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Consultations in Pathology Practice: Clinicians & Patients

Consultations in Pathology Practice: Clinicians & Patients. Jennifer L. Hunt, MD, MEd Associate Chief of Pathology Massachusetts General Hospital Associate Professor of Pathology Harvard Medical School. Agenda. Background Direct Patient Consultations Training program Summary.

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Consultations in Pathology Practice: Clinicians & Patients

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  1. Consultations in Pathology Practice: Clinicians & Patients Jennifer L. Hunt, MD, MEd Associate Chief of Pathology Massachusetts General Hospital Associate Professor of Pathology Harvard Medical School

  2. Agenda • Background • Direct Patient Consultations • Training program • Summary

  3. Personalized Medicine The task of science is to stake out the limits of the knowable, and to center consciousness within them -Rudolph Virchow

  4. 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

  5. Tonsil Tumor

  6. Case Presentation Tumor pathology Predominantly non-keratinizing squamous cell carcinoma of tonsil with metastases to neck HPV testing p16 strongly positive HPV (high risk) in situ hybridization negative Reference lab HPV in situ negative HPV PCR negative HPV positive at outside facility

  7. Our patient’s tumor PIK3CA mutation: E545K Normal Control

  8. Diagnostic Timeline Diagnosis 3/2009 Neck Dissection 12/2009 Molecular Testing Lung mets 5/2010 Recurrence 11/2009 Brain mets 9/2010 Erbitux Chemo Rads Chemo/Rads 3/2009 11/2009 6/2010 9/2010 3/2011

  9. Personalized Healthcare Impersonal Healthcare

  10. Direct Patient Consultation: Model • Clinician sends patient to pathologist for consultation • Review the tumor morphologic features • Go over staging parameters • Review any molecular or ancillary testing • Answer questions • Discuss treatment options

  11. Direct Patient Consultation: Why? • Education and information for patients • Informed patients participate in medical decision making better • Health literacy correlates with outcome

  12. Direct Patient Consultation: Why? • Better patient satisfaction • Patients like access to their healthcare team • Advanced technology is a driver of satisfaction

  13. 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

  14. 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

  15. 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

  16. Willingness: CAPToday Article

  17. Willingness: CAPToday Article

  18. Logistics: Best Practices • Optimize information flow and communication • Consultation questions and discussion • Use good hand-off procedures and documentation • Letter or note in chart

  19. 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

  20. 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!”

  21. 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

  22. 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

  23. Where They Practiced

  24. How Often They See Patients

  25. Comfort Level Consulting with Patients

  26. Constructive Feedback from Patient

  27. Constructive Feedback from Patient

  28. Improvement in Specific Skills

  29. 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”

  30. 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

  31. Summary • Case Presentation • The Model: Direct Patient Consultations • Standardized Patient Simulation Training Program

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