Patient, meet your Pathologist. Pathologist, meet your Patient

This morning I read perhaps one of the driest and most painfully boring articles of 2014 at CAP Today, the online publication of the College of American Pathologists.

But wait! That critique pertains to the writing only. The content was amazing.

The article, entitled Introducing Patients to Their Pathology Reports, made the ground shift under my feet. I have never read anything like it before. In it, a Rochester pathologist discusses a pilot project she carried out in which she, as a pathologist, explained cancer pathology reports directly to patients.

The pathologist, Dr. Julietta Fiscella of Highland Hospital, writes, that "despite calls dating back more than 30 years for direct communication between surgical pathologists and patients, little is known of such communications."

This is an area of the newly diagnosed cancer patient's experience that is widely misunderstood. When a patient undergoes a biopsy and the results come back as a cancer diagnosis, the information is given to them by their primary care doctor, or an oncologist ... but the actual diagnosis has not been made by that doctor in front of them. The diagnosis was made in a lab by a pathologist who the patient will likely never meet.

The Faulty System in Place

This system has issues. For example:

-- Non-pathologists are not necessarily very good at explaining pathology reports, or at answering specific questions about pathology, yet in this setting they do it all the time, with varying results (patient confusion probably the most common outcome).

-- The incorrect assumption that the doctor relaying pathology results is the same doctor who made the diagnosis very likely prevents many patients from seeking a second opinion. In lymphoma it is impossible to overstate the importance of second opinions, yet patients often don't want to appear to be challenging the authority or experience of the doctor in front of them by requesting a second opinion. If they knew that this doctor had virtually no active role in reaching the diagnosis, they may be more inclined to seek a second opinion.

-- With as many as 50,000 misdiagnosed cancers made annually in the United States, perhaps a pathologist might double or triple check their work before sending it along if they knew they would be communicating directly with the patient about those results. In the past, patients have undergone full chemotherapy regimens and double mastectomies based on misdiagnoses made by pathologists. Anything done to prevent mistakes in medicine is worth doing.

Changing Pathology

Pathology is experiencing some big changes right now. In breast cancer for instance, a company called Delphinus has introduced a diagnostic breast imaging device that could one day replace the discomfort and health problems resulting from mammograms.

In skin cancer, Caliber ID's VivaScope optical biopsy can allow a patient and pathologist to view and discuss the patient's skin condition in real time, right there in the exam room.

University of Michigan researchers are at work on using a microchip to perform a liquid biopsy that would collect circulating cancer cells from the blood for use in pathology.

I would imagine that some pathologists are immediately uncomfortable with the idea of having to tell someone, to their face, that they have a malignant cancer. As Dr. Fiscella notes, pathologists lack empathy training. But is any doctor comfortable with this?

Delivering bad news sucks but getting bad news is worse. The effect is compounded if the messenger can't offer accurate and understandable answers to pressing questions the patient is bound to have.

When I think about all the confusion surrounding a patient in the wake of a cancer diagnosis, Dr. Fiscella's pilot project strikes me as an idea both long overdue and one whose time has come.

.....

Links:
-- Dr. Fiscella's Introducing Patients to Their Pathology Reports.
-- Caliber ID's VivaScope optical biopsy
-- Delphinus' diagnostic breast imaging device.