In 2006, Jeffrey Myers, MD, started at the University of Michigan as the Director of Anatomic Pathology, after spending 16 years at the Mayo Clinic in Minnesota. A practicing pathologist, his subspecialty interest is lung pathology. Part of the passion that drives his practice is an additional interest in quality and innovation. Those two interests combined sparked a curiosity as to how pathology operates in a complex healthcare ecosystem.
And how do they operate? From Dr. Myers’ point of view, there is a lot of room for improvement, and what’s more, many opportunities to do so. Pathology, he says, often passes on a number of opportunities to be the leader in patient-centric care. Throughout his career he has reflected on why the laboratory has said no to programs that would put pathology in more direct contact with patients, and what he found often boiled down to the assumption that the programs weren’t needed because patients weren’t asking for them, and clinicians didn’t want them. But, Dr. Myers notes, “We’re assuming that clinicians can always articulate what patients need and want, and the truth is, they often can’t. It made me think that pathology really could be a forward-thinking leader in thinking about care pathways.”
And that way of thinking was part of the genesis that led Dr. Myers to develop the Patient and Family Centered Care Program at the University of Michigan. Critical Values talked with Dr. Myers about the program, where it’s been, where it’s going and most important, the crucial role pathology plays in its success.
Critical Values (CV): How did you start out bringing pathology and patients together?
Jeffrey Myers (JM): My thinking at the time, around 2010, was that if I got hit by a bus, there weren’t people who could easily step into my role, and that really bothered me. So, I identified a group of staff and faculty, and we hired an external consultant, to launch a combined strategic planning and leadership development initiative in anatomic pathology.
Part of our work was to imagine pathology in 2025, and each person was asked to write a story and share it with the group. And it was amazing because everyone was thinking the same things. Everybody was imagining a future in which pathology was working directly with patients to drive the experience of care. We were excited and decided to put our ideas together in a more coherent story and road test it with other staff and faculty and see how they respond. We wanted to know if we were just speaking to ourselves after too many meetings, or if this idea really had legs.
We shared some of our stories and the context including literature that we’d been reading with staff and faculty and met with them to learn what they thought about the future of pathology. And after two cycles of that, we realized this idea, what we called the Michigan innovative Patient-centered Pathology project (MiP3), really had legs and we should be working to change the future of our discipline.
CV: Where did you take MiP3 next?
JM: We took the information we’d gathered and presented our vision at an all-faculty, all-staff quality meeting. We kicked off that meeting with two patients, because we understood the importance of doing this work with patients. One patient joined us from Chicago via Skype, and one patient was a member of our staff who is a breast cancer survivor.
The patients shared their stories, and we shared our vision, and at the end we asked staff and faculty to participate by attending one of 20 scheduled small group meetings. Our guest list was 217, and 211 showed up. The purpose of those small group meetings was to hear their vision for the program, since they had already heard ours. What we heard from them were very consistent themes, and everyone said that patients were at the center of everything we do.
By the end of the 20 small group meetings, we had almost 20 people who wanted to join our initiative, and we knew we needed to start running some experiments to understand how to build a bridge from where we are today to the bold vision, recognizing we’ll have to do it in baby steps. We did an experiment where we put a pathologist at the weekly lymphoma clinic. She had an office and a microscope and we invited patients, with the cooperation of their providers, to have time with the pathologist if they wanted to learn more about their diagnosis and maybe even see it under a microscope.
We did another experiment with the College of Social Work and put their graduate students with a supervising faculty member at the Wayne County Medical Examiner Office, which is part of our program. They do almost 3,000 autopsies a year. They identified a need for the families of the decedents who find themselves at our Medical Examiner’s Office, and we wanted to understand what value having a social worker there might provide in terms of their experience of death and loss.
CV: How did these programs evolve into the Patient and Family Centered Care program?
JM: We were doing those sorts of projects as part of this visioning strategic planning initiative and while we were doing that work, we were inviting institutional leaders to some of our meetings so that we could learn from them what was happening in their space. We met with the administrative director of our cardiovascular center who shared with us a story about how adapting Patient and Family Centered Care as a formal program in our cardiovascular center had been transformational. That was our first connection to Patient and Family Centered Care and we got very curious. So, I met with the manager of our Patient and Family Centered Care program on the adult side, and shared with her the work we were doing and she said, “Yep, you’re doing patient and family centered care.“
I wanted to understand what the tactics are that enabled Patient and Family Centered Care as a strategy and what we learned was that fundamental to the tool box for implementing Patient and Family Centered Care at any level is a Patient and Families Advisory Council, PFAC for short.
So we launched a PFAC in July 2016, and in November 2016, we took a team of 22 of our PFAC members to an intensive seminar done by the Institute for Patient and Family Centered Care, with the goal of learning because we were early in our evolution and struggling to understand our work.
Our mentor was a family practitioner from Wisconsin who has been very active in the Institute, and he loved the way we were thinking about Patient and Family Centered Care from a laboratory platform. Since that seminar we’ve been learning how to work directly with patients and their families.
CV: How does Patient and Family Centered Care differ from other projects?
JM: The difference between patient and family centered care and everything else is learning how to do things with patients rather than simply doing things for them. The opportunity for our discipline is learning how to close the gap between our assumptions regarding providers as a sufficient surrogate for the patient’s voice, and the voice of our patients themselves. It’s not a criticism, it’s just how it is. Patients see things differently. We might say, for example, that a three-day turnaround time is fine because they don’t have a follow-up appointment for five days, and the provider agrees it’s fine. But I’ve never had a patient tell me that a three-day turnaround is fine. The patient would say it’s really not fine, that waiting five days is awful, and if you’re giving me a choice, I’d like to know the results today. We need to figure out tools and processes that make direct communications healthy and viable for at least some patients. Some might predictably say, “Not all patients want that.” And my answer is, “Yeah, that’s true. But some do.”
We keep talking about personalized care, so why do we keep sticking with a one-size-fits-all view of the opportunity?
CV: What do you envision for the future of Patient and Family Centered Care?
JM: I think that one of the things we lack is real evidence of the sort likely to influence decision-makers about the value of the proposition. By that I mean, there is some stuff in the pathology literature relevant to family centered care, but mostly, there are small experiments where the evidence is survey data that says people liked it and I don’t think that’s going to influence CMS or other payers.
We need to figure out how to study the impact of Patient and Family Centered Care in scientifically valid ways that demonstrate how it changes outcomes in a way that is meaningful. I think as we figure out how to do that, which I think is what we need next, ultimately that will influence payers and providers in ways that will make Patient and Family Centered Care a sustainable strategy for pathology. To me that’s kind of how we see our current state in this journey and we’re trying to figure out how to do some of that work now. I think that will require a different generation of scientists who really learn how to study healthcare outcomes in meaningful ways and can apply that science to pathology work.
Every one of our patient family advisors started by asking, “What is pathology, really? I didn’t know you were there. I didn’t really understand the role it played in my care.” Every one of them, once they learn the answers to those questions, is a little bit edgy, maybe even a tiny bit angry that they didn’t have access to us along the way. There is a real appetite among our patients and families that really mandates we learn new ways to show up. I think that has to be done in partnership with our clinical colleagues. This is not a rogue exercise.
There is a lot to be done. But, honestly, I think that if pathology chooses not to step into this space it really is a choice that may have a profound impact on what the pathology looks like 50 years from now. Everybody’s worried that everything we do will be done by others, whether that’s artificial intelligence solutions applied to images that are now available as data at a time when the microscope is no longer kind of foundational to our identity or, digital solutions that can be exported outside of our healthcare systems so the work can be exported to others at a commoditized cost or, tissue is fed into other analyzers that can compete with us in terms of diagnostic performance. I think if we figure out other unique ways to add value to care, healthcare won’t want to live without us. And that’s up to us.