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Explore the importance of direct patient consultations in pathology practice with insights from Dr. Jennifer L. Hunt, highlighting personalized medicine and the benefits of pathologists actively engaging in patient management.
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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
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
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
Our patient’s tumor PIK3CA mutation: E545K Normal Control
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
Personalized Healthcare Impersonal Healthcare
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
Direct Patient Consultation: Why? • Education and information for patients • Informed patients participate in medical decision making better • Health literacy correlates with outcome
Direct Patient Consultation: Why? • Better patient satisfaction • Patients like access to their healthcare team • Advanced technology is a driver of satisfaction
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
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
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
Logistics: Best Practices • Optimize information flow and communication • Consultation questions and discussion • Use good hand-off procedures and documentation • Letter or note in chart
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
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!”
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
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
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”
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
Summary • Case Presentation • The Model: Direct Patient Consultations • Standardized Patient Simulation Training Program