Pathologists as Gatekeepers For Improved Outcomes?  

Pathologists somewhere along the way became known as “The Doctor’s Doctor”. Not sure who this started with or when but it is an unfortunate term that the specialty has propagated. The implication for the public and healthcare providers alike I think is that the laboratory is a black box of bewildering equipment and microscopes where specimens are received, processed, tested and a diagnosis miraculously appears in your medical record. The pathologist is to be the liaison for the laboratory and the ordering physician taking care of a patient. The information communicated between the pathologist and the clinician will result in an action plan or treatment strategy or more tests or no additional treatment acutely.

This paradigm or algorithm for communicating laboratory findings to assist with patient care has served healthcare well but should pathologists do more?

Many institutions and healthcare organizations within their medical staff bylaws and clinical business policies require that “a new or unexpected diagnosis of malignancy”, as an example, require the pathologist to tell the ordering provider of the result at the time of diagnosis. A skin biopsy, for example, that was performed to “rule of seborrheic keratosis” that turns out to be a malignant melanoma, requires physician to physician notification of the “new or unexpected malignant diagnosis”, particularly when the pre-test clinical diagnosis does not match the pathology interpretation. There are many iterations of this but the communication would be provided to the physician who performed the biopsy, or perhaps to a supervised resident or fellow or physician assistant who performed the biopsy.

A 1:1 relationship exists between the pathologist and the ordering physician.

What happens when a “gatekeeper” is notified that may necessitate additional consultations? This part is usually of less consequence to a laboratory medical director. The lab did its part to notify the ordering provider and meet its responsibility to the patient. Or did we?

“Gatekeepers” I think are a term that became popular after the passage of the Health Maintenance Organization (HMO) Act in 1973. HMOs require members to select a primary care physician as a doctor who act as their “gatekeeper” to direct access to medical services. Commonly, in adult medicine, these are internists, but may be family medicine, pediatricians, nurse practioners (NPs) or physician assistants (PAs), particularly in the instance of “who did the biopsy” for the purposes here. Recognize that licensed physicians supervising the NPs or PAs would be the “gatekeeper” with newly formed “physician extender” models of care.

Except in emergency situations, patients typically need a referral from the primary care provider, or “gatekeeper” to see another specialist or other doctor.

With other insurance plans admittedly this may not be the case, a patient can schedule a personal appointment with a neurosurgeon at their discretion but with increasingly integrated healthcare delivery systems, accountable care organizations and bundled payment models replacing fee-for-service models, for purposes of this discussion let’s stick with a “gatekeeper” model.

What should a pathologist do if the gatekeeper orders, say a FIT test to screen for colorectal cancer and the test is positive, which given its published specificity for colorectal cancer, requires additional testing.

Is it enough to simply the report the test, perhaps “flag” the result as “abnormal” given this is a screening test and assume the internal medicine physician, family practioner or NP will 1) order a gastroenterology consult to 2) have a gastroenterologist perform a colonoscopy and 3) coordinate this in a timely fashion in case the patient has colon cancer? There is more actually before any of this happens. Since the test is actually collected by the patient on formed stool at home, there may be a delay between the time the patient gets the vial, collects the specimen and returns it to the laboratory…

Labs may track how many are ordered, how many are received and the date received in order to track % of tests returned for both efficacy of the screening test and cost of the actual testing.

It was recently suggested to me that when the lab has a positive FIT test, the lab should notify an endoscopist that the patient needs a colonoscopy. Why should the gatekeeper get the result after giving out the vial 2 months earlier, schedule a GI consult that reads “Positive FIT test. Needs colonoscopy” to have a GI doc schedule a colonoscopy?

Laboratories send out 6-month follow-up letters to providers on patients that have high grade pap smears without tissue follow up as a courtesy reminder so that patients are not “lost to follow up”.

Should we send those letters directly to the patients? Or to colposcopists?

Should every positive FIT test or high grade pap perhaps bypass the gatekeeper and generate a consult from a pathologist to a specialist? Ditto for malignant skin or GI or lung biopsies? Forget calling the dermatologist. Get a Mohs surgeon or colorectal surgeon or thoracic surgeon on the phone and tell them a patient they have never met, who they have no relationship with, may need your services. Call the patient and tell them “You had a positive FIT test – that thing you sent back in the mail, you may have colon cancer, you need to schedule an appointment to see me. I will hang up but you stay on the line and press 0 to speak with our scheduler about coming in and where we are located.”

The next time I see an abnormal blood smear on a routine CBC, perhaps just skip calling the patient’s primary care provider and just call my hematologist friend.

Next high grade pap – forget the NP and his/her preferred consultants and just call my favorite gynecologist to tell him/her I have another patient for them to see based on my read of a pap smear

So, pathologists as gatekeepers?

The idea is absurd enough it might just work.

Specialists for miles around will be providing their cell phones, emails, work phones, home addresses to every pathologist they know to call them anytime for any abnormal lab result that could potentially be in their wheelhouse.

After all, the pathologist is The Doctor’s Doctor. We didn’t actually specify which doctor.

The problem of course is where does this leave the patient’s doctor. Their “real” doctor, their real primary care giver, their primary care manager. The one who is responsible for all health screenings and coordination of care? One who oversees what they can treat and refers what they can’t?

Despite what some physicians have suggested to me recently about this I think I know what would happen, say if I called a gastroenterologist directly with a positive FIT test for a patient they do not know, they should say “Why are you calling me? Who is the patient’s doctor and why is a pathologist ordering a GI consult?”