Discussing Diagnosis with Patients During FNA: Do you do it or not?

[zao275]

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I like the idea of talking to the patient about their diagnosis after an FNA (if it is obvious, even on Diff Quik). But many pathologists really shy away from doing this, either because of personal discomfort, or (more often it seems) because they are afraid they are stepping on the consulting doc's toes.

The CAP Transformation site just sent out a short vignette that touched on this issue. I liked the way Dr. Abele handled the situation and how he spoke with the patient.
http://www.cap.org/apps/docs/membership/transformation/new/stories_index.html

How many of you tell your patient the diagnosis immediately after FNA? Or is there any other time you discuss the diagnosis with the patient or a family member (Frozens, maybe)? Do the surgeons/primary care/consulting physicians seem ok with it or not?

Just curious.

 

[Entgegen]

I would think that as long as you're not pissing off the clinicians by talking to the patients about it, then the thing you would have to consider is whether or not you think you can answer all the questions they may throw at you (what's the next step, what's my prognosis, what are my treatment options, etc.). As a pathologist, if you couldn't answer all their questions and have to refer them back to their clinician for them to get answers, you may just be blue-balling them until they can talk with the other doc.

On the flip side, if you couldn't answer their questions, the time lag between your giving the diagnosis and when they can talk with the clinician may give them the opportunity to collect their thoughts and write down all the questions they may have once the shock as worn off (if it's bad news).

 

[2121115]

I never have.

First, if you haven't looked at the pap stain yet (which comes out later) then you have not seen all of the material and it is only a prelim diagnosis. What if you tell a patient that it looks negative on diff quick but then something pops up on the pap? Dangerous territory, IMO.

Second, they just met you. There is no doctor-patient relationship and you are just going walk in and drop a bomb on them that they have cancer then send them away and never see them again?

 

[levels x3]

I do not tell them for many of the same reasons listed above. Example; a few days ago I was called by an oncologist to their infusion center to FNA a supraclavicular lymph node of a woman with small cell CA of the lung. I did 2 passes, made 8 air-dried smears and rinsed the needles into some RPMI (later converted to Thinprep). I stained 2 with DQ to check for adequacy and it was obviously metastatic small cell. But I didn't know this woman. I didn't know how she would react to a metastatic diagnosis. It's not that I am incapable of handling such a conversation, but that the oncologist almost certainly would be better able to do so given that he already knows the patient and her personality. I'd rather not drop that bomb and then say "have a nice day".

I always just tell them that the sample is adequate, but that I need to stain the rest of the slides and that their doctor will have the results in a day or two. The fact that you haven't seen everything yet is another vaild reason to wait.

 

[Pathwrath]

Unless I have a reasonable supply of answers to their potential questions, I don't talk to patients. If a patient calls me to discuss my autopsy findings on a loved one, no problem. But living patients might be slightly more interested in treatment and prognosis than in what kind of pretty cells there are on the slide.

 

[KCShaw]

There's been scattered threads about why the public doesn't understand who pathologists are and what we do. This is one reason they don't understand.

I totally get the reasons many pathologists don't seem to want to get involved in giving patients their diagnoses. Some are very good reasons. We just need to realize it adds to our sequestration and the impression that at best we are tools of clinicians, rather than consultants and tissue/laboratory diagnosticians.

I don't do FNA's. When I was a resident, I don't recall discussing results with patients beyond "we got some good stuff" or whatever, if we were doing the FNA ourselves and were the only ones in the room. I seem to recall having discussions with patients & clinicians if the clinician was present or assisting in performing the FNA; rarely, the clinician would indicate NOT to discuss it beyond adequacy for one reason or another (language barriers with the patient, extreme anxiety, patient requested waiting until everything was done, etc.).

 

[pathstudent]

I wouldn't do it unless I knew the person as a friend or the clinician instructed me to tell the person. You could only get yourself in a bad situation by stepping out of your role.

If an anxious patient called for her pathology results on a surgical case would you give them a prelim or tell them the final?

 

[KCShaw]

Our "role" as defined by who or what?

In my practice I discuss my pathologic findings with next of kin for the most part quite readily, however, forensic pathology is relatively unique in a lot of ways. Generally my reports become available to public records requests. Although there sometimes -is- a clinician already involved with the family, often there is not (one reason why we may get involved), and I become the closest thing to a treating physician. In residency we rarely discussed autopsy findings with families except during conferences with their regular clinician. Even my own attendings were paranoid about discussing autopsy findings with families in the absence of a clinician. I still feel that had a lot to do with most path attendings not being particularly comfortable with autopsy in the first place -- and, of course, a lot to do with surg pathologists rarely dealing with patients or families.

But, again -- though I understand why most don't do it and don't want to do it, who defines that we don't? Is anyone aware of documented protocols at their institutions or practices stating the pathologist must not (or that "only" the "treating" physician can) provide or explain pathologic diagnoses to patients/next of kin?

 

[KluverB]

My FNA rotation isn't all that fresh in mind, it was so long ago. However, I have fresh memories of transfusion medicine and interacting with plenty of patients on the apheresis/stem cell collection service. I routinely fielded, or rather "deflected" questions about their "next steps in management", but I had no issues of walking them through the process of stem cell collection, associated issues, and possible future transplantation (BMT), if that was the course that their heme onc had decided on. I could give them the "low power" overview, but emphasized that all such decisions were going to be made in discussion with their treating physician and if they had any questions to ask them. If any (medical) issues (such as vitals, new symptoms, etc.) came up during the time of assessment or collection I would immediately discuss them with the referring physician (usually the oncologist), and we would formulate a plan whether it was something I would handle myself, or whether I would refer the patient back to the onc clinic, or whatever. We tried not to "treat" anything other than some apheresis-related issues, but sometimes gray areas came up. But obviously this is more medicine-y (Palinism).

As for the OP's specific questions regarding FNA, I agree with the comments above. State that there is adequate tissue, and that those additional stains will need to be reviewed, etc. Basically the same spiel we give the clinicians, most of the time.

 

[pathstudent]

Our "role" as defined by who or what?


But, again -- though I understand why most don't do it and don't want to do it, who defines that we don't? Is anyone aware of documented protocols at their institutions or practices stating the pathologist must not (or that "only" the "treating" physician can) provide or explain pathologic diagnoses to patients/next of kin?

No documented protocols. Just common sense. Like I said I wouldn't over step my role and get involved in their physician-patient relationship unless the patient was a good friend or the doctor asked me to if there was a definite diagnosis on the initial slides for review.

But I never do FNAs and would consider that a waste of my time and skills. I am happy to look at them for clinicians that do them.

 

[2121115]

We just need to realize it adds to our sequestration and the impression that at best we are tools of clinicians, rather than consultants and tissue/laboratory diagnosticians.

I respectfully disagree. I see where you are coming from, but I think that a pathologist (or any physician for that matter) delivering a new cancer diagnosis to a patient that they do not know and will not ever see again is not appropriate.

I understand the need for pathologists to be more assertive of our role and whatnot, but this, IMO, is not the way to do it. I believe we can educate patients and our fellow physicians about our role and value without going this route.

 

[Gene_]

I think it is appropriate to tell patients the diagnosis in cases of recurrence where the clinician and the patient basically already know the diagnosis. I think it is not appropriate in essentially all other cases for the reasons already discussed.

 

[yaah]

Ideally you would have a close communication with the attending who scheduled the FNA for the patient, and they could come down and talk to the patient if you had something immediate. It is probably unwise to go and discuss specific findings with the patient unless you have discussed it with the primary physician - you can always say that the procedure is being done to assess adequate number of cells for diagnosis, and you don't have a diagnosis right now.