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Building Relationships with Your Clinician Colleagues

As much as we probably don't like to admit it, a large component of a successful pathology practice is customer service, and clinicians are our "customers." As a new-in-practice pathologist starting a job, you may have some preformed ideas about how the clinician/pathologist relationship should work based on your prior training experiences. However, each institution has its own culture and you will need to learn the culture to best serve your clinicians. 

For example, where I did my GI fellowship, I became accustomed to the hepatologists coming down to pathology quite frequently to review liver biopsies and discuss their patients' presentations so we could come up with the most unifying diagnosis. This was not always the case with the gastroenterologists. Over the course of the year, I only occasionally sat down at the scope to personally review a case of inflammatory luminal GI disease. 

This changed when I began my new position at my current institution. The gastroenterologists were very interested in looking at their luminal GI biopsies at the scope and held biweekly GI clinicopathological correlation conferences to discuss difficult cases and review all the pathology. These conferences had been staffed by four different pathologists so the clinicians were seeing a different person each week. As the new "GI guy" I made it a point to show up at each conference during my first year so I was available to join the discussion, even if I wasn't the person actually presenting the slides at the conference (I did this with the permission of the presenter, of course). This allowed for much more frequent face-to-face interactions with my clinical colleagues and these frequent interactions eventually helped me build good relationships.

It is very easy for pathologists to hide in their office and limit their practice to looking at slides and dictating reports. This may even sound appealing when you are new in practice and are just trying to keep your head above water managing large caseloads. Who has time to deal with clinicians' requests to review cases, clarify reports over the phone, or attend conferences one isn’t specifically presenting at? 

It may seem daunting at times, but doing these things to build solid relationships is very important. Not only is the clinician our "customer," but, more importantly, he or she is also the person who is going to convert your diagnosis into an actual treatment plan. A diagnosis that is misunderstood on the clinical end will likely not positively impact the care of your patient. This is where the clinician/pathologist relationship is crucial. One must trust the other and each must feel comfortable approaching the other with questions, no matter how silly they may seem, and clarifications to arrive at the best diagnosis for your mutual patient. 

So, what are some things a new in practice pathologist can do to develop these important relationships? After five years at my current institution, I have come up with a do's and don't's list:

1. Do: Make yourself available to discuss cases with your clinical colleagues in person.

While this does not mean you should drop everything the moment a clinician bolts into your office to discuss a difficult case, it does mean you should make a strong effort to temporarily set aside what you are doing to go over the case with him or her. If you need more time to evaluate the case, go over it briefly, tell them what you can in the moment, and then ask them to allow you more time to study the case in detail to provide more accurate information in the report. Or, offer to call them at a later date to discuss your additional findings. This shows the clinician that you are as interested in their patient as they are and a pathologist who demonstrates a high level of empathy for their patients is one that most clinicians will learn to trust.

2. Do: Learn to speak the clinicians' language.

I think we have all been at tumor boards where a lot of treatment verbiage gets thrown around and we politely nod our heads pretending to understand the chemotherapy regimens and treatment protocols being discussed. As pathologists, we will never have as in-depth a knowledge in treatment decisions as our clinical colleagues. We can, however, strive to understand where in our diagnoses important clinical decision points are reached so we know when and how to emphasize pathologic findings that directly influence the treatment discussion. 

This often takes outside study following attendance at several conferences so you can learn what types of questions commonly come up and how you might be in the best position to answer them. For example, I've learned I need to be ready to go into detail regarding microsatellite instability (MSI) testing and mismatch repair (MMR) protein expression in colon cancer at our tumor boards. After discussing the results of these tests, the most common follow up question I get it is "So, does my patient have Lynch Syndrome or not? And, if so, how do these tests prove that?" Remember, many oncologists spend their time thinking about chemorads protocols, not the nuances of molecular testing. Be the pathologist who can answer these types of common questions and you will be the pathologist they trust.

A second and even easier task is knowing why they care about certain diagnostic features you put in your report in some of their patient's cases but not in others. This goes back to "speaking their language." As another example, I know that my colon cancer oncologists don't care much about seeing lymphovascular or perineural invasion in a Stage IV colon cancer case. But, they absolutely want to see these slides for a patient who has Stage II disease as this may help them decide whether the patient needs adjuvant chemotherapy. 

By understanding their treatment algorithms, we can anticipate their decision points and target our conference presentations to answer their questions before they arise. This creates the perception that you are not simply a diagnostician but are also an integral physician partner in ensuring your mutual patient gets the proper treatment. It also ensures that you won’t forget to bring the "lymphovascular invasion slide" to conference when this is the one they really want to see (I've done this. It wasn't a good experience!). Remember, we all became doctors before we became pathologists so a little effort in becoming proficient in clinical speak goes a long way in establishing a good rapport with our clinical colleagues.

3. Do: Understand how your diagnoses impact the future care/testing of you and your clinician's mutual patient.

This goes hand in hand with the second point and gets easier the more you interact with the people interpreting your reports. Learn which clinicians require clarifying comments and which do not. I’ve learned that comments suggesting further serologic evaluation for celiac disease are not necessary for my in-house gastroenterologist colleagues sending me duodenal biopsies with compatible histologic findings but such comments are necessary for some of our rural "do-everything" community practice docs. Understanding these individual nuances over time has helped me avoid clarifying phone calls that I used to get quite often and has therefore allowed me to practice more efficiently. As a new-in-practice pathologist, this will take time. But, making mental notes early on regarding individual preferences will ultimately endear yourself to your "clinician customers."

In a similar vein, be prepared to understand the clinical impact of your diagnosis. A good example here is something we all regard as relatively easy: colon polyps. In my practice, I field a small amount of requests for second review of right sided hyperplastic polyps (HP). My astute clinicians are appropriately in-tune to the fact that there can be a lot of histologic overlap between HPs and sessile serrated adenomas (SSA) and occasionally want to review a diagnosis of HP in some polyps that they felt clinically resembled SSAs. I could get annoyed at this practice, but I try to keep in mind that the follow-up screening intervals are very different for these similar appearing polyps so the clinicians need to feel confident that they are getting accurate information on a case by case basis. With this knowledge, I find it much easier to acquiesce to these requests as I know this diagnosis will have a long-term impact on how they screen their patients in the future.

4. Do: Remember that your clinicians can be one of your strongest allies.

Pathology is hard. We make important decisions every day that impact the long-term care of our patients. Oftentimes, these decisions are cut and dry but sometimes we are in a gray "diagnostic zone" that requires additional clinical information to arrive at a correct interpretation. 

Relationships and communication are a two way street. Most clinicians appreciate a pathologist who is willing to reach out for more information regarding the clinical presentation of their patient so the pathologist can write a more clear and concise report. A short, accurate report is always more eagerly received than a long ambling report with a lot of "consistent withs and suggestive ofs." It is often the clinician who can provide the clue you need to properly interpret your gray zone. Establishing a consistent line of communication is essential in this regard. These clinicians will then support you if you are struggling with other aspects of your new practice such as administration, QA projects, establishing diagnostic testing protocols, etc. They will support you to their higher-ups who often have more administrative clout in a hospital setting than you do. Scratch their back and they will scratch yours.

For example, imagine you have an idea for improving the up-front sectioning and staining protocol for Hirschprung's biopsies. You can't change a long standing protocol such as this on day one before you have gained the trust of your pediatric surgeons. In time, however, you can suggest a change to the protocol and one of your clinician colleagues will say “Dr. Pathologist seems to know what he or she is doing. Let’s trust him or her with this change.” Suddenly, you've got all the support you need to make the improvements you want.

Also, keep in mind that our generation changes jobs more frequently than past generations. If you decide to transition to a different job, you will want recommendations from your clinical colleagues. I was recently a member of a search committee to hire additional pathologists for my practice. CVs and personal statements are important, but letters of recommendation are often where one really learns about the abilities of a potential hire. I found recommendations from clinicians who had worked with a pathologist applicant to be very informative. Clinicians often had much more to say regarding the diagnostic skills of an applicant than the person's laboratory colleagues. Trust me. You want the clinicians on your side if you are applying for a new job.

5. Do: Limit email as a means of discussing complex clinical parameters surrounding a difficult diagnosis.

In most practices, email is fine to relay a straight forward diagnosis, such as "Dear Dr. Clinician, the gastric mass you biopsied is an adenocarcinoma." On the other hand, email is usually not the best way to discuss the findings of an inflammatory liver biopsy in a pediatric patient. If you can't glean the information you may need from the clinical notes, reach out to your clinician with a phone call or set a meeting for a personal discussion. You will find face-to-face interactions more informative and more revealing. Clinicians will tell you things in person regarding their own diagnostic struggles that they might be unwilling to reveal in an email correspondence digitally available in perpetuity. 

An additional bonus feature of a personal conversation is that you can now write a much shorter report! Instead of a long comment documenting clarifying and correlative features of the biopsy, you can simply note that you discussed the clinical implications of the histologic findings with Dr. Clinician and often leave it at that.

6. Do Not: Hide in your office.

This is the only "don't" on the list. As a new-in-practice pathologist, making time for clinicians can seem difficult as we get used to our new responsibilities. Staying glued to your microscope, however, will only postpone the eventual need for you to meet and interact with your clinical colleagues. Begin this practice early on in your career and it will pay dividends immediately and in the future. Remember, we are doctors first and pathologists second. A complex diagnosis, regardless of how beautiful the report looks and how well thought out the findings are, is worthless if it is misinterpreted on the clinical end. Going out of your way to communicate effectively can only help your patients and your career. Make this a habit early on and you will quickly assert yourself as crucial member of the "patient care team." It will have a positive impact on your career and it will make you better pathologist in the long run.

Dr. Joshua Hanson is an attending surgical pathologist at the University of New Mexico in Albuquerque. He specializes in gastrointestinal and liver pathology. When not practicing pathology, he spends his days fly fishing on the pristine trout streams of northern New Mexico.

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