Breast Care Specialists:

A Multidisciplinary Approach to Breast Health (Three Surgeons, Two radiologists, 25,000 Patients)

Patients who fear they may have breast cancer are finding that many of their questions and anxieties can be addressed quickly and effectively at Breast Care Specialists, L.L.C. This revolutionary group practice of six female physicians in the Northside Hospital/Saint Joseph's Hospital area combines the expertise of four breast surgeons and two diagnostic radiologists in diagnosing and treating over 25,000 patients per year.

Surgeons Elizabeth P. Steinhaus, Jennifer L. Amerson, Brenda B. Simpson, and Laura M. Rivers work in tandem with radiologists Christine H. Murphy and Pamela M. Donlan to provide dual consultative care under on roof. In one visit, a patient receives a thorough review of all relevant outside records and films, a physical exam, radiological interpretation of their mammogram or ultrasound, and often, a tentative diagnosis.

"Most of the time, we can give the patient a tentative diagnosis such as a likely benign condition, such as a cyst or fiboadenoma, "says Practice Administrator Margaret Bramwell. "In other cases, we can give the patient the tentative results that point to a possible malignancy, according to our radiological study."

However, no cancer diagnosis is definitive until the pathology report confirms a malignancy. Breast Care Specialists' relationships with the pathology departments at Northside Hospital and other area facilities allow biopsies to be scheduled with-in just a few days of the patient's initial visit, resulting in a timely delivery of results. Their mission is to provide patient-centered care-- one of the essential requirements where the potential diagnosis of breast cancer is involved.

USING TECHNOLOGIES TO DETECT AND DIAGNOSE
Breast Care Specialists employs overlapping technologies to detect breast abnormalities and possible cancers. Ultrasound is often used in conjunction with mammography to obtain different views of the breast and its tissues. However, these technologies, while the best available at the current, are not infallible.

"I personally feel that mammography does a very good job. Is it perfect? No, but I don't know what is. It's the best we've got right now," states Dr. Pamela Donlan. "in the last 20-25 years, we've concentrated in this country on improving the technology, but we haven't sat back and said, 'That's good enough.' Medicine in America doesn't do that--it's one of the beautiful things that no other country can compete with."

There is another piece of equipment that is proving to be more sensitive at detecting cancers than mammogram and ultrasound--the breast MRI. Special dedicated-breast MRIs are available, including one located at Breast Care Specialists.

The aurora Breast MR imaging system the practice has purchased is ideal for a wide range of indications in breast disease management, including characterizing lesions, detecting occult cancer, determining the extent of cancer, monitoring cancer therapy, evaluating patients with positive surgical margins for residual cancer, excluding the existence of cancer in high-risk women, and evaluating breast implant integrity and detecting cancer in women with breast augmentation. These attributes are extremely helpful in examining women who have experienced impaired mammography due to dense breast tissue, scarring from recurrent cancer, high risk of breast cancer based on family history and more.

"If we find something of concern in the breast exam, we have to give the surgeon a map in order for him or her to be able to biopsy," explains Donlan. "The dedicated-breast MR allows us to do that with its systematic protocol."

PROFESSIONAL LIABILITY AND THE PURSUIT OF CANCER DIAGNOSIS: CAN THEY COEXIST?
Just as it is in other high-risk medical specialties, the liability insurance for physicians who diagnose and treat breast cancer is skyrocketing. Although Breast Cancer Specialists has been lucky in that its insurer, MAG Mutual, offers a special category for breast surgery, the practice's premiums still have escalated tremendously in the last two years, with another increase predicted for the coming year.

"What do we do? We have to have coverage by law. No one radiologically misses a cancer on purpose; it's human error, not negligence," says Bramwell. "But like other specialties, we need to control the rising cost of professional liability insurance, or else the cost of being in the profession will be too great."

Breast Care Specialists are advocates of tort reform in Georgia's legal system and caps on damages awarded by the courts, as well as the qualifications for expert witnesses utilized in these trials. "The idea that we should be able to detect every kink of cancer is a fallacy. A cancer may be here today, but three years before we have a mammogram that we didn't think had cancer on it, " says Donlan. "But you might find another radiologist who (for the right price) may say, 'I think I see something here.' It's so subjective."

In many ways, the professional liability issue has paralyzed the diagnostic community. Fewer people are choosing to go into the field-- it's tough work, the pay scale is relatively low, and the potential for being involved in litigation is high. In addition, many referring physicians choose to send their patients to specialists simply ecause they are afraid of the nature of breast-related claims in the industry.

We are going to fight the fight with the insurers," says Elizabeth Steinhaus, M.D. "The physicians who refer to us should be able to send their patients here if they choose. And we should be able to treat their patients without reservation."

THE BENEFITS OF COLLABORATION: RADIOLOGISTS AND SURGEONS UNDER ONE ROOF?
Having radiologists and surgeons practicing together offers numerous benefits to the patients who visit Breast Care Specialists.

In a regular screening and diagnostic scenario, a patient whose mammogram shows abnormalities might go through a series of many appointments with a screening clinic and a surgeon, possibly never seeing a radiologist. Ultimately, the patient may have had a waiting period of a few weeks before receiving a definitive diagnosis.

However, the system at Breast Care Specialists is fast, efficient and completely patient-focused. Patients who are referred to Breast Care Specialists pay fewer visits overall because the surgeons, radiologists and services are all under one roof, and many diagnostic tests can be performed on the same day before the patient goes home.

The multidisciplinary approach of Breast Care Specialists allows a patient to be examined by both surgeons and radioligists, all of whom are breast specialists. Each patient benefits from the knowledge and expertise of all six medical practitioners and their extended staff.

And the good news is that the majority of patients who visit Breast Care Specialists do not have breast cancer. Out of 25,000 patients seen in a year, about 445 cancers--two percent of the total--are actually diagnosed.

"Everyone who walks through our doors may think he or she has breast cancer, so the anxiety level is quite high," explains Bramwell. "When a patient arrives, we want to get them as far through the diagnostic process as possible on the first day so that we can at least send them home with some kind of opinion. It's important to appreciate that anxiety and profide comfort as much as we possibly can."