A Clinical Calculus

The role of the pathologist is growing and changing. Precision medicine has certainly brought about more biomarker testing from a volume perspective – but the nature of that testing is also evolving. Predictive biomarker testing in precision medicine is of the “high-risk” variety, especially when it is used to select patients for targeted therapies. Nowadays, pathologists are required not only to analyze and report more informational parameters for the same testing, but also to issue reports for more of the new, high-risk biomarker testing that necessarily accompanies precision medicine.

What does that mean for our day-to-day work? Precision medicine is an exciting development, but for pathologists “on the ground,” it is important to recognize that new advances – not to mention an aging population – are often accompanied by increases in the volume, complexity and risk level of our workload. On a routine basis, this translates into longer and more complex reports, additional quality assurance measures for all phases of biomarker testing, and the often-overlooked need for better training and administration to support these changes. Pathology residents need to be taught the new tests and reporting parameters; pathologist assistants need to be introduced to increasingly complex duties; pathologists need to devote more hours to quality assurance activities, meetings with colleagues, laboratory managers and administrators… the hours just keep mounting up.

How much is too much?

In kinder and gentler times, one of the best ways to determine a safe workload – or tell when it was being exceeded – was the simple act of listening to pathologists. But in today’s world of evidence-based medicine and data-driven decisions, that is unfortunately no longer a realistic option. Metrics and benchmarking now dominate such discourse – and in a world where numbers reign supreme, it can be difficult to establish qualitative boundaries like “safe” workloads.

Pathology is certainly one of the medical specialties where focus, attention, and mental fatigue need to be foremost in our minds. When considering the work we do in our everyday practice, we need to be aware of the level at which we are functioning. “Am I still capable of assessing these samples accurately? Am I experiencing fatigue? Am I having difficulty concentrating? Are my reports still of the same quality as they were when I began work?” Sadly, we cannot necessarily tell when we are beginning to exceed safe workload levels; often, that only becomes apparent after mistakes come to light.

Complexity at the office

The Automatable Activity-Based Approach to Complexity Unit Scoring (AABACUS), like any workload model, primarily captures work done in the clinical sphere. For pathologists, this includes not only activities relating to microscopic assessment and the generation of diagnostic medical reports, but also those around grossing, frozen section coverage, one-to-one resident teaching, and, of course, quality assurance activities like review of clinical charts or radiology images, and intra-departmental consultations from colleagues. Because it is an activity-based model, AABACUS takes information documented in one or more laboratory information systems (LIS) as part of usual clinical practice and translates it into workload activities. These activities are then counted, scored (by applying a complexity factor), and translated into the complexity units (CUs) – the base unit of AABACUS. What can we do with these clinical activity scores? We can attribute them to institutions, sites, practice groups or individual staff members, which allows us to appropriately filter the questions we ask. That way, we can conduct analyses of staffing levels, resource allocation, utilization, impact and case costing (see, “A Counting Frame for Workloads”).

It is important to remember that the amount of data that can be extracted for AABACUS is directly proportional to the amount stored in your LIS. The more you use the LIS as part of your workflow, the more robust the AABACUS data capture will be.

Data for decisions

AABACUS’ primary function is workload assessment for the purposes of staffing – helping to determine how many full-time equivalent positions (FTEs) an institution needs to perform the work it generates and receives. AABACUS accomplishes this by taking the total CUs for the target institution for a calendar year and dividing that by the total CUs per allotted (funded) FTE for a “benchmark” institution for the same time period. The result is the number of FTEs that the target institution would require to tackle a similar workload to that of the benchmark institution. We call this “relative benchmarking.”

Why does AABACUS work this way? It was developed in a multi-institutional, multi-site environment with general and subspecialty sign-out, incorporating both community and academic practices in anatomical pathology, cytopathology, neuropathology, and hematopathology (solid and liquid). This diversity made AABACUS robust and enabled us to isolate certain practices (for example, by institution) so that we could develop and apply relative benchmarks to staffing. It has also made the model a powerful tool – AABACUS can be applied to subspecialty staffing questions as well. For example, if overall staffing calculations determine that a new position is justified, which practice group would get the new pathologist? AABACUS can help answer that question by taking the total CUs from the work attributed to a practice group and dividing it by the total number of FTEs allotted to that practice group. But note that AABACUS only provides information that can assist with the decision; it cannot make the decision for you.

Workload models, including AABACUS, are a reflection of pathology clinical practice for the environment in which they are being used – not the other way around. Any workload model has underlying assumptions, and the most important underlying assumption AABACUS makes is that your pathology clinical practice is legitimate and appropriate. Workload models can provide data and information, but the significance of the information must be interpreted in the proper context and by the proper decision-makers. AABACUS should reflect appropriate pathology practice; it should neither influence nor dictate such practice. Again, it is not a decision-maker – it is a tool to support the people who have to make the tough decisions.

Unfortunately, there are no magic bullets to alleviate pathologist workloads. Fiscal realities will always affect the practice of medicine, especially in the face of an aging population and an increasing availability of novel therapies as precision medicine expands its remit. I hope we get to a point where pathologists no longer have to keep their own workloads under control as individuals – that’s just one more challenge to be addressed during a busy workday. Instead, I hope that non-pathologists will become more aware of the importance of our work to clinical care – and between that awareness and the availability of tools like AABACUS, workload management will become integrated into institutional processes to provide the best – and safest – care possible.