From Bench to Bedside: Clinical practice examples
Example 8: Outpatient thyroid cancer consultation, Lausanne University Hospital
Background
Lausanne University Hospital is a tertiary academic medical center in Lausanne, Switzerland. Patients with thyroid cancer are treated by a multidisciplinary team, with the majority being followed in an ambulatory setting at the thyroid consultation of the Service of Endocrinology, Diabetology and Metabolism. Paper-and-pencil-based PROMs were introduced in this consultation in late 2024.
The PROMs are intended as a screening tool for thyroid cancer patients in outpatient consultations, covering somatic, psychological, and other concerns. They capture both issues that physicians should routinely check anyway and complaints that may be missed in a standard, targeted medical history during a routine visit.
Instruments: We use the EORTC QLQ-C30 and QLQ-THY34, the latter being a module that is specific to thyroid cancer patients.
Assessment timing and frequency: Patients complete both PROMs before their scheduled outpatient consultation. After discussing the results, they are asked whether they want to complete them again at the next visit. Consultation frequency varies: typically every 6–12 months in remission, and much more often during active treatment.
PROMs are highly valued in our hospital, including because their use is now a criterion in Newsweek’s “World’s Best Hospitals” ranking (we ranked 13th worldwide in 2024: https://www.newsweek.com/rankings/worlds-best-hospitals-2024).
Paper-pencil-based PRO assessment: We chose paper-based PROMs as we currently lack infrastructure and central support for ePROs. Consequently, PROM implementation in our service must rely on existing resources and staff.
Clinical workflow: Before a scheduled consultation, patients receive a mailed invitation to complete PROMs at home and bring them to the appointment. Physicians compile the patient list; a secretary mails invitations and questionnaires. For telephone/video consultations, a pre-stamped return envelope is included. The invitation explains that PROMs are sent to all patients, assess HRQoL, are scientifically validated, will be discussed during the consultation, and then become part of the hospital medical record. Non‑French-speaking patients receive questionnaires in a language they understand when available; the physician checks responses against the French version.
Lerning material: As most participating physicians lack formal training in QoL issues and have limited time, each receives a short (half‑page) written instruction sheet on handling PROMs. After the consultation, completed questionnaires are scanned into the patient’s electronic medical record (EMR).
At the consultation, patients hand in the PROMs (QLQ-C30 + QLQ-THY34). The physician quickly screens the four pages in the patient’s presence, looking for responses in the upper or lower half of the relevant Likert scales (depending on item direction) that may indicate concerns. This visual check takes only a few seconds.
Discussion and documentation: After the quick visual screen, the physician discusses with the patient every questions that indicates a concern, to clarify issues (e.g., misunderstood or not relevant questions). A brief PROM note is then added to the EMR within the consultation note, documenting:
- whether the PROMs were completed
- whether the patient completed them unaided
- each discussed question with a short note on the issue and how it was addressed
- whether the patient wants to complete PROMs again before the next visit
These documentation points are listed on a half-page guidance sheet each physician received at implementation start.
For each PROM item raising a substantial concern, the physician discusses it with the patient and, if relevant, agrees on an action (e.g., treatment changes, physiotherapy, referral to a psychologist, or referral to a nurse for social support). Issues unrelated to the current disease may be referred to other specialists. If no decision can be made immediately, the case is discussed with a senior physician and/or the multidisciplinary team.
Feedback is given directly during the consultation when the physician discusses the PROMs with the patient—sometimes as noting “ concerns” or highlighting a specific issue the patient reports. These remarks can also prompt further discussion.
Acceptance by patients: So far, the paper-based PROM approach has been easy to implement. Patients generally complete the PROMs and bring them to the first consultation when invited. Afterwards, some want to continue routinely, while others prefer to complete only when they feel it is necessary. Some patients are initially surprised and unsure whether PROMs are meant to benefit them or the physician.
Need for evaluation: Responses sometimes reveal unexpected issues not anticipated during PROM development, while some questions are confusing, ambiguous, or not relevant for certain patients. In the medium term, a formal analysis of patient and clinician feedback is needed to assess the added value of routine use.
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