December 2011
Feature Story

Karen Titus

Craig Horbinski, MD, PhD, was astonished when he looked out over the sea of faces in the hotel ballroom. He was at the front of the room, seated on a dais with a handful of other physicians, all of whom were participating in a mock tumor board at the annual meeting of the American Brain Tumor Association, held in Chicago this summer. Dr. Horbinski, the lone neuropathologist on the board, was joined by a neurosurgeon, three neuro-oncologists, and one radiation oncologist.

The idea was to have the group discuss cases they’d selected in advance in front of a live audience of patients and family members, to unwrap the mysterious process of how physicians arrive at diagnoses and treatment protocols.

“When I got the invitation, I thought, ‘Sure, I’d love to do it—but I just don’t know,’” says Dr. Horbinski, assistant professor, Neuropathology Division, Department of Pathology, University of Kentucky Medical Center, Lexington.

The pathologist-patient encounter is fraught, to say the least. The familiar list of concerns can be recited like a rosary: Pathologists don’t normally see patients directly. They don’t want to talk down to patients, nor do they want to overwhelm them with complex verbiage. They don’t want to step on clinicians’ toes with their advice. They don’t want to add more tasks to their already busy days. They may not want to give free advice.

Fortunately, the mock tumor board was not so care-laden; instead, Dr. Horbinski found the atmosphere electrifying.

There were hundreds of people in the room, for starters. And they were there to deal. “I was surprised with how engaged they were, how knowledgeable they were,” Dr. Horbinski says.

The audience had plenty of questions, which they submitted to the moderator, who then decided who on the board could best address them. “I figure, I’m not going to get any questions,” Dr. Horbinski recalls. Who wants to talk to a pathologist? “Well, I got the most questions. I couldn’t believe it when they handed me the stack of questions—‘This is all for me?’” he says, laughing.

The final surprise came when the tumor board adjourned—and people began lining up to ask Dr. Horbinski more questions. “I was completely floored,” he says.

“I had a wonderful time,” Dr. Hor-binski says. “I’d do it again in a heartbeat.”

Is he now ready to start meeting with his own patients at the University of Kentucky?

Nope.

Tales of transformation aren’t necessarily tales of immediate triumph or turnaround. There’s never a guarantee that transformation will occur, or that it even needs to.

Dr. Horbinski has been thinking about these issues since the mock tumor board met. For now, hesitation outpaces change.

He’s not alone in his doubts. In a Nov. 1 essay in the New York Times, Lisa Rosenbaum, MD, lamented the latest fad in medical training: emphasizing empathy over competence. Will warm, caring doctors really deliver better, more cost-effective care, asked Dr. Rosenbaum, a cardiology fellow at New York-Presbyterian/Weill Cornell and an editorial fellow at the New England Journal of Medicine. “How do we even measure these skills?” she wrote.

Going into the mock tumor board, Dr. Horbinski says he wondered how he’d talk to audience members in the hotel ballroom—assuming they’d even want to listen to what a pathologist would have to say. What tone should he take? “I was trying to hit the right balance, but every time I said something, the moderator would say to the audience, ‘OK, to translate for the rest of you,’” Dr. Horbinski says.

“And I’m thinking, ‘Oh God, I screwed up again.’”

Dr. Horbinski found a clue in the caliber of questions he was getting. It was high. These audience members were informed, highly active in their own care—and motivated enough to attend the ABTA meeting. “We’re not talking about just any patient,” he says. They came armed with data. “All the databases I use, they certainly have access to all that, too.” As a result, they asked detailed questions about biomarkers, tumor features, and the like.

“I don’t think they necessarily get all that detail from their clinicians,” Dr. Horbinski says. Physicians don’t have a boundless supply of time to meet with patients or to answer every last question. And—“I don’t know how to say this delicately,” he says—sometimes the clinicians simply don’t know the answers.

Could this be a call for change? Do pathologists need to spend more time educating their clinical colleagues?

Dr. Horbinski demurs. The in-house institutional tumor board at the UK Medical Center is first-rate, he says. Weekly presentations from the various subspecialties keep one and all abreast of new developments—up to a point. Beyond that, it simply isn’t reasonable to expect physicians to track advances, no matter how critical, outside their own specialties.

“It wouldn’t be fair if a patient were to ask me, ‘What’s the best chemotherapy for such-and-such a tumor?’” Dr. Horbinski reasons. “I just wouldn’t know. The field has grown so much now, there’s no way, even in the subspecialized world of brain tumors, that one person will know everything about radiation oncology, about the diagnosis, about the treatment, about the surgical approach to every tumor. It can’t be done. Surgeons and neuro-oncologists already know a lot. They can’t be expected to know all the little, nitty-gritty details of certain biomarkers, especially the ones that don’t pass muster.”

So when an attendee at the mock tumor board asked about the value of CD133 as prognostic biomarker, it made sense for Dr. Horbinski, and not another specialist, to say it’s lousy. “Nobody else on stage could reasonably be expected to do that,” he says.

If anything, Dr. Horbinski would like pathologists to focus on their own limitations. He notices a tendency for pathologists—“And this is me speaking as a junior pathologist”—to feel they need to be right every time, to know the diagnosis independent of any clinical input. To do otherwise, he says, “would display a level of vulnerability that a lot of pathologists don’t want to show.”

At UK Medical Center, he’s become more comfortable with tough cases, and he asks clinicians how they’ll treat a tumor based on whether he makes one diagnosis versus another. It didn’t come easy. “I didn’t want them to think I was an idiot,” he says. But now he realizes omniscience is a myth, possibly even a dangerous one. “Let’s just admit that and move forward.”

Doing this requires pathologists to discuss, not dictate. “We do need exceptional interpersonal skills to be able to establish that kind of comfort with clinicians. We can’t afford to be a black box to them.”

The ABTA mock tumor board raises another specter: Should pathologists also use those skills to talk to patients directly? Dr. Horbinski greets this suggestion by clearing his throat, then pausing, exhaling a deep breath, and taking another long pause.

He chooses his words carefully, noting that his primary service is as a consultant to clinicians. His job, he says, is to give them the best information he can so they can treat patients. If he started engaging with patients regularly, the gestalt could unravel into “a mess,” he says. What would happen if a patient hears one thing from Dr. Horbinski, and something different from, say, the surgeon? “I don’t think it’s right for pathologists to get involved in that. It would muddy the waters and make the clinician’s job more difficult.”

Dr. Horbinski isn’t even sure that patients would want to talk to him, despite his exhilarating encounters at the mock tumor board. In his own practice, no patient has ever contacted him directly.

Nor have clinicians offered to put patients in touch with him to answer questions about their tumors. They might not even want pathologists to be part of the patient conversation. “Which is fine,” he says. “We’re pathologists. We’re sitting here in our offices with a microscope. We don’t know the kind of conversations the clinicians have already had with their patients. For us to step in midstream could get extremely complicated.”

Pathologists might not champ at the bit, either. There’s no reimbursement for the advice. And they don’t want their phones ringing off the hook, he says, with patients calling to ask questions that may have nothing to do with their tumors. “Is a patient going to ask, ‘Should I take aspirin or not?’”

If he were to suggest pathology consults to his colleagues, he says, the responses would range from warmhearted to violent. “Some would say, ‘Great idea! Here’s my number.’ And others would say, ‘If you hand my number out, I’ll kill you.’”

He gets their diffidence. “The model we have now doesn’t work that badly,” he says. “Why rock the boat?” That doesn’t mean improvements can’t be made. “But there should be reluctance to make changes that could just as easily make things worse, as opposed to better.”

He’s also wary of returning from something like the ABTA meeting and telling his colleagues that he’s got religion. If he were to suggest to them they should start talking to patients directly, he predicts, many would nod their heads, say they’ve heard it all before—and exactly nothing would happen. “To do this, you’d have to push against decades of inertia,” he says.

And not all patients are seeking more information. The ABTA audience was uncommon. “We can’t walk around the hospital floors bombarding patients with information they don’t want,” Dr. Horbinski says. “Some patients say, ‘You’re the doctor—you decide.’ And there’s nothing wrong with that.”

In short, there are plenty of reasons to keep pathologists where they’ve been for many years: in the lab, behind a microscope, at tumor board meetings—anyplace that’s far, far away from patients. Yet a nagging feeling persists: Is that all there is? Months after appearing on the mock tumor board, Dr. Horbinski continues to marvel over the absorbing fact that there are patients who want to talk to pathologists.

Why was he so popular at the ABTA event? “I’m the one person patients never see. They even see the radiologist,” he says, sounding a little amazed. “We’re the black box to them. Either they think of us as what they saw on TV shows years ago, where the pathologists were like walking cadavers, or that we’re like the supergeniuses from ‘CSI’ who can tell you what you had for breakfast by looking at your footprint.”

Obviously neither view is accurate. But the most widely held view isn’t necessarily any better. “Most patients don’t even know I exist,” Dr. Horbinski says.

Maybe the pathologist-patient encounter is meant to be an occasional event, like getting married or skydiving, and not an activity to be indulged in with any regularity. But the idea of something more—whatever it is—remains beguiling.