A Mixed-Methods Study of Clinicians' Attitudes Toward Pathology Explanation Clinics

Sarah E. Bergholtz, MPH; Sophia R. Kurnot, BS; Melissa DeJonckheere, PhD; Sarah T. Hawley, PhD, MPH; Scott R. Owens, MD; Cathryn J. Lapedis, MD, MPH

Disclosures

Am J Clin Pathol. 2023;159(5):437-447.

Abstract and Introduction

Abstract

Objectives: To characterize the attitudes of treating clinicians toward pathology explanation clinics (PECs).

Methods: Clinicians from a tertiary care academic medical center were asked, "How interested would you be in having your patient meet with a pathologist to discuss their pathology report and see their tissue under the microscope?" Clinicians ranked their interest, then expanded on concerns and benefits in a semistructured interview. Audio recordings of interviews were transcribed and analyzed using a qualitative thematic approach.

Results: A total of 35 clinicians were interviewed, with 83% reporting some level of interest in PECs. Clinicians felt that highly educated and motivated patients were most likely to benefit from a PEC. Clinicians recognized that PECs could improve understanding and emotional processing but that the patient's information needs must be balanced with the potential for cognitive overload and emotional distress. When integrating the pathologist into the care team, clinicians worried about the pathologist's communication skills, care fragmentation, and increased clinician workload. If performed well, clinicians felt PECs had the potential to increase clinician efficacy and improve quality of care.

Conclusions: Overall, clinicians are interested in PECs when they fulfill a patient's information needs and are optimally performed.

Introduction

The receipt of a pathology report without additional explanation can lead to confusion and exacerbate patient anxieties.^[1] Recent legislation, including the 21st Century Cures Act, has increased patient access to pathology reports delivered directly via patient portals.^[2] Novel methods for helping patients interpret these reports are emerging. A pathology explanation clinic (PEC) is an interactive visit whereby the patient and pathologist meet to discuss the pathology report and review the patient slides.^[3] In the literature, PECs are also referred to as a patient-pathologist consultation or a patient-centered pathology visit.

Practices within the United States as well as abroad are beginning to incorporate PECs into routine care.^[4–6] Early research shows that patients are highly satisfied with the interaction and find it useful.^[4–6] In addition to positive patient experiences, one study found significant quality improvement in the form of revised pathology reports, referrals for a second opinion, and even changes in treatment plans following the PEC.^[6] Early longitudinal studies in men with low-stage prostate cancer also show both patient-level and systemic-level impacts of PECs. On an individual level, men with low-stage prostate cancer reported a high level of satisfaction with the PEC as well as improved understanding of diagnosis and confidence in making a high-quality medical decision.^[7] On a systemic level, PECs positively affected the treating clinician experience and resulted in overall improvement in quality of care.^[7]

PECs are an interaction embedded within a core of key stakeholders including the patient, the pathologist, and the treating clinician Figure 1. To effectively study the value of PECs, it is essential to begin with a study of the attitudes of these key stakeholders. Early work in patient attitudes toward PECs shows that 85% of patients with cancer are either definitely interested or interested in meeting with their pathologist.^[8] Patients perceive that attending a PEC has the potential to improve disease understanding, demystify the process of diagnosis, and lead to patient empowerment. Early work in pathologists' attitudes toward PECs shows that 86% of pathologists are either definitely interested or interested in meeting with their patients to review slides and discuss diagnosis.^[8] Pathologists note potential the impact to patients, individual pathologists, and the field of pathology as a whole.^[9]

(Enlarge Image)

Figure 1.

Communication of pathologic diagnoses between key stakeholders. A, Current state: the pathologist communicates the diagnosis through a pathology report, which is sent through the electronic medical record to the treating clinician. Patients may access the report through the patient portal. There is no established route for the patient to contact the pathologist. All communication about the diagnosis is communicated through the treating clinician or through the patient's written pathology report. B, Communication functions of the pathology explanation clinic (PEC): the PEC would provide an established route for communication between patients and pathologists. It would also add to communication between pathologists and the treating clinician through the addition of a PEC note in the electronic medical record and a phone call as indicated for additional communication around pathology diagnoses. All communications between key stakeholders are embedded within the health care system and thus relate to quality and patient safety. Weight of arrow indicates strength of communication. Dashed lines indicate when communication may occur but does not always occur.

While the attitudes of patients and pathologists toward PECs have been preliminarily characterized, the attitudes of treating clinicians (ie, oncologists, surgeons, internists, obstetrician/gynecologists, etc) toward PECs have not yet been described. Treating clinicians are key stakeholders in the implementation and study of PECs, and thus understanding their attitudes is essential in designing a PEC that maximizes value for patients and treating clinicians.

To address this gap, we conducted a study using quantitative and qualitative methods to broadly understand treating clinicians' attitudes toward the utilization of PECs in health care delivery under optimal conditions. Optimal conditions for PECs included following best practice standards that (1) the patient had been told their diagnosis by the treating clinician, (2) the pathologist only discussed diagnosis and referred the patient back to treating clinician for questions about prognosis and treatment, and (3) the pathologist sent a follow-up note to the clinical team after the PEC.^[4,5,10] We quantitatively described clinicians' level of interest in PECs and assessed if this level of interest was related to any provider characteristics (ie, age, specialty, rank etc). Using a qualitative thematic approach, we described clinicians' attitudes toward PECs, concentrating on potential benefits and concerns for patients, treating clinicians, and the overall quality of care in the health system.

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Table 1. Characteristics of Respondents (n = 35) ^a
Characteristic	Value
Median age, y	39
Sex, female, %	54
Rank, %
Resident/fellow	23
Junior attending	26
Midcareer attending	23
Senior attending	29
Specialty, %
Pediatrics/gastroenterology	3
Pediatrics/internal medicine	3
Emergency medicine and hospice and palliative care	3
Orthopedic surgery	3
Surgical oncology	6
Pulmonary and critical care	6
Dermatology	11
Gastroenterology	14
Plastic surgery	14
Hematology/oncology	37

^aMost respondents were from hematology/oncology and surgical specialties.

Table 2. Potential Impact of PECs on Patients as Described by Treating Clinicians
Theme	Representative Quotes
Clinicians believe highly educated or motivated patients are most likely to benefit from PECs.	"And so I think patients in that camp who are highly educated and motivated would definitely benefit from sitting down directly with the pathologist."
	"I do think there is a subset of patients who are very analytical and if given the opportunity to have more information because they read about different types, then they might [be interested in PEC]."
	"So it's [PEC] beneficial for … the types of patients who read a ton about their thing and … definitely do like to understand every word on their pathology report."
Patient's pathology-specific information needs must be balanced with the potential for cognitive overload and emotional distress.	"I would say that an abundance of information is generally good for patients… . Having a solid fund of knowledge … is one of the great enhancements to autonomy as one of the principles of medical ethics for the liberty interest of the patient. So, as the patient is ultimately moving towards issues of informed consent that they are armed with as much information as possible to incorporate into their own stable value system in terms of making a choice."
	"The majority of our explanation of pathology results is verbally … there are some patients who, for whom I just think a picture would be worth 1000 words."
	"But there's some … possible reservations which may include information overload to the patient, which we as physicians are notorious to do … and oftentimes, the more information we give them when it comes to those minute details, … it might cloud the big picture occasionally."
	"I think … more of an in-depth understanding of exactly what the bone marrow showed would … help make some of the patients who are interested [in PECs] feel more empowered and more … clear and certain about the diagnosis and the pathophysiology about what's going on with them."
	"The reason I answered interested and not definitely interested is just because every once in a while, we do see patients who are just completely overwhelmed with information."

PEC, pathology explanation clinic.

Table 3. Potential Impact of PECs on the Care Team as Described by Treating Clinicians
Theme	Representative Quotes
Although clinicians value pathologists' expertise, they are concerned that pathologists will not be able to effectively communicate with patients.	"I feel as though those discussions [conveying results, discussing treatment and prognosis] are best left to the oncologist and I certainly respect and value my pathology colleagues' contributions, but I think it's really in the, in the course of making the diagnosis … I don't think it's necessary for them to be the messenger of the results."
	"Many pathologists don't like patient interaction—that's why they went into pathology. And so the bedside manner is another sort of issue for some people."
	"I feel like we already have … 'shades of gray' conversations with patients about pathology and imaging and the clinical scenario … [and the pathologist may be] another cook in the kitchen interpreting that."
	"They [pathologists] oftentimes know in general what the treatment will be, um but I think it will be very hard for them to not make not make recommendations on treatment and just discuss the pathology."
Clinicians worry about the logistics of adding a PEC visit into an already complex system of medical care.	"I think logistically just the challenge of setting up those types of appointments, it's hard enough to book appointments just to see providers at our clinic, and the clinic workflow is inefficient … and so I think if you were to throw something like this in the mix, people would get behind and you'd end up having less time with your patient."
	"And I have a feeling that if we open that Pandora's box [PECs], it would, to be selfish, probably give me a lot more work because people would, that would kind of, patients are already asking lots of questions, which is wonderful, but it would kind of open the door to many more questions that are not necessarily going to positively influence their care."
If PECs are performed well, clinicians believe there is potential for improved efficiency and quality of care.	"Yeah, so I think it would um decrease the amount of time repeating and educating surrounding the pathologic diagnosis, which I would say is probably, you know, between 5 and 10 minutes for each new patient visit and would allow me to more rapidly get to talking about management strategies."
	"I think [explaining] what all those words mean [from the pathology report], and more of an in-depth understanding of exactly what the bone marrow showed [from a PEC] would be really … helpful for both the patient and the clinician to move along clinic discussions."
	"The pathology guides the treatment, so it does seem like it would be helpful to have a pathologist available… . As we talk about like multidisciplinary care, you know, that's a big thing in academic settings is like having members of different teams all coming together and pathologists are a huge part of that. So, I do think from like a patient side of things, that does like promote optimal care to have all of the different specialties weigh in."