Pathologists on Clinical Rounds

[BurniNation]

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Due in part to some of the emerging ideas on the future of pathology and our role in healthcare, personalized medicine, etc and also partially as a result of a recent visit by CAP prez Dr Schwartz (who is adament about pathologists remembering that they are physicians), all residents at my program have begun attending clinical rounds while on CP rotations. Are residents at any other programs going on clinical rounds, and if so, what are you experiences like? Do you find it worthwhile or just a waste of time?

 

[KeratinPearls]

Due in part to some of the emerging ideas on the future of pathology and our role in healthcare, personalized medicine, etc and also partially as a result of a recent visit by CAP prez Dr Schwartz (who is adament about pathologists remembering that they are physicians), all residents at my program have begun attending clinical rounds while on CP rotations. Are residents at any other programs going on clinical rounds, and if so, what are you experiences like? Do you find it worthwhile or just a waste of time?

Wow, that's interesting. I forgot all about clinical rounds. What are pathologists supposed to gain from this?

 

[rockit]

Wow, that's interesting. I forgot all about clinical rounds. What are pathologists supposed to gain from this?

I like this idea but I don't think it's something a pathologist can ever get paid for. In odd cases or unusual situations the pathologist can have a lot to offer in terms of recommending diagnostics and integrating testing.

 

[SLUsagar]

Due in part to some of the emerging ideas on the future of pathology and our role in healthcare, personalized medicine, etc and also partially as a result of a recent visit by CAP prez Dr Schwartz (who is adament about pathologists remembering that they are physicians), all residents at my program have begun attending clinical rounds while on CP rotations. Are residents at any other programs going on clinical rounds, and if so, what are you experiences like? Do you find it worthwhile or just a waste of time?

for CP elective in peds path, we're required to attend the occasional PICU rounds from time to time (forcing one to master the art of faking paging one's self out of such situations).

 

[MirkoCrocop]

Due in part to some of the emerging ideas on the future of pathology and our role in healthcare, personalized medicine, etc and also partially as a result of a recent visit by CAP prez Dr Schwartz (who is adament about pathologists remembering that they are physicians), all residents at my program have begun attending clinical rounds while on CP rotations. Are residents at any other programs going on clinical rounds, and if so, what are you experiences like? Do you find it worthwhile or just a waste of time?

lol@yall!

rounds? thats why a lot of us chose pathology, so we wouldnt have to round... that kinda sucks...

in all seriousness, i can actually see some benefit.. i mean, it wouldnt hurt. if you recall, path used to be a 5 year residency (one of which was a traditional intern year.. i think). i suppose this gives a bit of that kind of exposure that was lost when path went 4 years.

 

[Psychopathology]

I think better questions are what can we contribute to rounds and realistically, what would our role on rounds entail?

Would we trail the medical team, never being acknowledge and never speaking to the clinicians or to the patient? How would they benefit from our presence?

Otherwise, I am curious as to how this would improve my knowledge and abilities. Is this felt to be compensation for loss of the transitional year? Will this measure improve communication between us and the clinicians? Wouldn't it then be equally as valuable to spend time rounding with surgeons, gastroenterologists, hematologist oncologists, and dermatologists while on AP rotations? Who has time for that?

I've visited patients in order to investigate potential transfusion reactions but those were rare circumstances. While some of us made a very difficult decision to let go of patient contact, we also are making a decision to become the best diagnosticians we can become, and that requires time and effort. I'm wondering if rounding would detract from that time and effort.

 

[SLUsagar]

I've visited patients in order to investigate potential transfusion reactions but those were rare circumstances.

good point. we also will often hit the floors and interact with clinicians regarding certain patients using a lot of products or with particular tranfusion-related issues.

 

[LADoc00]

Due in part to some of the emerging ideas on the future of pathology and our role in healthcare, personalized medicine, etc and also partially as a result of a recent visit by CAP prez Dr Schwartz (who is adament about pathologists remembering that they are physicians), all residents at my program have begun attending clinical rounds while on CP rotations. Are residents at any other programs going on clinical rounds, and if so, what are you experiences like? Do you find it worthwhile or just a waste of time?

what? hold it, ARE YOU SERIOUS??

LOLOLOLOLOLOLOLOLOLOLOLOLOLOLOL

what clinical rounds exactly?? There are dozens that occur in most modern medical centers every morning... Or do you pick 5?

 

[Gyric]

Did Dr. Schwartz really tell you to go out on rounds?!? I think I have heard a similar version of his pep talk and what I took away from it was the concept that Pathology’s turf is DIAGNOSIS and anything relevant to diagnosis should be part of our skill set. For example, pathologists should be comfortable using ultrasound guidance to perform FNAs. It makes most sense for pathologists to perform these procedures and ultrasound helps us do our job better and so it should be a reimbursable part of our practice, etc.

I benefit greatly from working closely with colleagues in other specialties, but not as their tag along diagnosis machine, this is the wrong approach. Clinicians should seek the pathologist out when they are stuck with a challenging case and this happens most readily if they know and trust you. Running interdepartmental conferences where interesting patients are presented or presenting patients at tumor board is a better use of your time I think.

 

[Psychopathology]

Pathology's turf is DIAGNOSIS and anything relevant to diagnosis should be part of our skill set... It makes most sense for pathologists to perform these procedures...

I benefit greatly from working closely with colleagues in other specialties, but not as their tag along diagnosis machine...

Disagree with the former and totally agree with the latter. I picture two internal medicine residents rounding with their teams...


Resident A: Let's order a stat troponin and CK-MB on Mr. Smith.

Resident B: But we're on rounds and it takes forever for labs to get drawn on this floor.

Resident A: Wait, don't we have a medical student with us?

Resident B: Even better! We're rounding with a PATHOLOGY RESIDENT on his clinical chemistry rotation! Venepuncture is part of his skill set since it is relevant to the diagnosis of myocardial infarction.

Resident A: We can have him draw the labs and maybe he can run them downstairs for us since he works there and can get the results faster. Since he rounds with us every morning, he can appreciate the need to have these results as soon as possible.

Resident B: Hurry up, pathology resident!

MS III: Do you need me to do anything?

Resident A: No, sit tight. We have a pathologist.


Likewise, the pathology resident mentioned above has no business participating in mediastinoscopic lymph node biopsies or brain biopsies. I know that some residents perform fine needle aspiration biopsies and in some instances bone marrows, but these are rare exceptions and probably should be.



On a serious note, I would greatly enjoy being a consultant and maintaining a strong alliance with clinicians. That's part of why I chose pathology. The field is fun and interesting but it is also integral to diagnosis and patient management. It is reasonable to expect the same levels of responsibility, compassion, and professionalism from us as we expect from our clinician colleagues. I'm interested in learning more about how we would fit in on rounds as I have had many positive experiences as a medical student rounding with clinical pharmacists, who are also "behind the scenes" more often than not and prove to be indispensable in helping us manage patients. I enjoy the thought of there being greater dialogue between pathologists and clinicians in light of encountering many interns and residents during clerkships who weren't quite sure what a pathologist actually does. I hope my silliness doesn't detract from this discussion.

 

[BU Pathology]

I actualy go on clinical rounds on an intermittent basis, which means spending about 1 to 2 hours per month. The group that I round with is the trauma critical care team and I will bring along one of the graduate students, post-doctoral fellows, or pathology residents working in my lab.

We round with the trauma surgeons because of mutual research interests, specifically having an NIH funded program project grant to study the immunobiology of trauma and peri-operative injury. My research team goes to their rounds, and the trauma surgeons/intensivists come to joint lab meetings.

The benefits of having a pathologist on rounds are multiple, from a clinical, research and business perspective.

Clinical: During rounds the clinicians do have questions, such as appropriate use of lab testing, interpretation of anatomic pathology reports, when to contact a medical examiner and numerous other issues. These issues are not sufficiently pressing that they will call you (remember these are critical care people) but they will ask if you are standing right there.

Research: It is very impressive for the graduate students to see how the trauma surgeons work in both the clinical and research arenas. The best data to show that this collaboration is effective: we were able to secure a large NIH grant to fund trauma research. The review group was impressed with our clinical investigations.

Business: Rounding allows you to network and maintain appropriate relationships with your customers, i.e. the clinicians. Pathology is viewed as a partner working for the health of the patient, rather than a remote entity only interested in reporting lab results. Maintaining customer satisfaction is key, even in a large academic medical center.

This is a specific example of where rounding yielded tangible benefits. While pathologists cannot attend every single rounds in the hospital spending a few hours a year is a worthwhile investment.

Dan Remick, M.D.
Chair of Pathology and Laboratory Medicine, Boston University

 

[pathdoc68]

But, who will be siging out my cases, covering frozens, reading paps and managing the clinical lab while I am rounding? Sounds like a nice indulgence for those individuals who have protected time for teaching or research. But in the real world I need to slap that glass for my baby to eat!

 

[2121115]

I benefit greatly from working closely with colleagues in other specialties, but not as their tag along diagnosis machine, this is the wrong approach.

I agree. This puts pathologists on the level with pharmacists and other allied health professionals that are there to assist with questions during rounds. We have other stuff we need to be doing (as the post above pointed out) and tagging along with rounds to answer questions if needed is not our role. Anesthesiologists do not round with surgeons in case they need a anesthesia question answered do they? No, they are busy in the OR (or checking their stocks, as the case may be). 🙂

My program is going to something of this model on CP rotations. Our coagulation residents go to hematology rounds and micro residents to ID rounds. While this may occasionally be good from an educational standpoint for residents (although I'm still a bit skeptical) I think it is not a good use of time for attendings. Overall I agree that this is likely a distortion of what Dr. Schwartz intended.

 

[exPCM]

I agree. This puts pathologists on the level with pharmacists and other allied health professionals that are there to assist with questions during rounds. We have other stuff we need to be doing (as the post above pointed out) and tagging along with rounds to answer questions if needed is not our role. Anesthesiologists do not round with surgeons in case they need a anesthesia question answered do they? No, they are busy in the OR (or checking their stocks, as the case may be). 🙂

My program is going to something of this model on CP rotations. Our coagulation residents go to hematology rounds and micro residents to ID rounds. While this may occasionally be good from an educational standpoint for residents (although I'm still a bit skeptical) I think it is not a good use of time for attendings. Overall I agree that this is likely a distortion of what Dr. Schwartz intended.

I agree completely with your post. The first thing we need to do is close half of the pathology residency programs. If there was not such an oversupply of pathologists, we would not see pathologists feeling compelled to kiss a** by rounding with clinicians. You do not see anesthesiologists or radiologists doing this kind of nonsense. If a clinician wanted a pathologist to go out and pick up the clinician's dry cleaning, I bet there are pathologists out there who would do that too.

 

[yaah]

I think you guys are missing the point. It's not about sucking up or increasing business, it's about trying to increase your knowledge of the interaction between pathology and clinical specialties, and figure out if we are doing things that don't help (and are therefore unnecessary and wasteful) or not doing things that do help. Obviously there are certain practices where this is not practical. And I don't think the suggestion is to spend every day on rounds. It's to increase, even if mildly, our interaction with clinical colleagues who depend on us. This can take many forms, only one of which is rounds. The truth is that many pathologists do a really crappy job of relating to clinicians, and this negatively impacts patient care and results.

 

[BurniNation]

Thanks for all the comments. Sounds like this is not something that is very common among residency programs. I believe that what BU Pathology said is most in line with what our program is trying to accomplish with the clinical rounds. We basically just spend 1 hour per week (and only while on CP rotations). It is something that we are trying out, and if it is not very useful, we will probably stop doing it. The main purpose is to encourage better interaction with our clinical colleagues. In an academic institution, rounds serve two main purposes: to get work done and to educate. I think we fall mainly into the 2nd category. We can definitely help the clinicians understand laboratory testing (particularly residents who have little exposure to pathology and laboratory medicine), and in turn, we can learn some clinical information which might make us better diagnosticians, lab directors, researchers, etc. I also think BU Pathology makes a great point from a business standpoint. It is important to "know and be known." It is good for our clinical colleagues to know us, to know the services we offer, and to know that we are available for them. In the grand scheme of things, 2-4 hours per month is not much to sacrifice if used appropriately.

Also, I did not mean to put words in Dr Schwartz's mouth by any means. The reason I mentioned him is because he places great emphasis on pathologists remembering that they are doctors/ physicians/ clinicians, and this is simply one way to demonstrate that. He never encouraged going on rounds (that I remember), and he might not even like the idea himself. So sorry for that confusion.

I'll update on how this works out and whether it turns out to be beneficial.

 

[docbiohazard]

Also, I did not mean to put words in Dr Schwartz's mouth by any means. The reason I mentioned him is because he places great emphasis on pathologists remembering that they are doctors/ physicians/ clinicians, and this is simply one way to demonstrate that. He never encouraged going on rounds (that I remember), and he might not even like the idea himself. So sorry for that confusion.

In his recent visit to Houston, at the HSCP he talked about how Anesthesiologists instituted a "pre-OP" visit, not so much to make money, but to increase their visibility to patients, increase their payment rate and decrease their incidence of being sued. He asserts that practicing gas-passers hated the idea at the time, but after the pre-OP visit became mandatory practice, many of them actually found they enjoyed it. They also increased their relevance by becoming the guardians of patient safety in the OR, and so forth. He pondered if, in some (not ALL) cases, patients (and the practice of Pathology) would benefit from meeting with a pathologist before they have a surgical excision / Whipple / whatever.

His other main point seemed to be that we should be laying claim to all things diagnostic, and embracing technology rather than fearing it. He also stressed how we were ultimately playing a role in determining therapy in certain instances (ie. if you diagnose a cancer as Her2+, you're effectively writing a script for herceptin).

DBH

 

[Patholo-gyst]

On our microbiology rotations, we rounded with infectious disease. We started in the micro lab, with everyone looking at the plates. I was asked about 10,000 questions per day about diseases, bugs, and antibiotics. It was actually really useful (for them) and I felt like they needed me or someone like me there. They always wanted to do things incorrectly--like swabs of wounds, etc., and they never knew what to ask for. I'm sure it varies, but I felt like I was helping them out more than I was getting ready for pathology boards or the practical practice of pathology. The idea was good, in practice, perhaps not so good.