New pathology patient consult program takes off

Lija Joseph, MD, chief of pathology and medical director of pathology and laboratory medicine at Lowell General Hospital in Lowell, Mass., says a colleague’s presentation about social media and medicine led her to launch the patient pathology consult program in March.

Lowell General Hospital radiation oncologist Matthew Katz, MD, suggested in his January presentation that attendees check out the CAP’s tweets (@Pathologists). Dr. Joseph did not have a Twitter account, but after signing up and scrolling through the CAP’s tweets, she came across a 2016 mention of Michael Misialek, MD, associate chair of pathology at Newton-Wellesley Hospital in Newton, Mass. The tweet contained a link to an article Dr. Misialek coauthored with a patient who had been diagnosed with non-small cell lung cancer in 2005.

The article, “A cancer patient and pathologist—brought together by Twitter—strike up an unlikely connection,” published Oct. 17, 2016 in “Stat” (produced by Boston Globe Media), described how after he and a patient connected on a Twitter chat about lung cancer he invited the patient to the laboratory to review lung cancer slides.

Inspired by the story of Dr. Misialek’s interaction with the patient, Dr. Joseph began researching the possibility of reviewing biopsy slides with patients at Lowell General Hospital. She reached out to Dr. Misialek for advice and consulted several Lowell General departments, including administration, risk management, and marketing, as well as the hospital’s cancer center and its pathology professional liability organization. Everyone was supportive and eager to jump-start the initiative, she says, in part because of the pathology department’s reputation.

“The CAP always tells us to be visible, so we participate in various conferences, give lab rounds, go to all the meetings,” says Dr. Joseph, who is also an adjunct associate professor, Boston University School of Medicine. “I think the main reason nobody raised an issue is because of the trust we have developed over a period of time.”

With the full backing of the hospital’s leadership, Dr. Joseph established the free consultation program quickly, scheduling her first patient on March 1. Despite the enthusiasm for the project, supporters kept their expectations low for the first year. “Honestly, when we launched this program we didn’t think anybody would be interested,” Dr. Joseph tells CAP TODAY. “We thought maybe a patient a year would show up.” By April, Dr. Joseph had already seen five patients, ages 30 to 83.

One patient showed up to the consultation with a three-ring binder containing tabbed pages of several reports, including her pathology report and CBC results. Another patient with a background in biology asked for a printed photo of the tumor to share with her family.

“These are the patients who are Googling their disease, trying to be on various forums talking about their disease,” Dr. Joseph says. “Most of them are not here to find fault or say, ‘Did you miss this? Did you miss that?’ They are truly here to see their disease.”

The 10 patients who had consulted Dr. Joseph as of mid-May had similar requests. All wanted to see what normal tissue looked like compared with abnormal tissue, for example.

“They do want to know what the purple and pink are” in the slide, Dr. Joseph says. “I try to explain that the purple is the nucleus and that’s the brain of the cell, and that’s the brain that talks to the cell to tell it what to do.”

Of the 10 patients, seven looked at their slides through the microscope and the other three opted to view them on the computer screen. Dr. Joseph plans to add a TV screen to the consultation area so patients can see a magnified image of their slides. “Looking through the microscope is a skill, and to get that monocular vision looking through two eyepieces can be challenging for patients,” she says.

Some patients met with her immediately after having received their diagnoses, while others had completed their treatments. Feedback from the 30-minute consultations has been positive, with each patient expressing gratitude.

“The 83-year-old woman said, ‘I have so much more understanding of what is going on in my body. I leave this room after this half hour with 70 percent more understanding of this disease than I ever had,’” Dr. Joseph says. A 69-year-old patient told Dr. Joseph she was “so excited” to look at her biopsy (“In the olden days, we could not do this,” the patient said). And a patient who met with Dr. Joseph in May said, “I had two different types of breast cancer and it was fascinating to see the differences. This was an awesome experience.”

“Often with a cancer diagnosis, there is not much they can control. So to truly see it helps them understand it,” Dr. Joseph says, and helps in tackling panic or anxiety.

Other Lowell General Hospital pathologists have expressed an interest in participating, but Dr. Joseph will be the only one to provide the consultations for the rest of this year. “Right now, as chief of the department, I am the most visible to the rest of the physician community,” she says, “and that level of trust, I have to build it with the other physicians who may want to participate. It’s a very calculated decision on my part that I am the only one doing it.”

Dr. Joseph credits the time she spent throughout her career teaching and explaining disease processes to students of all levels with preparing her to interpret biopsy slides for patients.

“You truly have to talk the layman’s language,” she says. “To try to explain ductal carcinoma in situ as something that is confined within a tube and how the basement membrane breaks and the tumor cell gains access to the adjacent tissue—you have to use language they understand.” Communicating with patients in plain language or at a grade-school level may not appeal to every pathologist, she adds.

Another consideration is the pathologist’s time. “You are spending a half hour with the patient, and there is no money involved. You could be signing out 15 biopsies in that 30 minutes,” Dr. Joseph says. For some, she adds, this could be frustrating.

Pathologists also need to be comfortable with conversation that goes beyond the slide review. Sometimes patients just want to talk to a physician besides their oncologist, though Dr. Joseph is firm about not discussing patients’ treatment plans. Patients may want to talk about, for example, their desire to ensure their children get screened for the same disease. Patience and compassion are crucial skills in these encounters, she says. “You can’t just say, ‘No, I don’t want to hear about that. I’m only here to discuss the biopsy.’”

Dr. Joseph advises colleagues who would like to develop a similar program in their own hospitals to think about the possible barriers: “Take at least six months before launching it and talk to all the chief stakeholders, because there are many layers involved in setting it up.”

For example, the risk management department advised Dr. Joseph to take great care to ensure that consultations are in compliance with HIPAA privacy rules. Patients must sign a medical records viewing consent form, and those who request to have a family member present must sign an additional consent form.

More advice: “Include the nursing teams,” Dr. Joseph says. She holds educational in-services for oncology and breast health nurse practitioners to give them an update on what she discusses with patients.

When the patient arrives at the pathology department, front office staff checks his or her driver’s license to verify the patient’s identity. The consultation with Dr. Joseph becomes part of the patient’s medical record, though there are no official notes of the discussion details. Patients are not allowed to record the discussion with video or audio or to bring a lawyer to the appointment. Dr. Joseph provides a notebook and pen for the patient.
She creates an addendum to the pathology report that says, “The pathology was discussed with the patient on” a specific date.

Staff uploads the addendum to the pathology report so the patient’s oncologist can see the addendum electronically and sends the signed consent forms to the medical records department to be uploaded to the patient’s electronic medical record.

The patient’s oncologist is welcome to attend or call in to the consultation, Dr. Joseph says, though none had done so as of mid-May. The staff tries to schedule appointments with Dr. Joseph immediately before or after another visit the patient has scheduled at the hospital.

A marketing campaign directed to patients and physicians has been successful in spreading the word about the program. Fliers contain instructions to call the pathology department to set up an appointment, which can be completed by the patient or by his or her oncologist or nurse practitioner. Links to a webpage describing the program appear on the hospital’s main website, the cancer center website, and the laboratory website. Dr. Joseph also promotes the program at medical committee meetings and plans to reach out to the hospital’s physician organization.

Internet-savvy patients may serve as secondary marketing channels, Dr. Joseph says, because they are apt to discuss the program in chat rooms and spread the word about the hospital’s willingness to let patients view their biopsy slides.

The program has significant potential to increase Lowell General Hospital’s visibility in a region with intense competition for patients, Dr. Joseph says. She had the hospital’s recently launched customer satisfaction initiative in mind when she developed her patient consult program. “It helps the patient realize that this hospital gives me the best care possible and the doctors here are truly doing everything they can to help me,” Dr. Joseph says. As one of the oncologists put it to her recently, “It definitely improves the patient experience.”

If the program grows, she says, it may find a permanent home in the hospital’s cancer center or another space more patient-friendly than the pathology laboratory.

The next thing she looks forward to seeing in her Twitter feed is a link from the CAP to this article because she hopes it will inspire other pathologists to establish their own patient consult programs. She acknowledges the motivation she received from the CAP’s “Visible Pathologist” program, which she attended at an annual meeting and provided the confidence she needed to pursue direct interaction with patients.

“We are no less a doctor than anybody else,” she says. “We can definitely communicate and sympathize with the patient who may be struggling with a difficult diagnosis. I think it is a service the patient deserves.”n

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Amy Carpenter Aquino is CAP TODAY senior editor.