Dr. Lauwers. A central theme of their talks: Why aren’t pathologists providing direct patient service routinely, rather than by special request?

The notion of a special request has proved a sticking point for Dr. Myers. When the aforementioned surgeon first entered the gross room with her request, she apologized multiple times before he could even learn what she wanted, he recalls: “‘I’m really sorry to bother you, I’m really sorry but....’ It made me reflect on why a clinician’s first response to a pathologist is, ‘I’m sorry,’” Dr. Myers says. When a clinician has a special request, he asks, why is the pathologist response frequently a grumpy one: I don’t have time to take a picture, or, We don’t normally do that.

Couching it in more diplomatic terms, he says, “We have a lot of opportunity to move our discipline when it comes to developing models of service excellence, let’s put it that way.”

When patients meet with their oncologists at MGH, says Dr. Lauwers, there’s no getting around one difficult logistic—given the sheer volume of cases, oncologists must jump from one patient to the next. So even though care is being delivered under one roof, so to speak, at the cancer center, disconnect can still wiggle its way in. “The patient may be left with the access nurse—who’s also very busy—to ask more questions,” including those specific to the diagnosis and its implications, says Dr. Lauwers, vice chair and head of the Gastrointestinal Pathology Service in the Department of Pathology, MGH, and professor of pathology, Harvard Medical School.

Dr. Lauwers sees a portal here for pathologists, and he is at the early stages of talking to the head of the GI oncology program about connecting patients with their pathologists.

He envisions the access nurse triaging patients. Some oncologists may not want to participate, and that’s fine, says Dr. Lauwers. Ditto for patients, not all of whom will want to speak with a pathologist.

As for his pathologist colleagues, some have already told him they regularly talk to patients over the phone. When he suggests a three-dimensional encounter, suddenly it’s a problem. “Not so much a negative answer, but let’s say I get a not completely enthusiastic answer from some of my colleagues,” Dr. Lauwers says. This makes him impatient. “The patients can talk to you. You can talk to them. They’re not going to bite.”

Other than Dr. Myers and another MGH colleague, Jennifer Hunt, MD (see “Face value—pathologists one on one with patients,” CAP TODAY, November 2010), he’s found no overflowing esprit de corps. “I can tell you, I feel very lonely,” he says.

Why the hesitation?

Dr. Lauwers hears several objections. He has answers at the ready.

One objection is time, or time as it relates to money. These would not be paid encounters, at least not initially. But even if meeting patients is not on the meter, so to speak, it could be a way for pathologists to demonstrate a value beyond looking at slides, he says.

Someone would also need to mastermind matters. What if one pathologist makes a diagnosis, but doesn’t want to meet with the patient? Would a different pathologist meet that patient—and review the slides—instead? “There are a few ‘political’ issues to solve,” Dr. Lauwers says.

The primary fear, he says, is that pathologists don’t want to step on clinicians’ toes. “It’s complete nonsense,” comes Dr. Lauwers’ swift reply.

One, he says, the idea is not for pathologists to enter patient discussions with a treatment agenda. The primary reason for their being there is to talk about the diagnosis.

Two, he says, pathologists might just need to worry less about whose toes they’re stepping on. Surgeons advocate surgery; radiation oncologists, radiation oncology. “They’re all biased in their approach,” Dr. Lauwers says. “And then you have epic discussions between the clinicians about what’s the best treatment.”

So, Dr. Lauwers wants to know, why can’t pathologists be part of those discussions? “Why in the world is it that a pathologist cannot, based on what he knows of a disease, have an opinion? Not to make a blunt, stupid statement, but to guide the patients to maybe look at other treatments. Nothing in our medical degree or subspecialty degree tells us, ‘You’re a pathologist—so now you don’t talk to the patient.’”

Third, he says, some argue that pathologists may lack so-called people skills. “Not that all surgeons,” he says, starting to laugh, “have them, for that matter.”

Training, rather than personality, may be the real culprit, he says. Many young pathologists sail from medical school to pathology residency with scant patient contact, other than what they glean in medical school. He’s told pathologist colleagues involved in residency programs that pathologists need to spend a year in surgery, medicine, or some other discipline. “Even if they are not going to be surgeons, we want them to feel the pain,” Dr. Lauwers says. “To really understand that we are clinicians just as the others are—but we look at different aspects of the disease.”

There’s a lot of truth to the training issue, says Dan Hanson, MD, now a retired pathologist. When the American Board of Pathology tried, several decades ago, to address the lack of clinical experience by requiring an extra year of residency with a clinical application, many residents found ways to fulfill the requirement with research programs and the like, says Dr. Hanson. Eventually the requirement was dropped.

Dr. Hanson also suggests that a large influx of foreign medical residents may have contributed to the problem. Those whose command of English was somewhat limited may have found pathology an attractive option, given its reputation as a patient-free bubble.

But his years of experience have also shown him that some pathologists just don’t welcome patient contact, a notion that has gained traction in the medical world at large, however unfairly. Back in his Navy days, when he told his commanding officer he wanted to pursue pathology as a specialty, his CO told him, “You’ve got too good of a personality to go into pathology.”

In his own training, Dr. Hanson and his pathologist colleagues would routinely engage with patients. They then carried those routines with them into practice, he says.

His own career included working in a group practice, serving an academic appointment at the University of Toledo (Ohio) College of Medicine, and chairing the pathology department at a community teaching hospital in Toledo. When the hospital closed during the consolidation frenzy of the 1990s, Dr. Hanson switched to practicing in an independent laboratory, where he was also a major stockholder. “But even in that situation, I still had quite a bit of patient contact,” he says.

His point is clear. Pathology-patient encounters once were the norm, and should be again. “Visiting with patients and discussing things with them is nothing unusual at all,” he says.

If the old reputation, as expressed by his CO, was less than flattering to the profession, there was another one that casts a much brighter light on pathology. A radiologist colleague told Dr. Hanson early in his career, “We were taught in residency that if you have a real problem, and you don’t know which way to go, go see the pathologist,” he recalls.

Dr. Hanson observes that pathology has also been called the conscience of medicine. Through tissue committees and other endeavors, he says, pathologists acquire a broad view of how practices are conducted and how patient care is given, both good and bad. Nobody else occupies that intersection. “Some unfortunate things occur because the right hand doesn’t know what the left hand is doing. We’ve all seen it,” he says. “That’s not to say a pathologist can act like an oncologist, or as a surgeon. But we’ve got all the information.”

Dr. Myers has floated another idea past Dr. Lauwers, though this, too, has not made it past the what-if stage, “for no other reason than it hasn’t reached my priority list,” Dr. Myers says.

This would be to engage with patients preoperatively. After all, Dr. Myers says, they meet with their surgeons. They meet with the anesthesiologists. They meet with their nurses. “I wonder what it would look like if they met with their pathologists?”

He envisions pathologists introducing themselves to their patients, followed by patter that would go, roughly, like this: This is my role in what’s going to happen in the next few hours. I anticipate that we’ll see parts of your resected specimen and the margins, and our goal is to see whether they got around your tumor. Pathologists could talk about the likelihood of successfully doing that, and explain the occasional limitations of their technology. They could then tell the patients that they’ll stop by to see them in a day or so to tell them how things went from the pathology perspective: I’m going to tell you what we know about your disease. I’m going to answer any questions you or your family might have. And I’m happy to answer any questions you have now, before you head to the operating room.

The possible value of such rapport could be considerable, Dr. Myers suggests. In no particular order, he offers these thoughts:

  • Plenty safety literature focuses on communicating critical results, or losing those results as patients navigate multiple handoffs in a disintegrated health care system. What could be more direct than a handoff from pathologist to patient?
  • Patient interaction could raise pathology’s profile as well as perceived value.
  • Dr. Myers has heard the fears pathologists voice about their future. Someone—either a large reference laboratory or a lab that provides digital diagnoses remotely—is not only going to eat their lunch, but steal their lunch money, their milk money, and make pathologists sit at another table, hungry, thirsty, and poor.
    As he listens to these anxieties, Dr. Myers has a couple of thoughts: “If you send them [patients] a bill, they have a right to think you’re their doctor. And if the only value we’re adding to care is interpretation of a slide, that isn’t very engaging,” he says. “Maybe we should lose our jobs.”
    There are reasons some have a blinkered view of their profession, he concedes. Pathologists are busy. Their hands are full keeping up with the demands of their subspecialties. “But at the end of the day, if we don’t give service, we are at risk,” he says. “And rightly so.”
    So much for Dr. Myers’ views. What do his pathologist colleagues at Michigan think? The most common response is, “I’m too busy.” Dr. Myers says his answer is a cynical one: “You’ve got just as much time as I do.” If pathologists could jump that hump, he says, they might find they’re not as tired and as overtaxed as they say. “Believe me, it wasn’t like I had an extra 10 minutes on the day I had to find this patient’s room in our big [900+ bed] hospital. But I have to say, it was an awesome 10 minutes. And I came back to my office absolutely energized,” Dr. Myers says.
  • Fellow pathologists have asked him who will pay for these interactions. Dr. Myers doesn’t claim anyone will. “But keeping one’s job has monetary value, too,” he says. Touché.
  • Could patient interactions mitigate risk? Dr. Myers thinks so. It’s easy to get angry at “the lab,” he says, when the diagnosis is wrong. But if patients meet their pathologist, their first step, if a problem occurs, may not be to contact a lawyer or a clinician—it might be to call the pathologist and ask questions. “I’d much rather have that dialogue than to first learn of a patient’s discontent when I get a notice of intent,” says Dr. Myers.

Dr. Hanson knows from experience that it’s not always easy to talk to patients, especially when the news is bad. “It’s tough. It’s very tough sometimes. It’s uncomfortable for any physician to say to a patient, ‘You’ve got metastatic melanoma involving your lungs.’ But it’s much better for the patient to recognize exactly what that means.” Patients need straight talk about their disease, rather than being “overwhelmed by kind of a nebulous, I-don’t-know-what-it-is-but-it’s-awful type of thing,” Dr. Hanson says.

Pathologists can chip away at misinformation that often surrounds a diagnosis—what it really means, how it affects the body, how it affects the particular organ. “There’s a lot of mystery and ignorance about, Where the hell is the liver? Where is the kidney? What does it do?” Dr. Hanson says.

Those are simple questions for pathologists, though Dr. Myers recalls one patient who, he thought, would be coming at him with much harder questions. “She was highly, highly educated, not in the medical field, but worse—biostatistics,” he says. She was knowledgeable about her condition and, obviously, statistics—able to extrapolate with the best of them. He even became slightly anxious about her visit, and told himself he needed to study for it. “I had my references ready to go.”

He needn’t have bothered. “It was a great interaction,” he says. “And what was so gratifying for me was that when she left my office, she said, ‘I wish more doctors were like this’”—that is, willing to talk face to face.

Maybe it is that simple.

Sam Caughron, MD, recently assessed his own skills at a CAP training program at CAP ’10 in September. Meeting with the standardized patient was not all that difficult, despite the distressing diagnosis (breast cancer with a poor prognosis).

This “patient” wanted to know what the diagnosis means for her, Dr. Caughron explained. She looked for any sign of hope—could the diagnosis be wrong? The results mixed up with another patient’s? Both were unlikely, Dr. Caughron told her.

Those answers were important, she said later, in her feedback. But just as important, she reported, was the emotional connection she made with the pathologist. “I just listened,” says Dr. Caughron, a pathologist at MAWD Pathology Group, Kansas City, Mo.

He also did a little bit of self-disclosure. A relative had been diagnosed with breast cancer five years ago, “and it was relatively fresh in my mind what that meant for our family,” he says.

For Dr. Myers, bringing pathology consults to life is the art of the invisible. If clinicians don’t think it’s a fine idea for pathologists to speak with patients, it’s possible they can’t appreciate an in absentia practice.

Dr. Myers recalls a GI pathologist at Mayo who wanted to institute same-day service on GI biopsies. His fellow pathologists’ first response was hardly inspiring, Dr. Myers recalled: “We asked, ‘Is anyone complaining?’ It’s bizarre, right? Who’s complaining? That’s what we wanted to know.” No one was complaining—the pathologist thought same-day service would provide, um, better patient care.

His colleagues offered to poll some GI clinicians to see if they wanted same-day service. The clinicians said they were happy with their current service and saw no need to speed things up.

Despite this underwhelming call to arms, the pathologists launched a one-month trial. Only after the pilot stopped did the phones start ringing in the lab. “It was the gastroenterologists saying, ‘What the hell?’” Dr. Myers says. When the clinicians were reminded that they’d dismissed the idea earlier, they answered, We didn’t know we needed it.

Same-day results turned out to be important to patients who were coming from more distant towns and cities, who would no longer have to remain in Rochester an extra night. The faster turnaround also gave patients less time to wait around worrying.

Pathologists may provide excellent service to clinicians, but that’s no longer sufficient, Dr. Myers says. “We don’t think past them to the patient.”

He also wonders what else might give way if pathologist-patient meetings start taking place more fre­quently.

“Clinicians use us as an excuse all the time,” he says. When a clinician tells a patient, I’ll see you back in a week because we won’t have the path report until then, often that’s code for, I don’t want to see you again until next week because that’s what works best for me, he says. “We ought not to be co-conspirators in that.”

The lesson, to Dr. Myers, is clear: In pathology, and in medicine in general, it’s not always wise to wait for colleagues to tell you what they want. While there’s plenty who will tout the art as well as the science of medicine, day-to-day practitioners probably aren’t the ideal folks to foster a new practice. Doctors, in their day jobs, are scientists, not artists. They analyze what is, not what could be.

But here, the pathologist could play the part of the poet. “We have to be better at innovating around their unarticulated wants and desires,” Dr. Myers says. “Don’t ask. Do it—and learn.”


Karen Titus is CAP TODAY contributing editor and co-managing editor.