Galen Eversole, MD
Ann T. Moriarty, MD
What we have here is a failure to communicate.
—Cool Hand Luke (1967)
New guidelines for managing women with abnormal Pap tests were published in October 2007.1 These guidelines were evidence-based, representing data from clinical trials. A group of 146 experts and 29 professional national and international organizations participated in developing the guidelines. The American Society of Colposcopy and Cervical Pathology (ASCCP) sponsored the consensus conference in September 2006, and the conference recommendations updated the previous 2001 ASCCP conference2 and 2004 interim guidelines.3 The consensus guidelines are meant to assist all clinicians in managing women with abnormal Pap tests. Though a variety of professional organizations were represented, it may take years for the information from the conference to penetrate the grassroots.
A few weeks ago, not long after many practitioners had begun to assimilate the 2006 ASCCP guidelines, one of us got a call from an OB/GYN physician who wanted to know our laboratory’s policy on “enforcing” elements of the guidelines. His local laboratory cytology department was placing a disclaimer on orders for human papillomavirus testing in women 20 years and younger (adolescents), which he felt put him at risk with insurers. In another instance, a medical director was told his lab must offer low-risk HPV testing, though he was opposed to it, because of clinician demand. Low-risk HPV testing may account for a significant percentage of HPV DNA testing.
We have all had numerous conversations with our clinical colleagues, oftentimes primary care ancillary providers, in which it is clear that knowledge of the guidelines is limited or nonexistent. How do well-informed laboratory professionals routinely communicate new information? How can we communicate the 2006 ASCCP consensus guidelines to our colleagues? What are the usual routes of education in the medical community? What is the pathology lab’s role in informing clients of the guidelines, and, secondarily, in mediating adherence to them?
The issues are problematic. First, there are no well-developed “pipelines” for disseminating information in the loose gathering of medical practices that compose the medical “system.” Second, many clinicians have long resisted report-based guidance from pathologists. Third, the model of pathology practices has changed markedly. For most pathologists, the notion of a single pathology group servicing a single hospital has long vanished. More often, pathologists serve multiple hospitals in multiple functions and there is no “captive” medical staff awaiting “lab policy.” More important, Pap tests are no longer a local commodity. The medical staffs and offices generating Pap tests are far-flung and have varying educational backgrounds and expertise and patient populations with extremely different risk factors for cervical cancer.
Educating the local medical community about the 2006 ASCCP guidelines raises its own set of challenges. First, the ASCCP guidelines are just that. They are not hard and fast rules written in stone with proscriptive authority granted to any medical body. Many contingent circumstances in an individual case may forgive departure from a guideline. The first physician who contacted us points out that there are ASC-US cases that turn out on biopsy to be HSIL and that additive risk factors in a given adolescent (unknown to the pathology laboratory) may point to the need for a more assertive followup algorithm than enumerated in the guidelines. This particular clinician explained that he stopped doing definitive procedures in adolescents years ago, so overtreatment of an adolescent is not the issue. If the pathology report says as a disclaimer that the request for additional testing is not warranted, the assumption is that the pathologist has a better ability to make a clinical decision based on population-derived guidelines than the clinician who has the patient in front of him. On the other hand, a clinician or physician extender may have formed ideas based on previous ASCCP guidelines that are hard to dislodge. Overuse of high-risk HPV testing and continued use of low-risk HPV testing, coupled with unnecessary excisional treatments, makes clear that clinical providers do need guidance, education, and even limited ordering options.
So what to do and how to do it?
First, it is not the job of the pathologist to be an enforcer. The consensus guidelines are a joint clinicopathologic product, and any proscriptive force must come from the professional organizations acting in unison. There is some attempt in the guidelines to grant leeway—for example: “In exceptional circumstances, a diagnostic excisional procedure is acceptable.” But, for the most part, more specific potential exceptions are not enumerated and discussed. However, because the ASCCP guidelines are jointly written with input from multiple societies, pathologists can, and should, question chronic deviations from the guidelines if they can identify them in their practice. Directed questions to physicians or practice managers about questionable ordering practices places the pathologist in the position of consulting physician. Oftentimes the aberrant practice patterns are based on misguided office staff, not on physician ignorance of the guidelines.
It may be effective to use an educational statement with reference to the guidelines (to ACOG or to the ASCCP Web site for guidelines download) rather than a disclaimer. The pathology report has always been an effective vehicle for disseminating information, guidance, and references and should continue to be so.
Laboratories often employ monthly or quarterly laboratory updates that can be used for educational purposes. Often these updates never reach the physician but may be read by office staff or physician extenders and have the desired educational impact.
Other venues for disseminating the guidelines are jointly sponsored dinner and CME events for clinical practitioners, discussions before tumor boards and other hospital committees (risk management), and medical society and medical insurance programs to reduce practitioner risk (as part of premium-reduction educational events). These interventions require that pathologists get involved and visible in their local medical communities. Visiting physician offices with the laboratory’s sales or support staff works for some practices as a means to disseminate literature or information. However, these visits should be noninvasive to the office staff and serve only as a way to be more visible. Most busy practices rarely have time for long-winded educational sessions.
Direct-mail campaigns can be effective, as direct-to-consumer marketing has shown. There may be an opportunity for the professional organizations to disseminate guideline materials to targeted clients in a way that protects the copyright protections of the ASCCP and ACOG.
The case-oriented approach has always been the most comfortable and possibly the most effective method to convey information, controversy, and consensus. It is preferable to present the information over time in a case-relevant piecemeal fashion rather than expect a provider to digest the entire set of guidelines in one sitting. This requires an organized program of education that may be beyond the means of individual pathology practices but which some may choose to try until such programs can be developed at the professional society level.
Web-based learning and communication is also effective. Most younger physicians (and young-at-heart physicians) are familiar with electronic learning. “Flash” or push-learning by e-mail to laboratory clients may be effective. While many of these methods are beyond the capabilities of most pathology practices now, this method of communication and learning will continue to be powerful and grow more so as technology advances inexorably into our lives.
Strong communication is one of the pathologist’s most important skills. Whether it is a metabolic profile or a cancer staging surgery, pathologists strive to convey effectively and accurately the results that are used to manage a patient. Educating providers about the ASCCP guidelines is another example of communication for the betterment of patient care.
How do you teach your clinicians? We would like to know what ideas you, the reader, have for guideline dissemination and education and how the CAP could play a role in supporting endeavors in clinician education. Please send your comments by Aug. 30 to Lisa Fatheree, SCT(ASCP), CAP Cytopathology Resource Committee staff, firstname.lastname@example.org.
1. Wright TC, Massad LS, Dunton CJ, et al. 2006 consensus guidelines for the management of women with abnormal cervical screening tests. J Lower Gen Tr Dis. 2007;11:201–222.
2. Wright TC, Cox JT, Massad LS, et al. 2001 consensus guidelines for the management of women with cervical cytological abnormalities. JAMA. 2002; 287: 2120– 2129.
3. Wright TC, Schiffman M, Solomon D, et al. Interim guidance for the use of human papillomavirus DNA testing as an adjunct to cervical cytology for screening. Obstet Gynecol. 2004;103:304–330.