Laying Out a Plan

See the video  about Montefiore’s nuclear medicine consultation clinic.

Thyroid cancer therapy has a high success rate, with five-year survival rates as high as 99% for most patients. But the path to that success feels uncertain, unfamiliar, and, in many ways, terrifying for patients. Words like nuclear and radiation understandably evoke fear — especially on top of a cancer diagnosis.

“Just the idea of coming to the nuclear medicine department is scary to patients,” says Renee M. Moadel, MD, MS, associate professor of radiology and director for the nuclear medicine residency program at Montefiore Medical Center in the Bronx, New York. “In most patients’ minds, the word nuclear is usually followed by disaster. It’s not a word associated with healing.”

To help patients feel more comfortable and prepared for treatment, Moadel developed a groundbreaking patient consultation program in the nuclear medicine clinic at Montefiore in 2005 — before the term patient-centered was a common part of the medical lexicon. Moadel meets directly with patients several days or weeks before their initial treatments to explain the care plan, address their concerns and questions, and ensure that they are mentally, physically, and emotionally equipped to deal with the realities of undergoing nuclear medicine treatment.

Renee M. Moadel, MD, MS, associate professor of radiology and director for the nuclear medicine residency program at Montefiore Medical Center, started a consultation program to help patients prepare for nuclear medicine treatment.

Even when patients don’t explicitly express fears, anxiety can affect their care experience and make it difficult for them to follow the precise preparations that nuclear medicine treatment requires. As a 2018 research project later confirmed, the consultations resulted in a smoother, less stressful treatment process for patients and physicians and quickly became the standard of care at Montefiore for thyroid cancer therapy as well as other nuclear medicine treatments. “I try to ensure that everything is laid out and planned appropriately so that patients can be treated in an orderly fashion,” Moadel says. “I try to treat every patient as if they were my family member.”

Preparing for Treatment

Moadel conceived the idea for the consultation program soon after she became an attending physician in nuclear medicine at Montefiore, an academic medical center serving a diverse population in New York City and its northern suburbs. She noticed that at least 50% of thyroid cancer patients arrived for their first appointments unprepared and uninformed about their treatments, leading to frustration, rescheduled appointments, and wasted time and resources.

Thyroid cancer therapy often involves radiopharmaceuticals, which sometimes sound scary to patients but are usually safe and effective when proper precautions are followed, according to Moadel. At Montefiore, nuclear medicine physicians and their teams take steps to ensure efficient treatment before patients arrive for their appointments. Administrative personnel coordinate with the patient’s insurance company and facilitate communication between the care team and the patient. On the day of the appointment, the nuclear medicine technician orders and prepares the medication and has it ready when the patient arrives.

Patients must also take steps to prepare for the treatment. These may include starting or stopping certain medications, modifying their diets, and, for women of childbearing potential, undergoing blood testing to rule out pregnancy. Patients also need to secure a place to self-isolate after their treatments to avoid exposing roommates or family members to radiation. In doing so, patients sometimes need to adjust their living arrangements, arrange for childcare, and take time off from work. “It’s a big process; there’s a lot the patient has to do,” Moadel says.

If all of the pieces aren’t in place, the appointment must be rescheduled, delaying needed care, causing undue stress for the patient, and wasting medical resources. As Moadel saw patients repeatedly arrive unprepared for their appointments, she knew something needed to be done and conceived the idea of meeting with patients prior to their treatments to explain what they needed to do to prepare for their appointments and ease their concerns.

Moadel pitched the idea for the consultation program to the chair of the nuclear medicine department (nuclear medicine was a separate department from radiology at the time). With their blessing, she began scheduling her first patient consultations using a spare conference or exam room.

Increasing Care Coordination

A few weeks before their scheduled treatment, Moadel meets with patients in a room that is set up more like an office than an exam room to help patients and their family members feel comfortable and allow time for questions and concerns about the recommended treatment. During the 45-minute consultations, Moadel reviews the treatment timeline with patients, using lay terms to ensure patients understand what they need to do and why, while giving them reassurance about what lies ahead.

At the first few appointments, Moadel wrote the treatment timeline on a piece of paper so that patients could visualize the treatment steps, but she soon developed a form she can easily fill out and share with patients. In it, she outlines what patients should do and expect before, during, and after treatment, including possible side effects. Patients use the form as a resource to help them stay on track with their treatment plans.

“The important part of the consultation for me was what the treatment pathway was going to be, how they were going to approach the treatment, what the outcomes were, and what I was going to have to do to manage myself in going through this treatment,” says Terence Ma, a Montefiore nuclear medicine patient.

When possible, Man Yu Chen, radiation safety officer at Montefiore, joins the consultations to determine whether patients have safe places at home to self-isolate or if they need to be admitted to the hospital for treatment. Finding a place with their own bedroom and bathroom can be difficult for many members of Montefiore’s patient population, half of whom qualify for Medicaid and another 10% of whom have no insurance. “You can’t send a radioactive patient home where there are five people living in a one-bedroom apartment,” Moadel notes.

Man Yu Chen, radiation safety officer at Montefiore, says the consultations help patients feel empowered to manage their care.

While most patients arrive with lots of worries about the long- and short-term side effects of radiation treatment and the possible impacts on their family members and co-workers, they usually leave the consultations feeling relieved and empowered to manage their care, Chen says. Ma agrees, saying, “The thing that was impressive about what happened at Montefiore was that the physicians kept very close track of what was going to happen and when.” The reassurance, he says, helped increase his confidence in the treatment and his care team.

Helping Referring Physicians

Although Moadel designed the program with patients in mind, she quickly realized that referring physicians also appreciated the consultations. She shares each patient’s treatment timeline with their referring physician and enters it into the electronic health record as a reference for the care team. “I’ve had referring physicians tell me that we’ve taken a huge load off of them. They’re overjoyed that we’re coordinating care and that patients understand what is going on,” she says.

In fact, soon after Moadel started the consultation program, referring physicians began asking other the nuclear medicine physicians at Montefiore if they offered a similar service to patients. The idea took hold at Montefiore’s two campuses, and the nuclear medicine department applied it to other treatments it offers, including those for liver, prostate, and neuroendocrine cancers.

Now, four nuclear medicine physicians conduct these consultations with 200 to 300 patients annually. Each physician tailors the consultations to their patients’ unique needs and treatment plans.
Moadel says that she and her colleagues continually update the content of the consultation and improve delivery of the information to patients and referring clinicians. The program has the full support of the division head, and it aligns with the radiology department’s emphasis on patient- and family-centered care and Montefiore’s comprehensive team-based care approach.

Planning Ahead

Since Moadel and the other physicians started the consultations, the department no longer has to reschedule appointments because patients are unprepared.

While the extra time that the nuclear medicine physicians spend conducting these patient consultations is not billable, Moadel still documents the visit in the record. Moadel believes programs like this have the potential to advance the recognition that radiologists and nuclear medicine physicians are patient-facing providers, especially as payers shift to value-based reimbursement.

Regardless of the availability of reimbursement, Moadel insists that meeting with patients to ensure the highest quality and most timely care is the right thing to do and encourages others to take a similar approach to patient care. “Whether or not the consultations were recognized as reimbursed was never the point,” she says. “The point is to ensure that treatment goes as seamlessly as possible for patients. Hopefully, we alleviate their fears when we talk to them about the therapy beforehand, and patients’ cancers are treated in the process.”