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

Discussion

In this qualitatively driven survey, 86% of pathologists were either definitely interested or interested in meeting with patients to discuss patients' reports and show them a microscopic image of their tissue. Pathologists felt that meeting with patients would impact patients, pathologists, and the field of pathology as a whole. The impacts were mostly felt to be positive in these areas, with respondents noting the potential for improved patient cognitive and emotional processing, improved pathologist job satisfaction, and improvement in the field of pathology through increased visibility and improved quality of care. Pathologists also noted specific concerns in these areas of impact relating to the potential for patient confusion, decreased pathologist job satisfaction stemming from the burdens of patient interaction, and the potential for decreased quality of care through inadvertent undermining of clinicians when talking with patients. Respondents also raised logistic concerns regarding reimbursement and finding time for consultation. The goal of our study was to understand the attitudes of pathologists toward interacting with patients by showing patients their slides and discussing their pathology reports, independent of reimbursement or other, specific logistical concerns. Given this goal, we will not address concern for reimbursement in this paper because it has been addressed elsewhere.[4]

Concerning impact on patients, pathologists identified similar potential beneficial impacts on patients as those patients with cancer expressed in prior studies.[8,12] Previous work shows that patients feel that a meeting with their pathologist to discuss their report and see their tumor could improve their understanding of their diagnosis and disease, clarify the process of diagnosis, and be empowering.[12] Similarly, pathologists in this study noted that the main functions of a patient-pathologist interaction would be in the areas of cognitive and emotional processing.

Most pathologists noted potential for improved understanding and emotional processing, but some worried about the potential to create confusion for patients that could be stressful. Indeed, a qualitative study of the role of health information for patients with cancer showed that patients have a critical need for information at certain points in their care, but at other points information can cause stress.[13] In that study, patients specifically voiced strategies for avoiding information once a treatment decision had been made because it was thought that such information could lead to a reemergence of uncertainty.[13]

Patient impacts were at the forefront of most pathologists' minds; many, however, noted that patient contact would be specifically beneficial to pathologists. These respondents saw patient care as a positive and thought that it would keep them humble and grounded, leading to greater job satisfaction through an improved sense of meaning and purpose in their daily work. This sentiment has been described by Gutmann et al, who interviewed pathologists who met regularly with patients.[3] These authors noted that after a positive patient-pathologist consultation, "both parties feel gratified."[3] Patients can gain control over a situation by getting more information, and pathologists experience the satisfaction of knowing that they have helped individuals cope, with Gutmann et al further stating that "in addition to the cognitive and emotional benefits that may accrue to patients, such encounters can bring pathologists closer to the source of their daily work. We know that helping patients is central to our vocational calling, but this notion may come into gratifyingly clear focus when sitting across from them at the microscope."[3]

This sentiment about a specific positive impact on pathologists in the form of improved job satisfaction is important given burnout and decreased job satisfaction among pathologists nationally. According to the 2020 Medscape National Physician Burnout & Suicide Report, approximately one-third of pathologists feel burned out.[14] Burnout adversely affects physicians, their personal life, and the quality of care they provide.[15] Burnout is associated with an increase in major medical errors and a decrease in patient satisfaction.[16,17] Meaning and purpose in work are key factors in reducing burnout and improving job satisfaction.[18,19] Including patient-pathologist interactions as part of a pathology department could increase the way individual pathologists who meet with patients perceive the meaning of their work. The inclusion of patient-pathologist interaction may even have a global effect on the department and field because the simple act of a few pathologists meeting with patients may change the perception of the field of pathology in the eyes of patients, families, clinical care teams, and hospital leadership.

It is important to consider the converse, as well, whereby increasing patient contact can lead to increased feelings of burnout, a sentiment expressed by a minority of the respondents, who noted that they did not have the time or desire to meet with patients and worried about being affected by patients' suffering through direct patient contact. Common drivers of physician burnout include excessive workload, work inefficiency and lack of work support, lack of work-home balance, loss of control and autonomy, and loss of meaning from work.[19] Challenging patient interactions are not cited as a common driver of clinician burnout. Instead, protecting patients' time with clinicians has been presented as an organization-level solution for burnout.[19] Nevertheless, a subset of pathologist would be particularly sensitive to interacting with patients, and some pathologists may believe that patient interaction would lead to burnout because of excessive workload and work inefficiency.

In addition to impacts on patients and pathologists, respondents indicated potential impacts to the field of pathology as a whole. Many pathologists noted that pathology as a field is not as recognized, visible, or integrated with patient care teams as they would like it to be. This sentiment is important given the field's current level of visibility and the way that visibility affects growth and innovation in the field. Pathology is an unpopular choice among medical students, with only 1% to 3% of medical students choosing pathology residencies.[20–24] Negative stereotypes of pathologists are common, with the prevailing image of a pathologist as being, at best, "geeky and boring," "introverts," and "antisocial" or, at worst, "creepy" and "scary."[24,25] These negative sentiments and the lack of visibility contribute to critical shortages of pathologists,[26] with increasing shortages predicted.[23,27] Pathologists themselves have been described as absent or unknown in clinical practice.[24] Pathologists in this survey pointed out that they are important members of the health care teams and that including patient-pathologist interaction may improve the image of pathology.

Hand in hand with improving pathology's image and visibility was the notion that including patient-pathologist interactions could potentially promote improved quality of care by increasing communications among patients, pathologists, and treating clinicians. Some pathologists felt that patient interaction could lead to a "closing of the loop," facilitating meaningful and insightful communications that would not otherwise occur. This type of interaction, described as "teaming" in organizational literature, can promote quality improvement. Teaming more readily occurs in multidisciplinary teams because people can learn from each other, enjoy a broader understanding of the work from start to finish, and better see and act on interactions for improvement.[28] Teams are currently used to integrate pathology knowledge in the form of tumor boards conducted among surgeons, oncologists, pathologists, and radiologists, but patients are not included in these discussions.

Some pathologists noted that they were concerned about miscommunication among patients, pathologists, and clinicians that could detract from overall quality of care. Research in the area of pathologists' attitudes toward medical error disclosure highlights a feeling of being unprepared to handle challenging direct patient communication and a view of pathologists as primarily consultants to treating clinicians rather than direct caregivers.[29] The integration of care teams and multiple perspectives can be difficult and has led some to worry that these difficulties may precipitate a decrease in quality of care and an increase in medical errors.[30,31] Nevertheless, the high-performing medical team is widely recognized as an essential tool for constructing patient-centered, coordinated, and effective health care delivery.[30,31] The National Academy of Medicine (formerly the Institute of Medicine) recommends following principles of team-based health care, including shared goals, clear goals, mutual trust, effective communication, and measurable processes and outcomes, whenever groups engage in team-based health care.[30]

Limitations

This study had significant limitations. First, we have no overt confirmation that the respondents are pathologists, although the responses contained abundant specific language relating to the field of pathology. All data from the survey were anonymous and self-reported, however, and we had no way to verify respondents' identities.

Second, participants were recruited through social media, so only people using Twitter were captured. Pathologists on Twitter may be more likely to be advocates of communication and thus biased toward interest in interacting with patients. To counteract this potential bias, we constructed themes with confirming and disconfirming evidence, noting that for each potential positive impact, there were pathologists who were concerned about an associated negative impact, even when these negative sentiments were voiced by a small minority of participants.

Finally, we do not have a true denominator of the number of people exposed to the survey but elected not to participate. People may have seen the tweet and declined to participate, or they could have missed the tweet entirely in their feed. Because we do not have a true denominator, we cannot report a "capture rate" or "response rate" for this survey. We do know that the survey had a potential reach of 74,700. Our 197 responses are likely a self-selected group of pathologists who have strong feelings on the issue.

Despite these limitations, this survey did reach thematic saturation and captured the voices of almost 200 pathologists who, in most cases, provided rich contextual responses about their feelings on the issue, allowing for the recognition of robust themes regarding the attitudes of pathologists toward patient interaction.

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