Foundation.cap.org v. # 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

HARVARD MEDICAL SCHOOL 2 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

HARVARD MEDICAL 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

HARVARD MEDICAL SCHOOL 6 Tonsil Tumor

HARVARD MEDICAL 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 tumor Normal Control PIK3CA mutation: E545K

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

Personalized Healthcare Impersonal Healthcare

HARVARD MEDICAL 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

HARVARD MEDICAL SCHOOL 13 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 14 Direct Patient Consultation: Why? Better patient satisfaction Patients like access to their healthcare team Advanced technology is a driver of satisfaction

HARVARD MEDICAL 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

HARVARD MEDICAL 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, MD Mass General Hospital

HARVARD MEDICAL 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

HARVARD MEDICAL SCHOOL 18 Willingness: CAPToday Article

HARVARD MEDICAL SCHOOL 19 Willingness: CAPToday Article

HARVARD MEDICAL 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

HARVARD MEDICAL 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

HARVARD MEDICAL 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!”

HARVARD MEDICAL 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

HARVARD MEDICAL 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

HARVARD MEDICAL SCHOOL 25 Where They Practiced

HARVARD MEDICAL SCHOOL 26 How Often They See Patients

HARVARD MEDICAL SCHOOL 27 Comfort Level Consulting with Patients

HARVARD MEDICAL SCHOOL 28 Constructive Feedback from Patient

HARVARD MEDICAL SCHOOL 29 Constructive Feedback from Patient

HARVARD MEDICAL SCHOOL 30 Improvement in Specific Skills

HARVARD MEDICAL 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”

HARVARD MEDICAL 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

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