View
213
Download
0
Category
Preview:
Citation preview
Foundation.cap.org v. #
Consultations in Pathology Practice: Clinicians & Patients
Jennifer L. Hunt, MD, MEdAssociate Chief of Pathology Massachusetts General HospitalAssociate Professor of PathologyHarvard Medical School
HARVARDMEDICAL SCHOOL
2
Agenda
• Background• Direct Patient Consultations• Training program• Summary
PersonalizedMedicine
The task of science is to stake out the limits of the knowable, and to center consciousness within them
-Rudolph Virchow
The task of science is to stake out the limits of the knowable, and to center consciousness within them
-Rudolph Virchow
HARVARDMEDICAL SCHOOL
5
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
HARVARDMEDICAL SCHOOL
6
Tonsil Tumor
HARVARDMEDICAL SCHOOL
7
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 tumorNormal Control
PIK3CA mutation: E545KPIK3CA mutation: E545K
HARVARDMEDICAL SCHOOL
9
Brain mets9/2010
Neck Dissection 12/2009
Recurrence11/2009
Diagnosis 3/2009
Diagnostic Timeline
Chemo/Rads
3/2009 11/2009 6/2010 9/2010 3/2011E
rbitu
xC
hem
oR
ads
MolecularTesting
Lung mets5/2010
PersonalizedHealthcareImpersonalHealthcare
HARVARDMEDICAL SCHOOL
12
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
HARVARDMEDICAL SCHOOL
13
Direct Patient Consultation: Why?
• Education and information for patients• Informed patients participate in medical
decision making better
• Health literacy correlates with outcome
HARVARDMEDICAL SCHOOL
14
Direct Patient Consultation: Why?
• Better patient satisfaction• Patients like access to their healthcare team
• Advanced technology is a driver of satisfaction
HARVARDMEDICAL SCHOOL
15
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
HARVARDMEDICAL SCHOOL
16
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, MDMass General Hospital
HARVARDMEDICAL SCHOOL
17
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
HARVARDMEDICAL SCHOOL
18
Willingness: CAPToday Article
HARVARDMEDICAL SCHOOL
19
Willingness: CAPToday Article
HARVARDMEDICAL SCHOOL
20
Logistics: Best Practices
• Optimize information flow and communication• Consultation questions and discussion
• Use good hand-off procedures and documentation• Letter or note in chart
HARVARDMEDICAL SCHOOL
21
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
HARVARDMEDICAL SCHOOL
22
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!”
HARVARDMEDICAL SCHOOL
23
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
HARVARDMEDICAL SCHOOL
24
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
HARVARDMEDICAL SCHOOL
25
Where They Practiced
0
2
4
6
8
10
12
Academic CommunityHosp
PrivateGroup
Commerciallab
HARVARDMEDICAL SCHOOL
26
How Often They See Patients
0
2
4
6
8
10
12
14
16
Never Once a year Once a month Once a week
HARVARDMEDICAL SCHOOL
27
Comfort Level Consulting with Patients
0
1
2
3
4
5
Average pre Average post
HARVARDMEDICAL SCHOOL
28
Constructive Feedback from Patient
0
5
10
15
20
25
Excellent Good Fair OK Poor
HARVARDMEDICAL SCHOOL
29
Constructive Feedback from Patient
0
5
10
15
20
25
Excellent Good Fair OK Poor
HARVARDMEDICAL SCHOOL
30
Improvement in Specific Skills
0 1 2 3 4 5
Treatment info
Relate as aclinician
Explain report
Post
Pre
HARVARDMEDICAL SCHOOL
31
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”
HARVARDMEDICAL SCHOOL
32
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
HARVARDMEDICAL SCHOOL
33
Summary
• Case Presentation• The Model: Direct Patient Consultations• Standardized Patient Simulation Training
Program
Recommended