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  When pathologists meet patients—lessons from one FNA practice

 

CAP Today

 

 

 

December 2010
Feature Story

Karen Titus

Melinda Lewis, MD, isn’t necessarily unique in the world of fine-needle aspirations. But she throws open the doors on a subject—meeting with patients—that pathologists often have a reputation for dodging.

Better make those French doors. Dr. Lewis brings a certain graciousness and flair to her job of performing and teaching FNA services at Emory University School of Medicine, Atlanta.

It doesn’t go unnoticed. She has, she says, a large file filled with thank-you cards her patients have sent her in the two-plus decades since she founded the FNA service at Emory. Dr. Lewis has staked her career on talking to patients, meeting with them and their loved ones, arranging for followup care, tracking down referring physicians, reviewing results from other diagnostic procedures, and, oh yes, performing and interpreting FNAs.

None of that is meant to sound overwhelming. To Dr. Lewis it has become routine. “It may seem daunting to say you have to transform,” says Dr. Lewis, associate professor, pathology and laboratory medicine, since it implies nothing less than wholesale and perhaps unwelcome change. Her message is meant to go down more smoothly: She and other pathologists are already practicing in “transformative” ways. They’re being reimbursed. And others can adapt their ways to their own practices.

There’s nothing particularly arresting about the individual steps Dr. Lewis takes during an FNA, but they add up to an exceptional experience for patients.

She starts by reviewing the patient’s medical information, reading the chart and/or any of the clinical and radiological data, including x-rays, CT scans, or MRIs, she says. Her first direct contact comes in the waiting room, where Dr. Lewis greets her patients. Just to be clear: Dr. Lewis—not an assistant, not a nurse, not a receptionist—meets the patients and ushers them into the room where she’ll perform the FNA. “I want to establish rapport with them, to create confidence and trust quickly,” she explains.

She also tries, in Holmesian fashion, to take cues from their body language and from what they say. Patients undergoing an FNA are extremely vulnerable. Those with an established diagnosis of cancer may be facing a potential recurrence. “Which is devastating,” says Dr. Lewis. Others may be dreading an initial diagnosis of cancer. “These patients are usually extremely anxious.”

Given the high stakes, many patients arrive with family members or other loved ones. Dr. Lewis greets them, too, and, with the patient’s permission, will typically invite them into the procedure room. Since she sees children as well as adults in her practice, she’s hosted extended family gatherings, including parents, grandparents, and siblings. “Really, we’re just trying to do whatever we can”—short of skipping the FNA entirely—“to make the patient feel comfortable,” she says.

Dr. Lewis and her colleagues (she typically performs the FNA with a trainee, either a resident or fellow) encourage patients and family members to talk about their concerns and ask questions. She also wants to know what they know. What is their understanding of the tests or procedures they’ve had? What do they know about the results? What have other physicians told them?

She’s seeking conversation, not information. It allows residents and fellows to see, in a highly personal way, the importance of their work. They can fathom a patient’s anxiety and concerns; they understand what a delay in diagnosis means. Lab work is not an exercise in abstraction. “They see the impact of the diagnosis, not only on the patient but on the family,” Dr. Lewis says.

After all this, Dr. Lewis is ready —to keep the discussion going.

“We then explain the procedure,” she says. “Very carefully.” This includes discussing its limitations and possible complications. She’ll answer questions, too. Many are of the how-long-will-this-take, how-much-will-it-hurt variety. Those are the easy ones. The what-if-it’s-cancer question is more loaded.

She also lets patients know she’s a pathologist. They tend to respond with an enthusiasm usually reserved for conquering heroes. “Almost universally, they’re excited to meet a pathologist,” she says. “They’ve heard so much about us on ‘CSI’ or ‘Forensic Files,’ and they really think being a pathologist is cool.” Their response gives a nice boost to her trainees, she says. It might also be a nudge to pathologists thinking about plunging unto the breach of patient consults—now might be the time to “stiffen the sinews, summon up the blood,” if not for Harry and England, then for patient care.

At last Dr. Lewis is ready to perform the FNA. After withdrawing the cells and staining them, she examines the slide in an adjacent room. She and her colleagues then return to the patient. It’s time for more talk. “We tell the patient what we’re thinking. If it’s malignant, we tell them.”

As difficult as that may be, Dr. Lewis sees the value of being the one to deliver the bad news. “It’s a private setting, where they often have the support of their family,” she says. “We’re very, very careful about the way we break that news, although I have to say that many patients are expecting it,” since their referring physicians often have talked to them about a possible malignancy.

Even so, she faces all sorts of questions. Patients will ask about treatment, next steps, referrals. They’ll ask about possible implications for their family—does their diagnosis mean their children or siblings might also get cancer? They’ll also ask, How bad is it? Am I going to die?

Emotionally, this can take a toll. “In the laboratory, looking at an organ, you may be detached from what the patient is going through. So when you come face to face with it, it can be draining,” Dr. Lewis says. But even then, there’s an upside. “The patient is so relieved to know what’s going on, it trumps any emotions you might have,” she says.

Ernie Johnson, studio host for TNT’s “Inside the NBA,” knows firsthand what it’s like to have Dr. Lewis deliver tough news. He was diagnosed with non-Hodgkin’s lymphoma in 2003. “It was actually my 21st wedding anniversary that day—Aug. 21,” Johnson recalls.

A couple weeks earlier he had spoken with another doctor about a swelling near his ear. That doctor suggested it was likely a benign parotid tumor, but directed Johnson to Emory if he wanted a second opinion.

Which he did. A physician at Emory’s Winship Cancer Institute recommended an FNA, and later that day Johnson wound up under Dr. Lewis’ care. “She was the one who stuck me,” he jokes.

After examining the cells, she returned to Johnson and told him, “I’m not real thrilled with what I saw there. I want to do this again, just to make sure,” he says. The second sample was also disquieting, but Johnson recalls the moment with something approaching awe. “She said, ‘When I see this, I see a lot of lymphocytes, in both of these samples.’” The word “lymphocytes” meant nothing to Johnson, who asked what the finding meant to her.

“Well, it looks like cancer,” she told him.

The two then proceeded to talk for nearly three-quarters of an hour about followup tests, possible treatments, and so on. “We just sat there and had a long talk,” he says. “She was really reassuring, and it had a profound impact on me. It was a matter-of-fact, down-to-earth talk, without a lot of doctor-speak.”

Johnson was all too familiar with bad news delivered badly. When one of his sons was diagnosed with muscular dystrophy in the early ‘90s, Johnson says, more than one physician delivered dire news with bluntness and little else. “Just like, ‘This is what he’s got’ and ‘Nothing we can do about it,’” Johnson says, the memory still sounding fresh.

Physicians often come to patients at a tender time, and the repercussions last far longer than they may realize. Johnson has found that to be true both with his son’s diagnosis as well as his own. “With Melinda, it was the exact opposite,” he says. “I could not get the conversation out of my head. It was so well done”—so much so that Johnson uses the word “nice” to describe the way he learned he had cancer. And while the information she imparted was important, “It was probably secondary to the compassion,” he says.

If it’s hard to give bad news, it’s a pleasure for Dr. Lewis to deliver good news. “I can’t even tell you—that’s another thing that’s so gratifying for me, to be able to tell somebody who’s visibly anxious that their mass is benign,” she says. “Or a child—to be able to tell a parent that.”

Dr. Lewis considers herself lucky to be working in a multidisciplinary setting at Emory, not the least because she can then help her patients navigate the next steps in their care. If there’s an unexpected diagnosis of a malignancy, she’ll call the referring doctor and establish a followup appointment for the patient. “I do that so the patient doesn’t ever feel abandoned,” she says.

She’s serious about that. “I give them my card with my cell phone number on it.”

“I feel like I’m one of the first people in the Emory system they’re going to be seeing,” she continues. “I want to establish their confidence not only in me, but in the Emory system. And I want to communicate that we’re going to take excellent care of them.”

She extends that outreach in situations that are less fraught as well. Dr. Lewis and her colleagues often perform immediate evaluations of nonpalpable masses that are sampled under CT- or ultrasound guidance. When the team is behind schedule, she’ll call the waiting patient, introduce herself, and explain the delay. “And I’ll tell them this isn’t one of the procedures where you can’t have anything to eat beforehand—if they want to get something to eat, or have some coffee, they can,” says Dr. Lewis.

To Dr. Lewis, it’s a matter of being thoughtful, considerate, and respectful of patients, she says. “You know, whatever you would do for a guest in your home.”

How did Dr. Lewis arrive at her hospitable ways? “I’ve always done it this way,” she says simply.

She seems drawn to it naturally. Though she sees her share of non-­signout, non-FNA specimens, which entail no patient contact, they’re not her raison d’être. She hungers after something larger: to put pathology practice squarely into a clinical context. “To see a patient, to feel what a mass feels like, to feel what the needle feels like in the mass, to have that clinical context, is so important,” she says.

For too long, she says, some pathologists have labored under the perception that they’re good at talking with clinicians, but not with patients. “We’ve relinquished that role.” Maybe, she suggests, it’s time for pathologists to take it back. Who better than a pathologist, she asks, to communicate pathological findings to a patient, especially when there are nuances to explain, uncertainties to broach?

Pathologists could also fill in gaps left by other physicians. “Patients have actually said that to me,” Dr. Lewis says. “I was talking with a patient yesterday, and he was saying, ‘You explained everything so well. I really appreciate it.’ He hadn’t heard from his referring doctor, so he called me.” Dr. Lewis didn’t hesitate to call the doctor herself. “Patients come to me for a procedure, yes, but I’m also there to help in any way I can. I am their doctor, too.”

If pathologists can educate clinicians, why can’t they educate patients, she asks. And if patients are often stuck at a crossroads (though to some it may feel more like crosshairs) when they seek medical care, why can’t pathologists help guide them?

They can, says Dr. Lewis. It’s natural for pathologists to integrate information, she maintains. When she signs out cytology cases, even ones on which she hasn’t performed the FNA, she requests the related imaging information, clinical laboratory data, and patient history. She says it’s not unusual for her to look at a CT scan with a patient, for example, and talk about those findings alongside the pathological findings. She wants to be the one to put it all together for patients, rather than being yet another doctor who sends patients on their way after giving them yet another piece of possibly confusing (to them) information.

All of this is hard work, Dr. Lewis concedes. It takes time. Pathologists don’t have the same support system that has evolved in clinical practices. And, at least in an academic center like the one where she practices, “you pay a price” for patient interaction, in the sense of renouncing other opportunities. “But it’s always been worth it to me,” she says.

Apparently it’s been worth it for her patients, too. But if she needs a reminder, well, there’s that file full of thank-you notes in her office.


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