In medical consultation, patients want to know they are receiving the most informed expert opinion about their condition, care and treatment. But does that opinion always have to come from a Medical Doctor (MD), or is it possible that someone else might have equally — or even more — relevant information worth sharing?
The same question applies to Diagnostic Management Team (DMT) leadership. The DMT concept is gaining ground as a way to reduce the high incidence of medical errors occurring in the United States by convening a multi-disciplinary group of medical experts to meet on a regular basis, evaluate specific current cases, and provide an easy-to-interpret written report that becomes part of the patient’s medical record.
Many might automatically assume that an MD is the best person to lead a DMT, but this may not necessarily be the case. Other medical experts also have valuable expertise and unique skill sets to contribute in a DMT leadership role.
Finding the most qualified person to lead a DMT is a critical factor in establishing the group’s potential for success. Firstly, any prospective DMT leader must demonstrate deep knowledge of the specific area or topic to be addressed.
The DMT leader can be a diagnostic expert from any department, as long as the leader understands that the group must be able to generate a differential or specific diagnosis based on the results of diagnostic tests in a clinical context without actually performing a physical exam on the patient.
Although there’s no question that many non-MDs possess the levels of knowledge and experience required to lead a DMT, reimbursement issues may hinder them from doing so.
“Insurance companies only currently pay individuals with the MD or DO designation for creating interpretations in a diagnostic management team setting,” said Dr. Michael Laposata, Leader of a Coagulation DMT at the University of Texas Medical Branch in Galveston. “The unwillingness to pay PhD laboratory experts, who may have more expertise in certain areas than their MD/DO colleagues and can often provide advice that’s more valuable to the diagnosis, may discourage PhDs from pursuing DMT leadership.”
Dr. Laposata singles out toxicology as a field in which the vast majority of experts hold PhD degrees, not MDs.
“MD psychiatrists and PhD psychologists are both paid for their clinical activity,” he continued. “It’s my personal opinion that it’s time to pay all doctoral-level experts who lead a DMT that provides accurate, timely diagnoses for their time and contributions.”
The talents of many non-MDs lie in research and knowledge of interferences in test performance, both areas of high importance in the DMT format, and also in the additional training they receive on the technical side of test performance.
“Pathologists hold certain advantages for becoming DMT leaders,” Dr. Laposata said. “Their lab leadership responsibilities make it easier to request the performance of additional tests, and the focus of their training is to learn what diagnostic tests indicate and how they might possibly be misleading.”
Dr. F. Michael Walsh, Chief Medical Officer of Aurora Diagnostics, agrees with Dr. Laposata.
“Diagnostic and medical practice silos are a major barrier to achieving effective, efficient patient care,” he said. “Since diagnostic information constitutes approximately 65 percent of the medical record, the pathologist is ideally positioned to review, analyze and opine on the data. Integration, timely review and interpretation of patient data are what will reduce the probabilities of diagnostic error that may result in patient harm and increased costs.”
Once a DMT leader has been established, the next step is to assemble the rest of the team. A well-rounded DMT should include representation from across disciplines and departments to provide the most comprehensive and diverse level of insight.
“Individuals from different backgrounds read different journals,” Dr. Laposata pointed out. “Because of that, articles that shed light on cases at a DMT come from many prominent journals outside of the ones most commonly known to the group’s leader.”
Dr. Laposata’s coagulation DMT at UTMB includes physicians from critical care and hematology, clinical laboratory scientists, and trainees from different clinical programs. In Toledo, Laboratory Medicine/Aurora Diagnostics consultants are coordinating a multidisciplinary project in breast pathology designed to enhance diagnostics and improve patient experience and satisfaction. Pathologists lead this DMT with participation from physicians in radiology, oncology and surgery; and non-physicians in pharmacology and social work. Enlisting the services of a librarian or research expert can also support the goals of any DMT, especially in time savings when gathering data.
For residents, DMT participation can provide valuable learning opportunities in a one-of-a-kind teaching/mentoring environment.
“Clinical pathology residents aren’t usually trained in formal consultative support for patient care, when the goal should be to teach residents about the value of effective consultative communication regarding test utilization and interpretation,” said Dr. Juan Olano, Director of the Pathology Residency Training Program at the University of Texas Medical Branch. “Through the UTMB curriculum, residents in the coagulation DMT get online tutorials for rotation tools and learn how to select cases, service an initial review, and create the DMT report in EPIC.”
UTMB residents who participate in the DMT demonstrate a statistically significant increase in coagulation RISE scores between pre- and post-DMT timeframes.
“Resident satisfaction levels with fully developed DMTs are high,” Dr. Olano added. “We’ve concluded that this educational experience should be included with conventional lecture-style sessions and discussions during rotations.”
It’s Dr. Laposata’s hope that a certification exam will eventually become the gold-standard qualification for DMT leadership. For now, he’s happy to see the concept finding applications as a teaching tool for all involved
“New DMT leaders gain case experience when they help formulate the interpretation of the test results and the recommendations for diagnostic or therapeutic action in the presence of a more experienced expert,” Dr. Laposata explained. “By the time 100 to 200 cases are discussed, in my experience, a new DMT leader can sign out more than 95 percent of the cases independently.”
He also expects to see the first DCLS DMT leader in place at UTMB after she graduates next year.
“Her special interest is in the diagnosis of anemias,” he said. “She is highly capable of identifying the individual anemias from morphology to genetics, and she will be supported strongly by members of the pathology department in this role.”
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