CEO SUMMARY: At the University of Michigan Medical Center, the Department of Pathology is learning new ways to add value that include face-to-face meetings with patients as part of UMMC’s patient- and family-centered care initiative. One lesson learned is that patients appreciate the opportunity to get a better understanding of the results from both anatomic pathology and clinical pathology tests. Pathologists see such interaction as a useful part of personalized and precision medicine.
ALL OF HEALTHCARE IS SHIFTING TO A patient-centered model of delivery. Primary care physicians work in patient-centered medical homes, and specialists are working alongside PCP’s in patient-centered neighborhoods
“It’s a natural progression, then, for pathologists to meet with any patient interested in gaining a deeper understanding of their care and explain anatomic and clinical test results,” stated Jeffrey L. Myers, MD, Vice Chair of Clinical Affairs and Quality and Director, Pulmonary Pathology Fellowship in the Department of Pathology at the University of Michigan School of Medicine.
“In 2013, as a strategic imperative, our pathology department launched several pilot programs to test the concept of delivering patient-and family-centered care (PFCC),” explained Myers, who is Division Director for MLabs. “Today, the PFCC initiative at the University of Michigan Medical Center is believed to be the largest such program in any pathology department in the nation.
“In this style of care delivery, pathologists learn that patients have important stories to tell us, and those stories inform how pathologists deliver care and interact with patients,” he said. “These interactions also help our pathologists to deliver more value.
“We launched these pilot programs based on the anecdotal experience of interacting directly with some of our cancer patients,” stated Myers. “This included a pilot project in which one of our hematopathologists held office hours in our regularly-scheduled outpatient lymphoma clinic to provide direct consultation to cancer patients. That was very well received.
“In another pilot, pediatric pathologists meet with families who have lost neonatal children,” Myers added. “We can now support those families by providing detailed answers to their questions.
“In one other program, our pathologists collaborate with the university’s School of Social Work to have social work graduate students work in the Wayne County Medical Examiner’s office in Detroit, an outpost of the university’s pathology department,” he said. “From that, we’ve learned how we can deliver better care for families by having a social work capacity in a large forensic practice.
“From these pilot initiatives, we are gaining experience in two ways,” stated Myers. “First, we are identifying the best ways to get patients more involved in how our pathologists deliver care to them. Second, we are then using this knowledge to engage patients. Our success with these pilot programs drove our decision to embrace PFCC as a strategic imperative for our pathology department.
“Direct interaction between a pathologist, patients, and their families is largely uncharted territory,” he continued. “Thus, our pathologists need to learn the skills required to navigate this aspect of medicine. That is why our pathology department is developing a curriculum to train pathologists, trainees, and staff in how to have difficult conversations with families and patients.
advisory Council Launched
“Based on what we learned, in July we launched what may be the first patients and families advisory council (PFAC) based in a pathology department,” noted Myers. “This council includes seven patient and family advisors (PFAs) who work directly with our pathologists to transform the ways in which our patients and families experience health and disease.
“One way to look at this program is that it involves understanding the things our pathology department left untapped in our quality improvement efforts,” he explained. “A couple of years ago we created the Division for Quality in Health Improvement to identify larger opportuni- ties in the inpatient and outpatient settings for pathology to drive value.
“At the moment, our pathology department’s focus is less on operational quality and on Lean because we already do both of those well,” he added. “Going forward, the question we wanted to answer is this: ‘what would patients say that we don’t do well?’”
The pathology department’s PFCC program is one of about 30 such initiatives in the University of Michigan School of Medicine. “We worked with our institutional colleagues to learn how to understand this work, including how to organize advisory councils of patients,” said Myers. “While we took the advice from other departments, we also went outside the rules a bit, such as about the size of our PFCC. We were told that the ideal size is 10 to 12 members of a department.
Much enthusiasm
“We have about 40 members in our advisory council, in part because—as we discussed this program—we discovered a lot of enthusiasm for this approach and didn’t want to discourage anyone from participating,” emphasized Myers. “Also, because one of our goals for this program is cultural transformation, we didn’t want to close the door to anybody who wanted to be at the table.
“In our PFCC of 40 people, we have seven who are called patient and family advisors,” Myers concluded. “These are patients or family members of patients who have volunteered to be part of our patient- and family-centered care program. They want to share with us what it’s like to be standing in their shoes. These volunteers are vetted and trained and then are available to respond to questions or participate in surveys.”
When patients meet with pathologists at the University of Michigan Medical Center (UMMC) to discuss their care, they are often shocked at what they learn but also are pleasantly surprised and grateful for the depth of understanding they gain.
“These patients say, ‘Had we known there were people behind our lab results, we would have wanted to find you,’’ explained Myers. “They also ask, ‘Why are you not in a better position to help us understand the information you have and how to apply that information to help us make better choices as we become more vested in our care?’
“When patients ask questions like these about their care, it can have a powerful effect on how pathologists interact with patients and family members,” noted Myers, who leads the patient- and family- centered care (PFCC) initiative in the Pathology Department at UMMC.
“There is a huge appetite among patients, family members, and our patient and family advisors who want to understand their laboratory results,” he continued. “They make that message loud and clear during these face-to-face meetings.
“Patients know they are cared for by teams of multiple providers with different areas of expertise,” he said. “And all of those providers use some laboratory information to come to different conclusions. So patients ask, ‘Where are the pathologists and clinical lab scientists who produce this information?’
“They ask a good question, and it’s one we are answering here at our medical center,” continued Myers. “For these patients, PFCC is the missing piece and— without that approach to care—they’re a bit angry that we haven’t been around.
patient Volunteers
“For example, we have one patient who is a very savvy, hard-nosed, healthcare consumer with breast cancer,” he related. “She has been disease-free for 10 years and in that time has learned a lot about her condition, about stem cells. She even knows our chief researcher and she might know more about Oncotype DX than I do.
“After I met with her for the first time, she asked why she hadn’t met with a pathologist earlier in the course of her care,” added Myers. “She asked, ‘Could I have met with a pathologist to understand my care?’ Well, ‘yes,’ I said. ‘You would have had to work at it, but of course.
“At that point, she wanted to look at her case reports. So I got all of her slides together, even those that were not done here,” he explained. “Now, remember, she’s a very hard-nosed, tough lady. When we met in my office to look at her slides on the monitor, she started to cry, which I would not have predicted. I was surprised but fine with it, and asked her to tell me what she was thinking.
“She said, ‘There are so many cells. I was told that my cancer had a good prognosis, which made me think that the enemy was small,’” said Myers. “But the enemy was big and I didn’t know that. And I wish I had known that at the time.’
“Thinking about what she said, I realized that, other than a pathologist, there is no other person on her healthcare team who can provide that experience,” Myers commented. “I suppose a cynic would ask, ‘What value did that experience add for this patient?’ But that’s not for us to define; that’s for her to define. And that experience shows that we’re not very good at understanding value from the perspective of our patients.
“Here’s another example,” he added. “We’ve had patients who learned about our tumor boards and asked why they were not invited. Of course, our reaction is to immediately list all the reasons patients cannot attend tumor boards. And when we offer our reasons, the patients say, ‘Well surely you can figure out how to overcome those problems!’ And, of course, we can do that.
University of Michigan Pathologists Aim To Be At Forefront of Patient-Centered Healthcare
FACE-TO-FACE MEETINGS between pathologists, patients, and their family members have provided many useful insights to the pathologists at the University of Michigan School of Medicine as they develop their departments’ patient- and family-centered care (PFCC) program.
“We’ve learned that not every patient will want such a detailed view of their conditions,” acknowledged Jeffrey L. Myers, MD, Vice Chair of Clinical Affairs and Quality, Division Director for MLabs, and Director, Pulmonary Pathology Fellowship in the Department of Pathology. “But as the movement toward personalized medicine becomes more popular among patients, our pathologists are learning that patients want to know more about the cause of illnesses and the prospect for cures.
“Our effort to get pathologists involved in patient- and family-centered care (PFCC) is driven by our conviction that pathology should not be dragged kicking and screaming into the age of patient-centered care,” noted Myers. “Instead, we think pathologists should lead the way, especially in those institutions that may be dragging their feet.
“I’m convinced that laboratory medicine is at the precipice of something good and if pathologists pass on this opportunity, other departments will step ahead of us,” he added. “If that happens, pathology will lose a golden opportunity to become the patient- centered discipline required for pathologists to be successful in today’s rapidly shifting healthcare landscape.”
For pathologists, the compelling question about patient-centered care is how to get paid for consulting with patients when clinical and anatomic pathology is viewed as a commodity service where costs must be contained. However, Myers sees the shift away from fee- for-service payment toward capitated and bundled payment as an opportunity for pathologists who consult with patients to demonstrate that they have more value in a patient- centered healthcare system than those who do not deliver patient-centered care.
“This effort is important as pathologists try to understand how we keep a place at the reimbursement table as the fee- for-service payment model diminishes,” Myers explained. “I don’t know exactly how we’re going to get paid for this, but I believe that if we don’t figure this out, we may not get paid at all.
problem To Solve
“Here’s the problem we’d like to solve: In the current healthcare system, as providers, we dictate value from what we think it should be,” Myers said. “But we don’t really understand value from where patients stand. So, as we get better at understanding value from the patient’s perspective, we will find ways to add value to care that we have not yet imagined.
“When pathologists learn to do that well, the value of pathology will increase. In turn, it will mean that health systems will be unable to export my job with digital whole slide images to China, India, or elsewhere,” he continued. “Exporting what pathologists do will be impossible if patients are saying, ‘The best experience I had was meeting with the pathologist who helped me understand things I wouldn’t know otherwise.’
“I’m not being overly dramatic when I say that’s where the opportunity lies,” he added. “If pathology can figure this out, I am absolutely convinced that it will be part of the salvation for pathology services because we will define new value from the perspective of patients in ways that they will not want to live without.
“Who knows what reimbursement will be like 10 years from now?” asked Myers. “We don’t know and so in many ways patient-centered care could be what pathology needs in this changing reimbursement environment.”
patient Volunteers
Another relevant experience started with an email I got from one of our very well- known breast oncologists,” he continued. “’There’s a patient who wants to talk to you about her pathology and I’ve explained why there was a change in the grade of her tumor but she insists on talking to you,’ he said. I was happy to talk to her and told him to give her my phone number.
“When the patient called me, she said, ‘First, they think they know what I want to learn from you, but they don’t. And second, I’m not stupid; I’m a drug rep. I’ve got a degree and my work in the drug industry is in oncology and particularly breast cancer. I know a lot about my disease,’” related Myers.
“Then she added this: ‘I always imagined that—as a pathologist—there must be times when you look into the microscope, see somebody’s tumor and think, ‘Holy crap, I’m really glad that’s not my tumor! And there must be other times when you look in the scope and say, ‘If my wife had breast cancer, this wouldn’t be the worst one to have.’
Question From patient
“What she said was true, of course,” he added. “That’s what we think sometimes. Then she asked, ‘Which one was I?’
“I hadn’t anticipated that question, but I had her slides right there and I said we could look at them and I would try to imagine I’m looking at them for the first time and answer her question,” stated Myers. “I told her, ‘Honestly, as breast cancer goes, this isn’t a bad one.’ And she thanked me. So, there’s another example of where no one else on her care team could have told her that! She had to ask a pathologist to get that answer and when she got the answer, she was thankful.
“The point of both of these stories is that whenever you talk about patient- and family-centered care, many physicians and other providers will say, ‘Oh, yes, we’ve been doing that for years.’ And certainly they’ve done many wonderful things for patients,” observed Myers. “But they are not doing what we, as pathologists, are uniquely equipped to do.
“That’s the point: Historically, pathologists have had the best of intentions to deliver the best care we can for patients,” he explained. “The difference in patient- and family-centered care is that you do things with patients. You partner with them directly in their care. That is very different from the traditional practice of pathology.”
“How pathologists will get paid for this is an unanswered question,” he said. “We don’t get paid to sit with patients and look at their slides. To that, I say, ‘No, we don’t now, but we will and here’s why.’
“Nobody knows exactly how or how much we’ll get paid for this care,” continued Myers, “But certainly, as bundled and capitated payments increase and as we ask ourselves how will pathology demonstrate its value, we will find a way to be paid for this care.
“If the pathology profession does not do this, then it will continue to be distilled down to a commodity service, which means administrators will compare our fee schedule to that of the large commercial lab companies and the comparison will not look good,” Myers explained. “That’s why pathologists must find other ways to provide value and—even if we don’t get paid for it today—it will preserve pathologists’ employment for tomorrow.
“There is the potential that, ultimately, patient- and family-centered care may completely upend the test-ordering algorithm,” explained Myers. “Currently we talk about how we can educate physicians to use laboratory resources more effectively. But that’s the wrong model. We wouldn’t think of telling physicians in any other sub-specialty discipline how to do some other sub-specialty procedure. So, why do we do that differently in the lab?
“That’s why the future of our discipline will hinge on how pathologists engage differently with patients and providers,” he noted. “The role of pathologists will be to understand the problem physicians are trying to solve for each patient, and we will decide which lab tools will solve that problem. Then, pathologists will use those lab tools and consult with other physicians and with patients directly. When pathologists do that, our profession will be delivering patient- and family-centered care.”
Contact Jeffrey L. Myers, MD, at 734-936- 1888 or myerjeff@med.umich.edu.
What University of Michigan Pathologists Learned about Patient-Centered Care, Clinical Pathology
ONE QUESTION ASKED about patient- and family-centered care is whether this method of care delivery works for anatomic pathologists only or for both anatomic and clinical pathologists.
“It’s both!” declared Jeffrey L. Myers, MD, who leads the patient- and family-centered care initiative in the Department of Pathology at the University of Michigan School of Medicine. “Very definitely, patients want to know more about their clinical lab results. In fact the appetite for clinical lab test results is at least as great as it is for anatomic results.
“To address that need, our pathologists are developing experience in how we can help patients understand the tsunami of numbers and information that populates their medical records in ways that help them be more directly engaged in their care,” he noted.
“In doing that, we heard complaints, such as, ‘Well, not every patient wants that.’ Of course, that’s true,” he continued. “We know that. That’s why we call it ‘personalized care’ or ‘precision medicine.’
“Our pathologists want to address each patient’s individual preferences,” commented Myers. “What we are learning is that there is a very large number of patients and families who want to know more about their healthcare because they want to participate in making decisions about their care. However, a huge chunk of their healthcare is embodied in laboratory information that they cannot unlock.
“As the pathology department’s contribution to our medical center’s patient- and family-centered care initiative, it’s our job to try to unlock that information for them,” he said.
