Pathologist-Patient Consults - Insight into a Unique Care Model

Dr. Emily Green:

Hi everyone. Thanks for listening to this CAPcast. I'm Dr. Emily Green, a private practice pathologist and a fellow of the College of American Pathologists. Today I'll be discussing pathologist's patient consultations with Dr. Favia Dubyk, who goes by Dr. Favia, and Dr. Lija Joseph. Both are pathologists with unique practices where they interact directly with patients around their pathology results. Dr. Joseph, let's start with you. Would you take a minute to describe your practice and introduce yourself?

Dr. Lija Joseph:

Yes. Thank you, Dr. Green, for having us here today. I'm Lija Joseph. I'm the chief of pathology at a community hospital about 20 miles north of Boston. My practice is at Lowell General Hospital and I have seen close to 150 patients now through this program.

Dr. Emily Green:

That's great. Thanks for the introduction. Dr. Favia, would you let us know about your practice and introduce yourself?

Dr. Favia Dubyk:

Yes. So I'm Dr. Favia. I just finished my HEPA fellowship this past June at UNM, University New Mexico. And I am currently the physician on staff for one of my climbing sponsors, Kinesio Tape that's located here in Albuquerque. So in addition to being a physician, I am a professional rock climber and I competed on American Ninja Warrior twice. During my fellowship year, I actually started Dr. Favia's Diagnosis Education Clinic where patients can bring their PATH reports to me and I explain them. That was difficult during fellowship year and right now it is my full time job.

Dr. Emily Green:

That's great. Favia, what inspired you to do this kind of consultation practice?

Dr. Favia Dubyk:

Well, there were two things. First, when I was in pathology residency, I really enjoyed interacting with patients, but that was kind of limited. I could see them on transfusion medicine services. I guess I mean autopsies of talking with the families, but that just wasn't really enough for me. And I was telling one of my advisors this, "I really want to talk to patients." And he said, "Well, there's this article that just came out by Dr. Joseph up in Massachusetts. Why don't you give it a read?" And I said, "Okay." And I read it and I was like, "This is what I want to do." I knew instantly that this was the career path I needed to take. So it was my need to see patients, but also Dr. Joseph's incredible work.

Dr. Emily Green:

I just kind of got goosebumps about the inspiration. There's those moments that we get. Dr. Joseph, what was your inspiration for starting this kind of practice?

Dr. Lija Joseph:

Thank you so much Favia for saying that. I really appreciate it. Back in 2017, I read a story about a patient from Lowell, her name is Linnea Olson, who has since become a dear friend of mine. She has given me permission to share this story with you. She has lung cancer and she has participated in many clinical trials. She's just a truly curious patient who really wanted to know what does lung cancer look like and what happens when I take these experimental medications, what happens to the tumor? I was just inspired to read her story and to recognize that she had to drive 20 miles south of Lowell to even see an example of what lung cancer looks like and I was determined to make that journey easier for any patient who wanted to see their tumor or their biopsy so that started my interest.

I was inspired by a patient, but then the journey has been, I wouldn't say difficult, but when you are doing something that nobody else has done before, you have to kind of make your own path. So I'm glad that I made it a little easier for Favia.

Dr. Favia Dubyk:

Me too. Me too.

Dr. Emily Green:

What are some of the barriers to getting your practice going, Dr. Joseph?

Dr. Lija Joseph:

The first and most important step is to get support from your organization. So I went with that story to the administrative leadership. But before I went to them, I had spent a significant amount of time building trust and building a relationship so that they knew that I was just not a random person coming and saying, "Oh, I want to do this."

Dr. Favia Dubyk:

I did.

Dr. Lija Joseph:

So getting that professional support was very important. And then, of course, to get support from the consultants who would trust their patients with me, that was a very important step as well, because, of course, they did not want the patients come to me and me say something different from what they have advised their patient. So I want to say credibility and trust. To build that was the most important first step.

Beyond that, I had to deal with my liability insurance to make sure that this is something I'm authorized to do to create a HIPAA-compliant space for the patients to come meet with me, as well as a process for documenting and providing feedback to the consultants who were referring the patients to me to make sure they knew what I had discussed with the patient. So those were further steps that were further down along the way but the first step was trust and credibility,

Dr. Emily Green:

Really getting trust and credibility and I guess sort of a sense of commitment from you. If we go down this road, we're going to see it through. It makes sense. What about you, Dr. Favia? What were some of the barriers for you getting things started?

Dr. Favia Dubyk:

Well, the barriers that she just described are still my barriers. Those are some of the main ones I'm trying to overcome right now is getting an institution or just regular, like single oncologist or family practitioner doctors to send patients my way. That has been the biggest barrier now that I have the business up and running. When I had just trying to get the business up and running in a private practice setting, getting liability insurance was very difficult because I got rejected many, many times. I had to keep trying and adjust how I word it or adjusted my language to get approval. So that was many, many months of work just trying to get liability, trying to find a space, building a website, because I was doing all of this during fellowship and I had brought all this to my institution, but they had all declined. They weren't interested in it, so I had to figure out how to do this all on my own. So that was quite difficult.

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Dr. Emily Green:

I can imagine. How long did it take you to get everything pulled together?

Dr. Favia Dubyk:

It took probably a year and a half or so, and then I opened before I had everything pulled together.

Dr. Emily Green:

I'm sure it's continues to evolve for both of you. I can imagine that for sure. And you guys have both spearheaded something, right? So anytime we do something new, I think one of the things we talk about a lot in the CAP and about pathologists is we're not just behind the microscope physicians and we are physicians. And I think a lot of medicine has stopped thinking in that way about us. And so I think what you guys are doing, I'm sure, helps change people's mind about it. And I can imagine that you're sort of being pioneers in a field. Well, thank you for that. Speaking of being pioneers in a field, I think one of the things that comes up as a question for people is do you guys get reimbursed for this? And how does that work if you do, and what were any barriers for that getting accomplished? Should we start with Dr. Joseph? Okay.

Dr. Lija Joseph:

Sure. I'm happy to. I knew right from the beginning that this was never about me. It was definitely about the patient. A patient inspired me to start this program and clearly 150 patients down the line, I know that patients want it. I think many stars are aligned for this to happen at this time, specifically because patients have access to all of their medical records. The Cures Act truly opened that door for the patient. The patients have access to the internet, they have access to Dr. Google, and they have a lot of questions that they go to any source that will provide them the answers and I realized that why not be there for the patient? Why should we hide behind the paraffin curtain?

And that kind of was the reason I wanted to do this, but I knew that if other pathologists have to pursue this and offer this for their patients, they would need to know that this is a good investment of their time and they do have return on investment for this business model.

So I worked very hard with CAP as well as our business office in order to figure out a way to make this work. I knew that I'm in a community practice. We are a group of four and a half pathologists to make sure that this is viable. I needed to make sure that it is a reimbursable project. So I've worked very closely with our business office. They found out a way that a pathologist can be reimbursed for the time that they spend with the patient, provided there is adequate documentation. So we came up with a script. We came up with a template that we can use, and I had to gain access to enter clinic notes in a patient's chart so all of this required administration support. And so once I started documenting exactly what the insurance companies want to see, I've had no trouble getting reimbursed for this service.

In addition to that, every patient that I meet, I am fully transparent with them and I disclose to them that this is how the rest of the system works. I will make sure that there is a bill that is generated for it, but I also give them a thank you card for coming to visit me. I also give them my business card. If they have any difficulty making a payment, I have asked every single one of them to email me or call me on my cell phone in order to make sure that they do not see that as a barrier for them to come and see me. And up to this day, I have not had a single rejection for that reimbursement request.

Dr. Emily Green:

That's great. What about you, Dr. Favia?

Dr. Favia Dubyk:

So mine is, since it's a private practice structure, I don't accept insurance. I don't have a medical bill or anybody to do all that. So it is just charged per 15 minutes. And on my website, I have what type of report it takes, how much time. So if you have a simple biopsy report like basal cell carcinoma, you would need the 15 minutes. But if you have a Whipple, that would be an hour.

Dr. Emily Green:

Yeah, makes sense.

Dr. Favia Dubyk:

I give them a 10-minute consultation for free so they can kind of understand what it is and how the whole process works. But mine, right now, is just buy the 15 minutes and they can use a credit card online.

Dr. Emily Green:

That's great. Makes sense. And I think as both of you discussed, patients are interested in this and people are willing to pay for the knowledge and experience so that's great. And it's good that also insurance companies also recognize the value of it, of the physician consultation. Let's just switch gears a little bit. I'm wondering if you guys have a story, or just an anecdote about what you find most rewarding about the work. I think we touched on that a little bit and what inspired it, but maybe there's just something else you would want to share about just the rewards of this kind of interaction.

Dr. Favia Dubyk:

I can start with that one.

Dr. Emily Green:

Great.

Dr. Favia Dubyk:

There's many that I think of. It's hard to pick just one, but one of my earlier examples kind of wasn't actually a patient. It was while I was trying to create it, and I was telling my friends about this new idea I had. And so one friend came to me very concerned about her lab results. She saw that she had something that was off the charts. Her Beta-hCG was just really, really high. And she knew she was pregnant because she took the pregnancy assessments from her doctor who said she was pregnant, but no one had gone through her lab results and said what a Beta-hCG was. And so she came to me, she's like, "I think I'm going to die and my babies are going to die," because she had twins. And I said, "No, no, no, you're fine. That just means you're pregnant." And she was like, "Oh, my goodness."

Dr. Emily Green:

Really?

Dr. Favia Dubyk:

So that took me 30 seconds to relay her fears that she or her babies were going to die and that really stuck with me that lab results can cause immense stress for patients when they don't understand. And as pathologists, we can interpret some of them really quickly and help them out in a mere minute.

Dr. Emily Green:

Right. Like we mentioned with the Cures Act, patients are getting access to all of their lab work kind of instantaneously and sometimes out of context. So then that can create that real need for someone maybe besides Dr. Google, because that can get really scary even for a physician, right? Yeah, I can see the real value there.

Dr. Favia Dubyk:

That's actually probably one of the biggest parts of my clinic now isn't actually reading all large dissections or Whipples. It's actually just lab results because they see something is elevated or down and they're worried, but their clinician didn't mention anything. They said they were fine, and they were wondering, "Well, how could I be fine with this is..." Say your hemoglobin is 0.1 above. For us, we're like, "Oh, that's nothing." But they see red and it raises a concern. So that's actually been my biggest population of patients is for those type of questions.

Dr. Emily Green:

That makes sense. Yeah, I think it can be confusing for sure. What about you, Lija? Is there a story or some [inaudible].

Dr. Lija Joseph:

Yeah. I have so many stories. I just want to highlight a few just so that it brings out that it could be anybody who really needs your help and just being open and being there for the patient. Just really very fulfilling and rewarding. My youngest patient is 11 year old who was diagnosed with Crohn's, and the family was so curious to know what is really going on with their child and just sitting down with them, making a PowerPoint for the child saying, "This is what's going on. This is what normal colon looks like, this is what your biopsy looks like." And just that moment of understanding even in 11 year old mind was just so beautiful to see that this helps them cope with a chronic illness and they truly understand what's going on with their body. That was an inspiring moment for me.

Every patient inspires me. My oldest patient is over 80 years old. I think he was 83 years old, did not speak one word of English. He came with his young daughter. He really just wanted to know what's going on with his body. He had gastric carcinoma and sat there and looked through the, I showed the pictures of the biopsy on a TV screen and sat for that entire half hour, asked a lot of intelligent questions and was so grateful at the end of it all. And that was again, another very fulfilling moment for me. And then there was a patient who truly made it clear why this service is so important for a patient.

This is a breast cancer patient who came and saw her estrogen receptor positive tumor cells, and I still can picture her face. When she saw those ER positive tumor cells through the microscope, her eyes really widened. She looked at me straight in the eye and said, "Dr. Joseph, if I had seen these slides, I would've been so much more compliant with my anti-estrogen medication."

That was truly a moment for me that I realized this is not just about them being curious. This is about compliance. This is about survival. This is about, again, a patient who may live an extra five years if you took that five minutes to explain what's going on in their body. So I have many more, but I'll stop there.

Dr. Emily Green:

It sounds incredibly empowering to those patients, and I can imagine that 11 year old, that'd be the story that they write on their medical school statement of interest, personal statement. Doesn't it sound like that kind of story, but really inspiring. Absolutely.

Dr. Lija Joseph:

It also makes all of our problems much smaller when you encounter these brave and courageous patients who are really now has often a life altering diagnosis, but they are taking so much of control. Trying to understand, comes to me and says, "Knowledge is power, Dr. Joseph. I really want to know what's going on so that I can deal with this." And then when somebody cuts me off on the drive back home, I say, you know what? This is really nothing.

Dr. Emily Green:

Yeah. It puts it into context.

Dr. Lija Joseph:

Everything's in the context.

Dr. Emily Green:

I can imagine also, as pathologists, our job can be pretty tough. We can be delivering these really difficult diagnoses and we don't necessarily have that patient feedback to put it into a wider context of care. It can kind of lose some meaning in that way and I can see just hearing your stories I can understand that it brings a lot of that meaning back. That even though we are sometimes giving difficult information, it's information and that really impacts people and empowers them to make the right decisions and the decisions that are the best for them so.

Dr. Favia Dubyk:

I'd like to kind of piggyback off that. So I was diagnosed with Hodgkin's Lymphoma in med school, and I sat in the hospital bed for a month getting biopsy after biopsy, waiting for the pathology to come back for which cancer I had, and I really didn't know anything about pathology back then. So I remember asking my doctor, so when is the pathologist going to come?

Dr. Emily Green:

That's a [inaudible], right?

Dr. Favia Dubyk:

"I've seen all these other doctors rounding. When is the pathologist going to round?" And they're like, "Oh, no, that's not how it works."

So I'm kind of in a unique situation where when I was signing out and looking at slides, since I did a hematopathology fellowship, I kind of understood both sides and I could see how easy it was for me to forget how life altering these decisions we're making are. I'd be like, "Okay, leukemia, lymphoma, leukemia, lymphoma," is what I did every day for that year. But then I would sit and thinking about like, "Oh my goodness, oh, that poor person." I know how horrible their day is now and how their life is going to change after they receive this PATH report. So it is been very interesting being on both sides of waiting for the PATH report for a whole month.

On the other hand, giving people out these diagnoses, which is why I think for my clinic, it is somewhat useful for me to be telling them how the pathologist came up with this because I can understand the questions they've had or I can even give them feedback on what's going to happen next. Like what chemo can be like, what getting a chest tube is like. So it's kind of, my clinic is a little bit of both sides like doctoring, but also this is what it's like being a cancer patient for the rest of your life because it's not like an event, it's forever.

Dr. Emily Green:

Wow. That's really inspiring. And I can see how you are drawing on a personal experience and that's really enriching your practice. And I can also see how after the both of you are interacting with patients, how that can further inform our experience, and our knowledge, our connection with the patient when we're on the diagnostic side. So yeah, that's really special. I can see that. And I know that that's not happening in my personal practice right now, and I can imagine that I would enjoy it, for sure. Well, I'm wondering if you have any final words of advice for pathologists who are considering starting this type of practice? Dr. Joseph, do you want to start?

Dr. Lija Joseph:

Yeah. I would say don't give up on your patients. Favia and I have really opened that door for you. There is no taking no for an answer from your administrators or from your chief or whoever else is going to say no to you multiple times. If you want to do it, pick up the phone and call us. We'll tell you how it can be done. Don't take no for an answer. It can be done.

Dr. Emily Green:

That's great. Favia do you have final words of advice, a challenge to lay out? No.

Dr. Favia Dubyk:

I can second that because that's actually exactly what I did. I got a bunch of nos and then I called Dr. Joseph.

Dr. Emily Green:

Yeah.

Dr. Favia Dubyk:

She helped me keep my fire going.

Dr. Emily Green:

Right. And also, like you said, you guys have opened the door and you're willing to share your experience and your process so that's the reason why we're having the discussion today is to let people know about that. Well, I want to thank you both for a really fantastic discussion. I'm inspired. I hope that the people listening are also. Thank you guys again for this great discussion.

Dr. Lija Joseph:

Thank you for allowing us to be here and thanks to CAP for helping us disseminate this excellent and wonderful opportunity.

Dr. Favia Dubyk:

Yes, thank you so much. It was wonderful.

Julie McDowell:

Thank you for listening to this CAPcast. To listen to our other episodes, find us on the MyCAP app, available for CAP members as well as SoundCloud, Apple Podcasts, Stitcher, Google Podcasts, Spotify, and Amazon Music. Just search for CAPcast from the College of American Pathologists on these apps. Once you find our podcast, be sure to click the subscribe button so you don't miss new CAPcast episodes.

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