Bridging the Gap: Tips for Effective Pathologist-Clinician Communication

• Latest resources from the New-in-Practice Committee

Becca Battisfore:

Welcome to the latest edition of the College of American Pathologists' CAPcast. I'm Becca Battisfore, content strategist with the CAP. In this episode, I'm joined by three members of the CAP's New-in-Practice Committee who will share their experiences and advice for effective communication with clinicians, especially outside of pathology. So before we get into the questions, let's learn more about our guests. Dr. Yoon, let's start with you.

Dr. Esther Yoon:

Hello everyone. My name is Esther Yoon and I'm a staff pathologist at Cleveland Clinic Florida, practicing breast GYN and cytopathology. I'm a member of New in Practice Committee in CAP, which our goal is to identify, understand, and address the needs, issues, wants, and challenges of new practicing pathologists. We put together webinars, podcasts, blogs, and much more to support our pathologists in their first years of practice. Thank you.

Becca Battisfore:

Awesome. Thank you for the introduction for the committee as well. Okay. Dr. Nebbache?

Dr. Hafsa Nebbache:

Yes. Hi. Hello everyone. My name is Hafsa Nebbache. I'm currently a PGY4 in University of Kentucky. I'm interested in cytology and breast pathology and I am also the junior member of the CAP New-in-Practice Committee. Thank you.

Becca Battisfore:

Great. And Dr. Woo?

Dr. Jennifer Woo:

Hi, my name is Jennifer Woo and I'm a pathologist in Southern California at the City of Hope National Medical Center. I specialize in transfusion medicine and clinical informatics and we are excited to be here today.

Becca Battisfore:

Awesome. Well, thank you all for being here. I think everyone here and beyond would agree that clear communication is an important skill for everyone, but essential for pathologists and anyone in the medical field. So can you share a little bit more about why we're talking about this today?

Dr. Jennifer Woo:

We're here to talk about communication with our non-pathology physician colleagues. This is an important topic for those new in practice because although we learn communication skills as a trainee, we gain primary responsibility in communication when we are starting a career as a practicing pathologist. In preparing for this podcast, we surveyed pathologists from the Council on Membership and Professional Development to understand their communication styles with non-pathology physicians, their attitudes toward communication and the advice they have to offer. The first question asked pathologists to assess the importance of communication with non-pathology colleagues, and it's no surprise that nearly all survey participants shared that it was very important. Dr. Nebbache, what did other pathologists say regarding the forms of communication that they most preferred and their order of effectiveness?

Dr. Hafsa Nebbache:

Thank you Dr. Woo. So from our survey, both pathologists and non-pathologists tend to initiate almost equally on weekly basis. Email was most common method of communication followed by phone calls. However, pathologists thought phone calls and face-to-face meeting were the two most effective way to communicate followed by email. Also from our survey, the non-pathologist, which means like the other clinicians tend to initiate the communications most often and also the pathologist from the survey says that one to six times a week they had to communicate with the clinician on daily basis.

Dr. Esther Yoon:

So when we pathologists reach out to our non-pathology colleagues, it is mostly frequent to alert unexpected findings in their path report followed by trying to gain more clinical history before we sign out cases. Non-pathology colleagues contact us most frequently to ask for special requests such as additional tests expediting the results or to clarify our pathology reports that we signed out. Other reasons included to let us know the minor mistakes such as spelling errors that we have or ask for more expertise in selecting laboratory tests in blood bank or clinical chemistry or interpret our other lab results. All of these communications is definitely helpful and insightful when putting all together the clinical history and signing out a comprehensive path report. But the survey revealed it rarely changes our initial impression and working diagnosis.

Dr. Jennifer Woo:

In our survey we also explored how pathologists are directly engaging with patients and had some interesting findings and I think this was the most interesting part of our survey. We found that 40% of survey respondents have directly interacted with patients to discuss pathology or lab reports. Almost a quarter respondents shared that they had been called by physician colleagues to discuss pathology reports while they were directly with the patient. Finally, we wanted to gauge how interested pathologists are in directly speaking with patients and found that only a small minority expressed a complete lack of interest. Pathologists interest in speaking with patients varied with roughly equal numbers expressing slight to strong interest in transfusion medicine. We have consistent interaction with patients whether it's through apheresis or speaking with patients directly regarding their rare blood type or whether they need special products in surgical pathology. This is a little bit uncharted territory for me and something that would stress me out tremendously. Dr. Yoon or Dr. Nebbache, do you have any stories about communicating with patients or any examples of how pathologists and patients have been interacting?

Dr. Esther Yoon:

When I was in a different practice setting, I performed fine-needle aspiration as a cytopathologist and during that rotation I daily encountered patients where I have to deliver difficult news or uncertain diagnosis. So during that time the patients were very grateful for having the interaction with the pathologist who will eventually finalize their report. I was very grateful for their attitude towards my performing my job and I think I had always a positive experience and I can say delivering a bad news, it's not always easy, but answering their question really helps them to make their decision and emotionally stabilize their medical journey.

Dr. Jennifer Woo:

I totally agree with you there. Having conversations with patients and families, especially when prognosis is poor, is very difficult and they ask questions that sometimes should be better asked or answered by another physician and you get put in a difficult situation, but we find our best way to give them the information they need without compromising the overall care they're getting from the system in the hospital.

Dr. Hafsa Nebbache:

So there was a lady who came for an FNA, she had a mastectomy for a breast cancer previously and now she has a sort of a scar that turned to a mass and then she came to the clinic for an FNA and she was really scared. I still remember her and I remember I included her in my personal statement for my fellowship actually because she was really scared of having the cancer back and she doesn't know about other options. It might be benign, but it was very difficult for me because I wasn't able to tell her, okay, just calm down, don't worry, it might be benign or it might be malignant. I just told her that we're here to help you. We will make the diagnosis as best as we can so the clinical team can help you out for the treatment. However it's malignant or benign. And then we did the FNA and it was just a scar tissue that was kind of not keloid, but it was benign actually and she was really happy at the end.

Dr. Jennifer Woo:

That was a really great example. I know talking with patients is not the intent of this podcast, but sometimes physicians will call on pathologists to talk to patients, so I'm really glad that we got to talk about this. Next we're going to talk about our own personal stories speaking with our non-pathology colleagues. We're going to share a little bit of, I guess I wouldn't say horror stories, but situations where that really stuck out to us and stories that we definitely learned from.

Dr. Esther Yoon:

Sure, Dr. Woo. I know it's very challenging and sometimes very intimidating to communicate with non-pathology colleagues as a new practice pathologist, especially when you encounter someone who's well respected in the field and have many more experience than you. I remember one instance when oncologists argued with a radiologist over their own mistakes reading a pathology report, which I signed out. So navigating the conversation when emotions were running high is never easy, especially when someone is so vocal and passionate in a way that can create some uncomfortableness and confrontational atmosphere. At this point I had an unprepared encounter with the same individual. So over a short period of time I learned the keys to recognize that the intensity often comes from a deep committed passion for patient care and wellbeing. So I tried to stay calm and redirect the conversation back to the agenda focusing on the patient being discussed at tumor board.

I was able to diffuse the situation, but it's not uncommon situation to have yourself find. I reminded them during the tumor board that certain conversations are better suited for private discussion outside the tumor board. If there are difficult topics, I think it's a great advice to schedule a meeting either in person or Zoom where you can see their face and plan what you're trying to say and what you're trying to accomplish ahead of time. It's always better to have a game plan when you're meeting and talking to these clinicians and always thank them for their time and give them a chance to ask questions back but clearly voice your concerns and also address their concerns. Communication is bidirectional and reassuring them your willingness to change and work together will certainly lead to a successful communication.

Dr. Jennifer Woo:

I really liked your story Dr. Yoon because there are certain situations when physicians are very upset and handling those situations may be uncharted territory. I feel that the worst forms of communication are when there are no transparency between both parties. So either the pathologist hides something or not hides per se, but they may think that it's not necessary to share, but your colleague may expect that communication to happen or even vice versa. Basically, when no communication happens at all and we assume that everything's happening behind the scenes, I think that's when communication really goes downhill and takes a nose dive. Communication to me is difficult. I think it's difficult because it takes time. You have to be proactive and it takes a lot of effort to get all parties on board and even if you have everybody involved that you can think of, you're still going to forget somebody and probably upset someone because of that.

But the effort comes into the time you put into communication. So it's establishing connections, it's getting to know your colleagues and ideally your leaders in your department would help you establish those connections and that you would have a cohesive unit to have these conversations take place. And if that's not happening, then you would yourself need to establish those connections. But just be aware that those physicians might come to you first and that may upset your pathology colleagues, but maybe that is a quality improvement project that you can take upon to establish tight-knit interdisciplinary groups. For me, I have the best communication when everyone is on the same page, everybody knows what to do. We have confirmed certain processes for example, and no one is making any assumptions. That's definitely where you can go wrong. I get communications often by the EHR messenger and that's especially challenging because texts are flying back and forth and it's really easy to get a little bit confused.

So in those situations, especially when it's a difficult situation or one where it's a little bit more complex, I will go to the physician directly talk face-to-face or on the phone because you really can't get everything from a text conversation, so change the medium where you're communicating depending on the situation. Some things are easier by text, but some things do require a call and other situations may require face-to-face. We have been dealing with inventory challenges, for example, and when we run out of platelets, this is an example where I go to the physician and I tell them what the situation is, I give them an explanation. I speak with the nurses, I speak with the charge nurses. I may even speak with the director of nursing to explain the situation, but it's necessary. It establishes trust with others, but it does take effort basically. It took my whole day to deal with that.

And then lastly, I want to share a little bit of an embarrassing story, but I think it might resonate with some of the listeners. But as a trainee, you went through med school and you went straight to undergrad to med school. Now as a resident, and you may not have had real world communication experience but emails, I had one attending tell me that I wrote horrible emails and I was pretty devastated. I was like, why is my email bad? And I have come to realize that that attending was right and that written communication is an important skill to develop and because you need to be concise and yes, too much jargon that other people may not understand. Yeah, develop your email communication style. It's very important to be clear, be concise, not include jargon and make sure that it has all the elements that you need instead of following up with another clarifying email. I worked on it and I may not be the best email writer now, but I try to write everything with intention and making sure that my audience understands that.

Dr. Hafsa Nebbache:

As a resident, if I can share my personal experiences as a resident. The most frequent occasions we have to communicate with clinicians were during on-call shifts. I can recall positive encounters such as when a family requested an autopsy and the clinician went above and beyond ensuring all the necessary documentation was prepared for pathology to conduct the postmortem exam. Similarly, during blood bank calls, I one time had a negative encounter when a clinician requested blood product for a patient, there were instances where delays occurred due to challenges cross matching or to any pretest problem. Clinician can be frustrated given the time sensitive they're facing due to the patient clinical presentation. It is really important to talk to the physician, go straight to the point, give the result, approve or deny the blood product and explain why and give the opportunity to the clinician to communicate their concern.

Sometimes it's difficult when you have a negative kind of encounter and communication with the clinician and from our survey, some comments were shared by pathologists. Some of them said, always put the patient first. Don't feel pressured to order unnecessary testing or potentially even misdiagnose the patient. Also, when you communicate the results or any concern regarding the patient, always make sure to introduce yourself, confirm who you are talking to, confirm the patient who are calling about so you don't give the wrong diagnosis to the wrong patient. Bring up the reason for calling results question or concern and ask if they have any questions or if everything is cleared up, repeat the primary finding one more time before you close the call. Also, be direct. You use simple terms and be succinct and clear. Those are some of the comments that were shared by the faculty and I think they're really nice and they are really important when it comes to communication, communicate the difficult diagnosis.

To all the listeners to our podcast, please feel free to join our fireside chat at the annual CAP meeting 2024 in Las Vegas and we can discuss further about the challenges that can communication with the patient or the non-pathologist colleagues. Come talk to us. Feel free to approach us as well. Also let us know by social media what you think always if you can include the hashtag new in practice, which is hashtag NIPCAP or also on MyCAP app by comment as well.

Becca Battisfore:

Thank you all so much for joining the podcast to talk about the survey and your experiences. I want to end with one last introspective question for you all. Knowing what you know now, what advice would you give to yourself on day one as a trainee?

Dr. Jennifer Woo:

I think for me it's you do need the foundation of the medical knowledge in pathology as well as all the training you've had in medical school, but also the emotional intelligence portion is essential for practicing. It will help you tremendously or it will harm you tremendously if you don't have it, and I wish I knew that now because you'll make mistakes if you can't read the situation well.

Dr. Hafsa Nebbache:

For me personally, I'm a PGY4 right now, but going back to my PGY1, I would tell my young self, don't pressure yourself. Don't feel the pressure of when it comes to communication to give an answer right away. Like Dr. Woo said, you would sit, read the report, understand it, know, try to know everything like medical knowledge when it comes to that situation or that clinical presentation and then go back to your attending, talk to your attending, and then go back to the clinician for clear communication. Don't feel the pressure and just take it easy. Everything would be well.

Dr. Esther Yoon:

I agree. When someone requests something so unexpected that you're really caught off guard, it's better to say, I'll look into it. I'll get back to you. I'll find the answer for you than just saying something that top comes off of your head. The first thing, and I keep practicing that more and more as there's so much stake in patient care as a pathologist, every word you say, every diagnosis or anything that can be communicated to the path or non-pathology colleagues weeks could carry a significant weight in their treatment management and their journey. So if you're not sure or if you have a sense of doubt, don't say anything that can harm a patient and it goes on during frozen sections as well. I think that's really important.

Dr. Jennifer Woo:

I think we have a luxury as a pathologist that we don't necessarily have to give an immediate answer, so that time spent to think is time well spent and we're not in a bubble. We have other pathology colleagues that we can consult that can also be present for difficult conversations and we can support each other. We don't have to do it ourselves.

Becca Battisfore:

Those are all great answers. I love it. Thank you all for listening to this CAPcast. For those attending CAP24 in Las Vegas, the New-in-Practice fireside chat will be held in the morning on Sunday, October 20th. And if you're listening to this after the fact, there are still plenty of other ways to interact with the committee as Dr. Nebbache mentioned. For more information about the New-in-Practice Committee and the CAP visit cap.org.

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