Consultations in Pathology Practice:
Clinicians & Patients
Jennifer L. Hunt, MD, MEd
Associate Chief of Pathology Massachusetts General Hospital
Associate Professor of Pathology
Foundation.cap.org
v. #
Harvard Medical School
Agenda
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Background
Direct Patient Consultations
Training program
Summary
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Personalized
Medicine
The task of science is to stake out the limits of the knowable,
and to center consciousness within them
-Rudolph Virchow
Case Presentation
• 2009: 55 year old male
• Presented with a new rapid onset neck mass
• CT scan showed multiple enlarged lymph
nodes (largest 2.6 cm)
• FNA: squamous cell carcinoma
• Tonsil biopsy: squamous cell carcinoma
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Tonsil Tumor
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Case Presentation
• Tumor pathology
• Predominantly non-keratinizing squamous cell
carcinoma of tonsil with metastases to neck
• HPV testing
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•
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p16 strongly positive
HPV (high risk) in situ hybridization negative
Reference lab HPV in situ negative
HPV PCR negative
HPV positive at outside facility
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PIK3CA mutation: E545K
Normal Control
Our patient’s tumor
Diagnostic Timeline
Diagnosis
3/2009
Molecular
Testing
Erbitux
Chemo
Rads
Chemo/Rads
3/2009
Lung mets
5/2010
Neck Dissection
12/2009
11/2009
Recurrence
11/2009
6/2010
9/2010
3/2011
Brain mets
9/2010
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Personalized
Impersonal
Healthcare
Direct Patient Consultation: Model
• Clinician sends patient to pathologist for
consultation
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Review the tumor morphologic features
Go over staging parameters
Review any molecular or ancillary testing
Answer questions
Discuss treatment options
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Direct Patient Consultation: Why?
• Education and information for patients
• Informed patients participate in medical
decision making better
• Health literacy correlates with outcome
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Direct Patient Consultation: Why?
• Better patient satisfaction
• Patients like access to their healthcare team
• Advanced technology is a driver of satisfaction
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Direct Patient Consultation: Why?
• Allows the pathologist to be an active
participant in patient management
• Personalized interactions are rewarding
• Valuable role to play in the house of medicine
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The Clinician Perspective
“As a medical oncologist, I can’t look at
pathology slides and speak to what the
slides are showing with any real
understanding of what I’m looking at.”
Lori Wirth, MD
Mass General Hospital
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Direct Patient Consultation: Barriers
• Willingness: Pathologists and Clinicians
• Some pathologists are uncomfortable with the
idea, while others are totally excited
• Most clinicians are eager to try it.
• Logistics: Pathologists
• Organization and billing issues
• Experience: Pathologists
• Most pathologists haven’t seen patients since
medical school
• Exception: Cytopathologists
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Willingness: CAPToday Article
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Willingness: CAPToday Article
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Logistics: Best Practices
• Optimize information flow and
communication
• Consultation questions and discussion
• Use good hand-off procedures and
documentation
• Letter or note in chart
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Logistics: The Billing Conundrum
• There is no perfect E & M code (without
overstepping)
• Currently, billing for this may lead to
clinician hesitation
• The real answer will come with healthcare
reform
• Creating a valuable new service for pathology
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Why Some Pathologists Hesitate
• “I went into pathology so I wouldn’t have to see
patients”
• “I’m shy! I don’t want to see patients”
• “It isn’t paid!”
• “My clinicians don’t want me to see their patients”
• “I don’t have time!”
• “I haven’t seen patients since medical school XX
years ago!”
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Standardized Patient Simulation
• An experiential training program for
pathologists (sponsored by CAP
Foundation and Transformation Program
Office)
• One-on-one direct interaction with a
standardized patient (actor)
• Standard case with advance preparation
• Immediate feedback from “patient” perspective
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Standardized Patient Simulation
• Event held at CAP ’10
• 33 pathologists participated
• 30 did the pre- and post-surveys (91%)
• 24/30 were in practice for more than 10 years
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Where They Practiced
12
10
8
6
4
2
0
Academic
Community
Hosp
Private
Group
Commercial
lab
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How Often They See Patients
16
14
12
10
8
6
4
2
0
Never
Once a year Once a month Once a week
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Comfort Level Consulting with Patients
5
4
3
2
1
0
Average pre
Average post
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Constructive Feedback from Patient
25
20
15
10
5
0
Excellent
Good
Fair
OK
Poor
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Constructive Feedback from Patient
25
20
15
10
5
0
Excellent
Good
Fair
OK
Poor
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Improvement in Specific Skills
Explain report
Relate as a
clinician
Post
Pre
Treatment info
0
1
2
3
4
5
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Quotes About the Experience
• “Reawakened my dormant clinician!”
• “Training like this is vital for future
pathology services”
• “I will speak to the clinicians I work with to
offer patient consultations”
• “I will be more open to opportunities, even
in informal unpaid situations”
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Next Steps: Patient Consultation
• Science: A randomized controlled trial
• Does patient consultation improve health
literacy, patient satisfaction and disease
management (coping)
• Education: Standardized patient simulation
• Offer again at CAP 11
• CAP Foundation fundraising campaign to
expand the program to offer more broadly
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Summary
• Case Presentation
• The Model: Direct Patient Consultations
• Standardized Patient Simulation Training
Program
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