A Qualitative Study of Pathologists' Attitudes Toward Patient-Pathologist Interactions

Cathryn J. Lapedis, MD, MPH; Lauren Kroll-Wheeler, MD; Melissa DeJonckheere, PhD; Dustin Johnston; Scott R. Owens, MD

Disclosures

Am J Clin Pathol. 2021;156(6):969-979. 

In This Article

Results

Five tweets from our university's Twitter page led to 137 retweets and 173 likes. Several key influencers retweeted the tweet, leading to a potential reach of approximately 74,700 followers. In total, 197 pathologists responded to the survey between March 15 and April 20, 2019. All IP addresses and locations were unique. The respondents were evenly divided between men (97 of 197 [49.2%]) and women (99 of 197 [50.3%]), with a single response (1 of 197 [0.5%]) of "other." The mean age (SD) was 39.4 (9.20) years, with a minimum age of 21 years and a maximum age of 66 years. More respondents were from academic practices (130 of 197 [66%]) than from community practices (53 of 197 [26.9%]) or other forms of practice (14 of 197 [7.1%]), which included US Department of Veterans Affairs (VA) and military hospitals, commercial labs, and international public hospitals. Participants were fairly evenly distributed by rank, with 59 of 197 (29.9%) of responses coming from trainees, 55 of 197 (27.9%) coming from junior attendings (1–5 years out of training), 33 of 197 (16.8%) coming from midlevel attendings (5–10 years out of training), and 50 of 197 (25.4%) coming from senior attendings (>10 years out of training) Table 1.

The vast majority of respondents (169 of 197 [85.8%]) indicated that they were "definitely interested" (141 of 197 [71.6%]) or "interested" (28 of 197 [14.2%]) in meeting with patients to discuss their pathology report and show a microscopic slide of their tissue. A minority (22 of 197 [11.1%]) had no interest, answering "not really interested" (7 of 197 [3.6%]), "not interested" (5 of 197 [2.5%]), and "definitely not interested" (10 of 197 [5.1%]) Figure 1.

Figure 1.

Pathologist interest levels. The majority of participating pathologists (169 of 197 [85.8%]) were either definitely interested or interested in meeting with patients to discuss their pathology report and show patients a microscopic slide of their tissue. Participating pathologists were asked to assume that their time was adequately reimbursed and that the primary clinicians had already told the patients their diagnosis.

The mean age of pathologists surveyed was 39.4 years, which is lower than the College of American Pathologists (CAP)–reported median age of 51.86 years (Tony Smith, email communication, January 2021). Nevertheless, there was no significant difference in interest level based on age. Interest level did not differ based on gender or the rank of the pathologist, either. Community practice pathologists, compared with academic practice pathologists (39 of 53 [74%] vs 118 of 130 [91%], respectively), were significantly less likely to be interested in meeting with patients (odds ratio, 0.28; P = .004). There was no significant difference in interest level between academic practice pathologists and pathologists in other forms of noncommunity practice (ie, VA and military hospitals, commercial labs, and international public hospitals).

Thematic Analysis

In total, we collected 196 responses from the 197 participants to the open-ended question, "Why?" Only 1 participant did not include a text box response. Most responses were contextually rich, with many strong feelings and long explanations for each pathologist's interest or lack of interest in seeing patients. Overall thematic analysis showed that pathologists felt that an interaction with patients, by way of discussing their report and showing a slide of their tissue, had the potential to impact patients, pathologists, and the field of pathology as a whole Table 2.

Impact on Patients. This theme encompassed responses indicating areas of potential impact on patients. These areas of impact fell primarily into 2 categories (designated as subthemes)—cognitive impacts and emotional impacts—which were occasionally connected in the responses.

Pathologists noted that they were uniquely positioned to affect patients by providing a service that would help patients better cognitively understand their disease. One pathologist explained, "I am the doctor who's [sic] insight determines a patient's treatment. I am the one who spend [sic] the most time thinking of the cancer and understanding it. Who better to explain it to the patient than their pathologist" (senior attending, academic practice). Pathologists also noted that they would be a valuable resource in explaining a patient's disease in detail: "They [patients] will be more informed about their disease and they will get the scientific information about their disease from the main doctor who has diagnosed it" (midcareer attending, academic practice). Another pathologist commented, "May be [sic] I can help him to fill the gaps. Give them another perspective of their disease" (junior attending, community practice). Others noted the unique visual aspect of seeing one's tumor on a slide, stating, "I think pathologists can offer patient's [sic] a different perspective—show them their tumor/cancer so they can see with their own two eyes. Our specialty has also always been very education-oriented and I can't think of any better opportunity to educate our patients" (junior attending, academic practice). Another respondent described how understanding the diagnosis more fully can help patients comprehend future disease management, commenting, "Showing the patient how and why we got to their diagnosis, and thus why their clinician is managing them a certain way can be very helpful provided we can make ourselves understood" (pathology trainee, academic practice).

While the majority of pathologists felt that they could affect patients positively by helping them comprehend their disease, some worried about a negative cognitive impact on patients, suggesting that additional information could be confusing, especially if not clearly communicated. One pathologist stated, "I think patients may become very confused because we use terminology the clinicians sometimes don't understand" (senior attending, community practice). Another noted, "I am not sure how much patients will understand from the details of the report and the microscopic features that are sometimes hard to explain to their primary clinicans [sic]" (pathology trainee, community practice). One respondent, however, saw the confusing nature of pathology as a specific reason for pathologists to meet with patients, stating, "Pathology is confusing and clinicians are very busy. Directly interacting with patients would provide an avenue towards better care for certain patients" (pathology trainee, academic practice).

In addition to the impact on cognition and understanding, many pathologists commented that meeting with patients could affect patients' emotional processing of their disease, focusing on trust, transparency, and patient empowerment during the process of diagnosis. One respondent, who is already meeting with patients, detailed the experience, stating, "I've done it. It gives them [patients] the certainty that their biopsy it's [sic] been treated by a person with expertise and that gives them peace of mind" (midcareer attending, academic practice). Some respondents described how difficult and emotional a diagnosis can be. These pathologists felt that interacting directly with patients could help them cope with the diagnosis. For example, "As pathologists we deliver diagnosis that can shake the foundation of a patient. Some patients want to know everything they can to cope" (pathology trainee, academic practice). Another stated, "I feel like that might give them some more insight into their diagnosis. It would seem less foreign or scary to them, perhaps" (junior attending, community practice). A minority of respondents, however, expressed concern for potentially worsening a patient's emotional state: "What is intellectually [sic] curious is unpleasant for the individual it affects" (pathology trainee, community practice).

Impact on Pathologists. This theme includes responses that indicate the possible impact that patient interactions would have on pathologists. The impact on pathologists was divided into the subthemes of patient contact and job satisfaction.

Many pathologists noted that they went into medicine to help patients and missed connecting and communicating directly with patients. As 1 pathologist exclaimed, "I miss interacting with the people that I am helping!" (midcareer attending, academic practice). Pathologists believed that talking with patients would enable them to take a more active role in patient care in the way that a typical doctor would: "To feel more like a doctor. To be appreciated" (midcareer attending, community practice). While many respondents were eager to be more connected with patients, a minority specifically noted that they were not interested in patient contact and that patient contact would affect them negatively. For example, "I primarily chose pathology because I do not want to deal with patients" (pathology trainee, community practice).

Pathologists often linked patient contact with job satisfaction, noting that in most cases, more patient contact would lead to a greater sense of job satisfaction because it would provide meaning and purpose. One respondent commented, "It would give pathologists a fulfilling reason to get up in the morning and would probably regenerate our motivation to complete the less interactive parts of our work" (pathology trainee, academic practice) Another stated, "Talking directly to you [sic] patient give a best ever job satisfaction of being a physician … . It will change a pathologist's perspective as well" (junior attending, other practice). Pathologists noted that they frequently felt disconnected from their patients and disassociated from the fact that they are diagnosing real people. As 1 pathologist stated, "It is good for me to be in touch with my patient. I will understand better the impact of my diagnosis and keep [sic] me grounded" (senior attending, academic practice).

From a disconfirming perspective, other pathologists noted the personal pain and suffering that may come from connecting with patients while explaining a pathologic diagnosis. For example, "I chose to be a pathologist because I don't really like to have a direct contact with the patient, and it is not because I don't care, but because sometimes I care too much. I am sure I would suffer if I had to explain I-don't-know-what to them" (junior attending, community practice). While some thought that patient contact would be gratifying, humbling, and energizing, others believed that it would be painful and overwhelming, leading to decreased job satisfaction.

Impact on the Field of Pathology. This theme included responses that indicate an impact on the field of pathology. Subthemes in this area included the image of the field of pathology and quality of care.

Many respondents were eager to change the image of pathology and were particularly interested in humanizing the specialty and increasing its visibility. Pathologists work almost entirely behind the patient-facing aspects of health care, and many pathologists commented that it was time for pathology as a field to become more visible to patients. One respondent noted, "It [interacting with patients] contributes to the visibility of our field: the patients have the right to know who are the members of the team helping to [sic] the diagnosis (and sometimes treatment) of their condition. Having more visibility is adding value to our job" (pathology trainee, academic practice). Another pathologist commented, "I think it would also make patients aware of pathologists as physicians, helping to improve our public image, assistance that is sorely needed" (midcareer attending, academic practice). A pathologist currently interacting with patients stated, "I currently do this and it has been a rewarding exercise that raises the profile of pathology among colleagues" (senior pathologist, community practice).

Respondents also noted that by becoming more visible, the specialty could also be more "humanized" and perhaps more attractive to medical students. One pathologist commented, "It would humanize and put a face to someone whose name they see on a bill" (junior attending, academic practice). A pathology trainee from an academic medical center stated, "I think this kind of program could address the 'pathologists don't see patients' concern that medical students have about entering the field." Some also mentioned that interacting with patients would help correct misunderstandings concerning the pathologist's role in medicine, such as that the profession primarily deals in autopsies, and thus improve the perception of the field and its ability to recruit and retain pathologists. For example, "I think by meeting the patient, the pathologist becomes a 'person' rather than a machine or lab which tests their samples … . We can bust the myth of pathologists do only autopsies. Last but not least, we can take credits from patients for our contribution in their care. We make the key decision in their management but they don't know that we exist" (junior attending, academic practice).

Some pathologists, however, did not want increased visibility and felt that the field of pathology works best as a nonpatient-facing specialty that communicates only with the clinical team. One pathologist stated, "Pathologists work best by spending time communicating with clinical team rather than patients" (junior attending, academic practice). Some believed in the separation of roles between clinicians and pathologists: "It is really best left to the clinician to provide integration with the clinical factors. Yes, as pathologists, we are physicians capable of (and expected to) interpret clinical and laboratory information, but the clinician is in the best position to fully integrate pathology with these findings … . As a surgical pathologist, I am best positioned as a consultant to the clinician, with whom I can discuss my findings and guide as needed" (junior attending, academic practice).

In addition to affecting the image of the field of pathology, some pathologists noted that there could be an impact on quality of care. Many pathologists thought that patient contact would help improve the overall quality of patient care through better care team-patient communication. One pathologist commented, "[Pathologist consultation] provides better care by better communicating results" (pathologist trainee, academic practice). Another said, "I think patients really don't get an opportunity to fully discuss their pathology report in a way that they deserve. And by bringing pathology into the in-person patient care team, this expands and brings a comprehensiveness to patient care like never before" (pathologist trainee, academic practice). Some believed that having direct contact with patients and clinicians would lead to greater information exchange in terms of symptoms, history, and testing considerations as well as being more efficient and increasing patient data confidentiality. Others commented that through direct interaction with patients, pathologists could verify that the comments in their reports are interpreted correctly and be able to clarify the specimen-handling processes and diagnostic decisions to treating clinicians.

In contrast to the potential positive impacts on patient care articulated above, other pathologists noted that patient consultation could negatively affect quality of care. One stated, "Pathologists don't have the clinical training and may even undermine the clinical team by giving out the wrong information" (junior attending, academic institution). Another echoed, "I'm not sure if there is a possibility of mixed messages from clinician and pathologist" (senior attending, community practice).

A small population of pathologists indicated that they had previous experience with or were currently engaged in patient-pathologist interactions. The responses overall were positive, with many specifically referring to benefits to patients. For example, 1 pathologist reflected on the benefits to patients' understanding:

I have done this many times over a 20-year career. The patients that want to look at their slides usually have cancer. They want to see the slides that the diagnosis was made on and get the cancer in their mind's eye. They want to view their enemy. A prominent judge who had breast cancer claimed that the hour she spent with me reviewing her slides helped her meditate and beat the aggressive cancer. (Senior attending, community practice)

Another respondent reflected on the emotional benefits for patients: "I've done it. It gives them the certainty that their biopsy it's [sic] been treated by a person with expertise and that gives them peace of mind" (midcareer attending, academic practice).

Finally, it is important to note that the themes frequently overlapped. Many respondents commented that this type of program could impact patients, pathologists, and the field of pathology simultaneously. Most highlighted positive impacts. For example:

I have previously participated in the See, Test, and Treat programs hosted by the CAP. To sit with patients is an honor and a privilege. It is amazing to see the immense impact and emotional response of patients when they see cancer for the first time … . I believe these opportunities can ultimately lead to higher physician satisfaction/lower burnout, greater patient understanding/compliance, and overall can bring light to the field of pathology. (Pathologist trainee, academic practice)

There was an overall sentiment that pathologists meeting with patients would be a synergistic interaction that could benefit the patient, the pathologist as an individual, and the field of pathology as a whole. Significant concerns arose, however, regarding patients' ability to understand pathology, the anticipation of negative emotional impact on pathologists through patient contact, and the thought that pathologists work best by communicating with clinicians and not patients.

Although the goal of this study was to investigate the attitudes of pathologists toward patient interactions without regard to logistic concerns such as reimbursement, many pathologists still raised these concerns. One stated, "It depends on compensation. I don't understand what this adds to patient care and expect it is not worth the time. Pathologists (docs in general) are seen more as $ generators. How many rvu's [sic] would it be? I expect insurance companies will not pay for it" (junior attending, community practice). Others felt that no time was built in for this type of service in the current practice of pathology: "This would dip into family time. In a busy private practice, this would likely not be feasible" (junior attending, community practice).

Subanalysis for Community Practice Pathologists. Based on the significant difference in interest level among those in academic practice compared with those in community practice, we performed a subanalysis of themes among community practice pathologists. Although community practice pathologists were less likely to be interested in meeting with patients, their reasons for this lack of interest were similar to those of academic practice pathologists. Uninterested community practice pathologists were equally likely to have logistic concerns as well as concerns over communicating results with patients and interfering in clinician-patient interactions (ie, the possibility of mixed messages to patients and clinicians). Interested community practice pathologists noted similar positive areas of impact to patients, pathologists, and the field of pathology as a whole.

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