Are physicians aware of how much they don’t know?
Probably not, according to Mike Laposata, MD, PhD.
His epiphany on the subject came in 1984, when he was a resident at Washington University’s Barnes Hospital in St. Louis, Mo. “We had a difficult case, and it was clear doctors had little understanding of [a particular] test result” dealing with prothrombin time, said Laposata, who now chairs the pathology department at the University of Texas Medical Branch at Galveston. As a result, they ended up needlessly giving blood to an 8-year-old boy who was getting a tonsillectomy; the blood turned out to be contaminated with HIV — a disease that was still a mystery at the time. The boy developed HIV and later died.
Upon finishing his residency, Laposata went to work at the University of Pennsylvania, where he became director of the coagulation lab there. “I said, ‘We’re not going to just send [test] results; we’re going to put an interpretative paragraph underneath the numbers,'” he explained. “We did it for 3 months and then I got a surprise visit from the chief of hematology, [who] comes to me and says, ‘Stop doing that.’ I said, ‘Why?’ and he said, ‘Hematology fellows are not seeing cases because you’re giving the diagnosis too soon.'”
When Laposata suggested that a quicker diagnosis was a good thing, the hematology chief replied, “Not for me, because without fellows, we don’t have research projects.” “I said, ‘I thought the patient comes first,’ but he said ‘No,'” said Laposata. “That was a shocker.”
He then went to work at Massachusetts General Hospital, where he became director of a lab. “I thought, ‘I’m going to go for it,'” Laposata said. “We have to change the paradigm for making diagnoses. We should have only experts providing opinions about different areas.”
So he started a diagnosis management team (DMT) for coagulation disorders, in which physicians who treated patients worked with lab experts to figure out the right tests to administer and to properly interpret the test results. Although there were a few skeptics among the physicians on staff, Laposata got encouragement from important higher-ups. “The head of medical education at Harvard was a great mentor to many of us … he said, ‘Keep doing what you’re doing.'” The hospital president also was encouraging, he said.
The CDC also is trying to address the lack of communication between laboratory professionals and the physicians who work directly with patients, according to Reynolds Salerno, PhD, director of the CDC’s laboratory systems division.
“One study specifically looked at physicians’ access to labs — that study, which came out only last year, found that only 20% of physicians in that particular survey [of almost 2,000 doctors] said they had an effective way to access lab professionals. So we know there’s uncertainty in the interactions with the lab space in general; we know there’s limited interactions with the lab space.” Another study found that only 4% of physicians reported contacting a lab professional at least once per week for a medical or scientific opinion; that figure jumped to about 26% when it came to missing test results, he said.
To foster more communication between physicians and laboratories, the CDC launched the Clinical Laboratory Integration into Healthcare Collaborative (CLIHC) in 2008. Part of the CLIHC effort is academic, with the aim of studying interactions between labs and physicians. But “another aspect of CLIHC we’re proud of is CLIHC-developed diagnostic decision tools and mobile apps designed to help physicians select tests and to understand what the tests say for particular conditions,” said Salerno, who spoke during an interview at which a public relations person was present.
One such app is a PTT [partial thromboplastin time] Advisor app. “It’s a decision support app that enables physicians who are seeing patients with prolonged PTT to understand what options are available to them and help them make better decisions,” he said.
One big barrier to increasing communication between lab physicians and their patient-facing colleagues is that the labs aren’t reimbursed for diagnostic consultations, said Salerno. “The lab is, in most cases, only reimbursed for the tests they conduct, and I think that’s part of what we’re really struggling against,” he said. “That reimbursement philosophy has helped shape the perception that the lab is just a service provider; you throw patient samples and test orders at them and they throw back the results of the test. In most cases, there is not a way for the pathologist to be reimbursed for diagnostic consultations; there is a real disincentive to do that.”
In addition, “we live in an extremely litigious society and system, especially when it comes to medical care,” he said. “So even in cases where the pathologist is extremely interested in supporting diagnostic decision making, it may be difficult for them to step outside that comfort zone, and nerve-wracking. It’s relatively easy to be the pathologist who’s just providing test results. Once the pathologist gets involved in diagnosing a patient case, they’re putting themselves at more risk.”
Culture change is still another barrier, according to Laposata. “Pathologists work 48 hours a week and make between $ 300,000 and $ 400,000 [a year]. Who wants to change that? Nobody,” he said. “They don’t want to join a group where they could be sued, where they could have poor outcomes that would affect a patient, or where they’d be called at night.”
Because there are so few lab professionals who can help with diagnoses in specific areas, Laposata would like to see regionally based diagnostic teams. “It would still be a quantum leap even to put in regional DMTs,” let alone having them in every hospital, he said. However, “I’m still struck that when we use [web conferencing applications], both ends have to know how to use it, and half the time, I can’t hear the voice or see the person. We really need help with putting connectivity together.”
And to increase the supply of lab professionals, a few universities now offer a doctorate in clinical laboratory science as well as bachelor’s and master’s degrees in medical technology. “We are hoping these midlevel providers are going to do what nurse practitioners and physician assistants have done; they will be the ones who can provide the expertise and work with us,” said Laposata.
Expanding DMT Use
At Vanderbilt, the medical center has expanded its use of DMTs, said Mary Zutter, MD, the hospital’s vice president for integrative diagnostics. The first DMT — started in 2010-2011 when Laposata was there — was around coagulation disorders. That worked well, so the staff decided to branch out.
“I’m a hematopathologist, so I diagnose leukemias and lymphomas, which are complicated and required multiple different types of testing,” Zutter said in a phone interview. “The question became, how do we take disparate data and do the right testing on any individual patient and provide a report that integrates all that data together, and provide a summary for the physician and also for the patient?”
So the hospital put a DMT in place in 2012 for leukemias, “and for the past 6 years, we’ve been really developing that whole process here,” Zutter said. “We’ve published a number of papers in this area.”
“Our opinion is that the DMT is really a two-sided process,” she said. “There’s the work on the front end, when the provider initially sees the patient and determines what the best strategy is — how much testing do they need? … And then when the testing is completed, the patient needs a comprehensive interpretation … to give a conclusion the physician can use for treating the patient.”