Common questions, uncommon answers

June 2007
Feature Story

Emily Stone

The course offerings at the CAP ’07 meeting this fall are heavy on practical lessons in clinical and anatomic pathology, as well as sessions that address pathologists’ needs as laboratory directors.

Forty of the more than 100 courses being offered at the Sept. 30–Oct. 3 Chicago meeting are new this year, says William F. Hickey, MD, chair of the CAP Education Committee and a professor of pathology and senior associate dean at Dartmouth Medical School, Hanover, NH. All of the courses focus on providing practical information that pathologists can start using right away.

For example, a new, full-day course will address incipient lesions and tumors. “How can you tell when something is just tipping over to becoming a cancer,” Dr. Hickey says. The course grew out of an Education Committee brainstorming session about what topics needed to be covered in areas where committee members knew they could bring in top-notch instructors.

“We’re trying to increase the breadth and depth in anatomic pathology offerings without shortchanging offerings in clinical pathology,” Dr. Hickey says.

In all instances, being able to recruit the best possible faculty was key, he adds. The committee made sure returning instructors had been rated extremely highly by participants in past courses. For new courses, Dr. Hickey says, they sought out those who had spoken well on their topics in other venues.

“The faculty is tremendous,” he says.

The committee also realized pathologists needed courses on how to be effective leaders and managers. “What’s been coming more and more into focus is the role of the pathologist as lab director,” Dr. Hickey says.

One such program, which Dr. Hickey took last year and praises highly, is a Practice Management Institute titled “Principled Negotiation—Reaching Agreement While Building Relationships.” The institute is taught by James S. Hernandez, MD, chair of the Division of Clinical Core Laboratory Services at the Mayo Clinic, Rochester, Minn., and Louellen Essex, PhD, a fellow of the University of Minnesota, Carlson School of Management’s Executive Development Center, Minneapolis. The goal is to make negotiations fair for both parties, so it’s not a win-lose outcome, but a win-win.

“Everybody who was there last year thought it was great,” Dr. Hickey says.

Six Practice Management Institutes will be offered in total, on finance, legal issues, patient safety, adding value, and the pathologists’ many roles.

Dr. Hernandez, who is also leading a roundtable discussion on practical negotiation tips for pathologists, will make his Practice Management Institute interactive, with a lot of role-playing and group discussion.

The concept of principled negotiation means both sides focus on the merits of their respective needs, not on the people themselves. Dr. Hernandez will start by explaining the four essential principles of negotiation: separating the person from the problem; focusing on the interests of both people, not their initial requests; generating a variety of options for an outcome; and using an objective standard to review those options. In the process, the two sides are more likely to maintain a positive relationship, since they are likely to need to work together in the future. “The last thing we want to do is sour the relationship,” Dr. Hernandez says.

The ante is upped as physicians advance through their careers and become medical directors or chairs of academic departments, because then they are negotiating on behalf of a group of people. “That puts pressure on the pathologist,” he says. People in that position want to know, “How do I get the reputation of being a good, sound, ethical, strong negotiator?”

The idea is not to teach tricks but to recognize when others are using tricks and then deflect them, a skill Dr. Hernandez calls “verbal jujitsu.” For example, the people you’re negotiating with may purposely make you uncomfortable by seating you in a shorter chair, employing a “good cop/bad cop” routine, or insulting you by making disparaging remarks about your choice of tie.

“You call them on that behavior and say, ‘I’ve noticed that you’ve made remarks about my tie. I’m sure we both want to negotiate a good agreement. Why don’t we talk about the substance of our negotiation,’” he says.

While pathologists often sign up for the class right before negotiating something significant, like a Medicare Part A contract, Dr. Hernandez points out that pathologists are involved in negotiations every day.

One situation Dr. Hernandez uses in the class is of two authors deciding who should get the first author spot for a paper.

“Everybody wants to be first author,” he says. But in a principled negotiation, the two sides would explore why it’s important to each of them. One person may want to be known as an expert in the field, while the other wants to advance through the academic ranks at his or her institution. The solution may be to let one person present the paper at a conference while the other is listed as first author. “We’ll figure out novel ways for us to both be winners that preserve the relationship,” Dr. Hernandez says.

The lessons are not limited to pathologists’ professional lives, Dr. Hernandez adds. “It’s a practical course,” he says, and the tips can be used equally effectively with teenage children and in-laws. “That’s what makes it so fun.”

Another practical session with appeal to laboratory directors will cover critical values. John R. Harbour, MD, medical director at Bon Secours Health Partners Regional Laboratory, Richmond, Va., will lead a new roundtable discussion on the process of developing reasonable and useful critical values.

“You need to have a thoughtful process that allows you to assess your own values appropriately,” Dr. Harbour says. “Are they being used in a way they should be used, and are they being reviewed on a regular basis?”

The way to start a review is to discuss current critical values with laboratory staff to see what’s working and what’s not. That group should then share its ideas with quality improvement representatives from relevant departments. “You ask, ‘In your practice, do these criteria make sense to you?’” Dr. Harbour says. Depending on the response and the practicality of proposed new or modified criteria, the group adjusts its recommendations accordingly.

The next step is to talk to the nursing and medical staff, with medical staff departmental representatives making sure various specialists feel the values have merit. The final stop is with the medical executive committee.

Along the way, it’s important to ensure the interests of physicians and patients are being balanced with the constraints of the laboratory, Dr. Harbour says. Often, clinicians will tell Dr. Harbour they’d like a critical value changed by even just a small percent. But that could create exponentially more phone calls for laboratory staff. “We prefer not having to deal with unintended consequences of a change,” he says.

Dr. Harbour tells the clinician he’ll take the question under advisement. Then he talks with his laboratory management team.

“I ask them to tell me what it would take for us to do that. Is it simple or complex?” he says. “At the same time, I’m looking at the request medically and saying, ‘This is ludicrous’ or, ‘I wish I would have thought of this. This is really important for the patients.’”

And based on these discussions, he’ll decide whether to alter the critical value.

While his roundtable will address this process, Dr. Harbour also plans to touch on what criteria should be used for critical values in anatomic pathology, as well as on how technology can help laboratories with their critical values notifications.

“There are ways to use technology to communicate this information,” he says, such as computer systems that require laboratory staff to log each call before moving on to the next one. His chief concern with automated notification systems, he says, is making sure the doctor actually receives the information. The laboratory could send the information to a pager if that’s what the doctor wants. But, Dr. Harbour asks, what if the doctor forgot the pager at home that day?

“You need to have confirmation of the physician receiving the information and, if not, a process to escalate notification to ensure timely communication,” he says.

Also new at the meeting this year is the option to enroll in a HER2 testing self-assessment module. Participants who correctly answer 80 percent of the test items will receive one CME/SAM credit. Those taking the test are encouraged, though not required, to attend a course on HER2 testing.

New meeting participants are invited to attend a first-time attendee orientation and lunch to learn how to make the most of the meeting.

In their downtime, all participants are encouraged to visit the more than 50 exhibit booths. Some of the exhibitors are also sponsoring breakfast workshops covering topics like digital pathology technology and monitoring your practice’s financial health.

Emily Stone is a writer in Chicago. To register for the CAP ’07 meeting, call 800-323-4040 option 1#, send a fax to 800-289-1815, or go online at www.cap2007.org.