Leading the Way

Why should pathologists become leaders? The very future of our profession hangs in the balance. Pathology’s future is brighter than ever, thanks to exciting new advances in biomarker discovery that let us deliver better healthcare outcomes for our patients through effective and timely laboratory tests and services. But as precision medicine grows increasingly popular, strong leadership from pathologists is paramount to ensuring that we – and not other specialists – are the ones actually performing and interpreting these new tests. We can’t afford to have internists or oncologists “eat our lunch!” Given hospital administrators’ relentless attention to the financial bottom line, nothing less than the viability and sustainability of our clinical laboratories is at risk. If we as pathologists do not lead the way and demonstrate our value to patients, to our clinical colleagues, and to hospital and regional health system administrators, it will also become increasingly difficult to encourage a new generation of physicians to enter our specialty.

The value of a pathologist

First and foremost, a pathologist’s job is to make a timely, accurate, clinically useful diagnosis based on the examination of a patient’s tissue or fluid samples. But our role does not end there. Every day, we provide guidance in terms of the effect of our diagnosis on patient care – possible genetic implications for the patient’s family; the need for further diagnostic testing or other investigations; guidance on clinical management and therapeutic decision-making (for instance, precision medicine based on the results of cancer biomarker testing); and much more. Clinical pathologists, in particular, guide clinicians on critical matters in transfusion medicine, infection control, and antibiotic stewardship, to name just a few of their key roles.

Certified pathologists are skilled in making accurate diagnoses and interpreting complex test results from ancillary techniques such as molecular diagnostics and flow cytometry. As physicians with special expertise in laboratory medicine, we are uniquely placed to combine information from laboratory test results and basic sciences with clinical medicine (for instance, the patient’s clinical presentation, diagnostic imaging, and intra-operative findings). Although many of our activities in patient-centered care are currently focused on personalized cancer treatment, our value is truly much broader than any specific disease group. Patient-specific blood product transfusion needs are a great example of this. Laboratory medical directors can ensure that patients have privacy when providing specimens for testing, followed by access to their test results via easy-to-read, plain-language reports through hospital patient portals. Pathologists can use their knowledge of medical informatics to advocate for interoperability of laboratory information systems across regional healthcare systems, so that patients’ results are available seamlessly across a continuum of care – for instance, from a community-based primary care setting to an academic tertiary or quaternary care hospital. Similarly, the adoption of digital pathology is enabling pathologists to provide more timely diagnostic information to patients in remote or rural communities. Examples that come to mind include interpretation of abnormal blood smears, Gram stains, or frozen sections.

Pathologists also play a vital part in educating clinicians, particularly in the realm of appropriate test utilization. For example, with the convergence of technologies in artificial intelligence, digital medicine, and medical informatics, there are tremendous opportunities for pathologists to create new value for their healthcare ecosystems through enhanced clinical decision support and appropriate test utilization. With new medical information arriving on a daily basis, our knowledge around laboratory tests increases – and clinicians are scrambling to keep up to date. Add to this the risk avoidance that our medical expertise offers to both clinicians and to hospital administrators, and it becomes increasingly apparent how much value an experienced, locally available pathologist brings tremendous value to the table. It is, quite frankly, indispensable!

Patient-centered care

The concept of “patient-centered” care seems self-evident; after all, haven’t physicians have always focused on the patient and advocated on the patient’s behalf? Of course they have! But the definition of patient-centered care has evolved. Its modern meaning deals with developing systems, processes and pathways that keep the patient at the center of the planning, rather than traditional healthcare models that place the physicians’ and hospitals’ needs first. Long wait times, poorly coordinated care amongst a variety of healthcare providers, and multiple specialists all duplicating their efforts in history-taking and documentation are all too evident in the existing model of care. Perhaps the greatest value that pathologists bring to the new model is their interest and expertise in the information in patient data repositories (laboratory information systems and electronic medical records), and their efforts toward making this critically important patient information quickly and easily transferrable from one health care provider to another. It is often stated that over 70 percent of clinical decisions are driven by laboratory results (1), but more work is required to ensure that this information can be accessed more readily by a wider array of healthcare professionals, including those working in medical data registries, pharmacies, and at the point of care.  Pathologists, by the very nature of their generally broad practice, tend to work in teams more often than other physicians – and, counter to common stereotypes, are more likely to have strong team-building skills and experience with collegial and collaborative approaches to problem-solving.

As we move from a volume-based to a value-based care model, these skills and attributes are becoming more important than ever. Modern-day technological, healthcare, and economic realities are such that volume-based care will likely not be sustainable beyond the next five years. Governments and payors are increasingly seeking innovative ways to fund healthcare, and I expect that we will see continued evolution of models of health funding reform (especially those based on the bundling of services that were once paid for individually). Efforts focused on healthcare outcomes for patients and institutions, rather than episodic care, will be rewarded for meeting predetermined favorable criteria – and punished for adverse events. This value concept can be neatly summarized in a mathematical expression:

patient outcomes × patient satisfaction × timely access to care

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cost

In such an environment, laboratories can demonstrate value – or even create new value – by focusing on clinical deliverables and helping to ensure that their organization performs well in external benchmarking with peer group institutions. For example, availability of point-of-care lactate testing in the emergency department for patients suspected of having sepsis can save lives through prompt triaging and timely care. The ready availability of critical test results – and thus, the ability to make rapid clinical decisions – lead not only to favorable patient outcomes, but also to better performance against other hospitals. And who better than pathologists to evaluate which tests to offer, which platforms to use, where to conduct tests, and which provide the best cost-benefit ratio and risk mitigation?

Value-based care will impact every pathologist differently. Those who currently practice primarily in fee-for-service environments (like high-volume dermatopathology or gastrointestinal pathology) may see a negative effect, as value-based care may result in fewer biopsies. In my hospital, for example, our gastroenterologists have a laboratory where they review images from tiny cameras that their patients ingest. Fewer endoscopic biopsies are required – which is better for the patient and saves resources within the healthcare system, but it also means that fewer GI biopsies are coming to the pathology department. On the other hand, pathologists working on salary may feel less impacted and more liberated to advocate for changes that make sense for their patients from a holistic perspective. The pathologist can have a greater role in tumor boards and in developing patient care pathways. In my hospital, as Laboratory Director, I am routinely asked to review and approve all medical directives (acts delegated by physicians to nurses) that involve ordering certain lab test panels and standardized “order sets” (comprehensive sets of orders on a patient’s chart based on their condition or intervention). Regardless of its effect on pathologists, though, patients undoubtedly stand to benefit from greater integration of their care.

Utilization management

With the advent of sophisticated computerized data analytics, utilization management is entering a new phase. Now we can focus our attention on physician outliers. Instead of expending a tremendous amount of time, energy and resources on educating and managing the behaviors of all physicians, the emerging trend is to channel resources into identifying the 20 or so percent of physicians who are responsible for 80 percent of the laboratory’s activity and cost. This is especially true for expensive send-out tests. A study from the 1980s demonstrated that there was very little value in getting physicians to reduce automated core lab testing, as the net savings was amazingly small. Manual tests are a different matter – so creating algorithms to reduce, for example, unnecessary manual differential cell counts is a useful approach. So is reducing send-out tests, which are often focused on molecular diagnostics and tend to be costly.  Our laboratory, like many across North America, focuses on reducing send-out test costs – which can easily run into six or seven figures annually. Clinician education remains a mainstay of utilization management, especially now that so many diverse groups of healthcare professionals (midwives, physician assistants, nurse practitioners) can order laboratory tests. But with residents and fellows rotating through clinical services every four to six weeks in teaching hospitals, it is impossible to keep up solely by providing education. That is where pathologists can help: by working collaboratively with their clinical colleagues to develop testing algorithms that are, whenever possible, evidence-based.

But these “soft rules” for lab utilization need to be accompanied by “hard rules” – logic rules built into order-entry software programs that stop access to tests that are expensive, not indicated, or require prior consultation with a pathologist. Those with a special interest in medical informatics can create additional value by developing rules frameworks for their systems, in concert with bioinformaticians and computer technology experts. As artificial intelligence and neural network technology continues to advance, pathologists who are comfortable working in those realms can develop algorithms to decide the most appropriate test-ordering strategies for their clinicians or consolidate information from multiple databases to create new knowledge. The possibilities are almost endless!

The dyad leadership model

Most organizations, especially larger hospitals, still seem to have dual reporting structures. The laboratory administrative director (or equivalent) reports directly to his or her supervisor, often a vice president, whereas the pathologist reports to the chief medical officer. Yet it is the laboratory medical director who legally bears responsibility for quality and patient safety. Administrative and medical directors who are not able to work closely on all aspects of laboratory operations (even if only to provide oversight or gain awareness of the decision-making that takes place) create serious interpersonal conflict – or worse, jeopardize the mission of the organization. By working closely together, the administrative and medical directors – like two sides of the same coin – can foster unity and advocate more strongly and effectively for the laboratory. That is the essence of the dyad leadership model: equal input from both administrative and medical experts, along with an acknowledgment of the roles and limitations of each.

In my experience, the combined strength of these two arms of the traditional organizational chart is far greater than the sum of its parts. This dyad model also builds greater transparency and trust with the senior hospital leadership to whom the duo report, and reduces strife and conflict. Each role is a necessary part of decision-making, so meetings are cancelled if both are not available to attend. Every pathologist who is concerned about a good working environment should be interested in ensuring a strong dyad leadership model in their organization.

Fortunately, it seems to me that more physicians are becoming interested in medical leadership. Witness, for instance, the interest and growth in America of combined MD/MBA degree programs and in leadership education. Check out the American Association for Physician Leadership (physicianleaders.org) or, in Canada, the Canadian Society of Physician Leaders (physicianleaders.ca). Pathologists began taking on leadership roles far earlier than many of their clinical counterparts, largely by virtue of the need to have management structure in the laboratory – but we’re still in the early stages. More pathologists need to get out of their comfort zones and mingle with other physicians. Find a role that crosses specialty borders and take it on as a challenge. In short, be involved or be outsourced!