Consultations in Pathology Practice Clinicians Patients Jennifer L

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 • • Background Direct Patient Consultations Training program Summary HARVARD MEDICAL SCHOOL 2

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 HARVARD MEDICAL SCHOOL 5

Tonsil Tumor HARVARD MEDICAL SCHOOL 6

Case Presentation • Tumor pathology • Predominantly non-keratinizing squamous cell carcinoma of tonsil with metastases to neck • HPV testing • • • p 16 strongly positive HPV (high risk) in situ hybridization negative Reference lab HPV in situ negative HPV PCR negative HPV positive at outside facility HARVARD MEDICAL SCHOOL 7

PIK 3 CA mutation: E 545 K 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 HARVARD MEDICAL SCHOOL 9

Personalized 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 HARVARD MEDICAL SCHOOL 12

Direct Patient Consultation: Why? • Education and information for patients • Informed patients participate in medical decision making better • Health literacy correlates with outcome HARVARD MEDICAL SCHOOL 13

Direct Patient Consultation: Why? • Better patient satisfaction • Patients like access to their healthcare team • Advanced technology is a driver of satisfaction HARVARD MEDICAL SCHOOL 14

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 HARVARD MEDICAL SCHOOL 15

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 HARVARD MEDICAL SCHOOL 16

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 HARVARD MEDICAL SCHOOL 17

Willingness: CAPToday Article HARVARD MEDICAL SCHOOL 18

Willingness: CAPToday Article HARVARD MEDICAL SCHOOL 19

Logistics: Best Practices • Optimize information flow and communication • Consultation questions and discussion • Use good hand-off procedures and documentation • Letter or note in chart HARVARD MEDICAL SCHOOL 20

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 HARVARD MEDICAL SCHOOL 21

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!” HARVARD MEDICAL SCHOOL 22

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 HARVARD MEDICAL SCHOOL 23

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 HARVARD MEDICAL SCHOOL 24

Where They Practiced HARVARD MEDICAL SCHOOL 25

How Often They See Patients HARVARD MEDICAL SCHOOL 26

Comfort Level Consulting with Patients HARVARD MEDICAL SCHOOL 27

Constructive Feedback from Patient HARVARD MEDICAL SCHOOL 28

Constructive Feedback from Patient HARVARD MEDICAL SCHOOL 29

Improvement in Specific Skills HARVARD MEDICAL SCHOOL 30

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” HARVARD MEDICAL SCHOOL 31

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 HARVARD MEDICAL SCHOOL 32

Summary • Case Presentation • The Model: Direct Patient Consultations • Standardized Patient Simulation Training Program HARVARD MEDICAL SCHOOL 33