June 2010

Stephen N. Bauer, MD

Big-picture thinking and opportunity

Self-made millionaires are four times more likely than the rest of the population to be dyslexic.

—Daniel H. Pink, A Whole New Mind

Conversations in the nation’s capital about health care reform were focused on uncertain details for a long time. At least we now have the big picture. The anticipated effects of the legislation are enormously complex; there is much to be done and done soon. Many continue to protest, and that is their right, but it is what it is and it isn’t all bad.

Pathology leaders came together with lawmakers, political analysts, and federal health policy officials for the CAP 2010 policy meeting in Washington last month, and for three days we learned about how the new law is expected to affect pathology. The challenges and opportunities are fluid, and that attaches urgency to the conversation. Our neglected opportunities can become somebody else’s opportunities, and when that happens they can become challenges instead. Health care reform offers a number of opportunities for pathology; the medical home model is one of those on the near horizon.

Speakers described the patient-centered medical home as a community-based system of care coordination by a team of physicians and affiliated health care providers. The focus is on local solutions that are collaborative and prevention oriented. The model has many appealing aspects. A patient-centered medical model could ease transition from acute care to rehabilitation to home care, for example, because the physicians in the diagnostic and rehabilitative disciplines, as well as nurses and others in community support services, are all on the same team.

At the policy conference, James M. Crawford, MD, PhD, chairman of pathology and laboratory medicine at North Shore University Hospital and Long Island Jewish Medical Center and a former president of the Association of Pathology Chairs, spoke about the role of pathology in advancing the patient-centered medical home concept. Pathologists already provide the primary data for much of health care outcomes assessment, he said. They have the health information technology expertise that primary care physicians need to track the success of wellness initiatives and chronic disease interventions within segmented patient populations. Dr. Crawford has interesting insights about our role in enabling clinical applications derived from population-based data on quality and safety. He is on target when he says the roots of pathology are in public health, and patient care improves when pathologists collaborate fully with other physicians to coordinate treatment.

The patient-centered medical home is envisioned as an entry point to the patient-centered medical neighborhood, where providers in the community are linked to the medical home via the electronic health record and robust health IT. Under federal “meaningful use” criteria, the EHR becomes a secure source of health information, fueled by robust health IT and accessible at all points of care, including the laboratory.

Primary care physicians will be expected to track data trends for their patient populations and are likely to welcome an offer of help from a pathologist with information systems expertise. The meaningful use requirement should foster this kind of collaboration, which could be only the beginning. Pathologists on the medical teams of patient-centered medical homes, who are meeting with colleagues to talk about practice metrics, could easily participate in patient treatment conferences and make themselves available to discuss test results with patients.

Thinking about this prompted recollections of a book I read recently. In A Whole New Mind, Daniel H. Pink presents theories about attitudes and aptitudes that will be most useful in the evolving economy. In the now-fading information age, Pink says, “left brained” technical and analytical abilities have been most valued. But in the emerging conceptual age, he says, technical abilities will no longer be sufficient. As more and more analytical tasks can be accomplished by robots or exported to countries where labor is less costly, Pink believes, those who toggle most easily between analytical and conceptual (big picture) thinking will have a definite edge. “Right-brained” thinkers, who are inclined to discern new patterns and think in relational terms, will be needed to interpret technical information and make it accessible. To illustrate the value of relational strengths, which he believes are stronger when left-brained abilities are restrained, he points out that self-made millionaires are four times more likely than the rest of the population to be dyslexic. It seems that limitations on the ability to manipulate data can be a blessing in disguise. And it reinforces the notion that pathologists’ expertise in testing and diagnosis can help improve the quality, efficacy, accuracy, and safety of health care for patients and the community.

Although Pink’s evidence is anecdotal, his logic has a certain appeal. While our work is not in immediate danger of being shipped overseas, that possibility is one way to think about the connection between technical versus relational work and our perceived value to patient care. That which can be reduced to a report is fundamentally a knowledge-based exercise that can be outsourced or automated. As health care reform moves forward, it may be our right-brained ability to see the big picture, to explain the meaning of test findings, and to make use of population-based health information that will be more readily recognized as critical to quality patient care.

Some of this may seem counterintuitive, but while our technical abilities will always be vital, our ability to help treating physicians apply what we know may be valued more highly in new care models. Pathologists need to take the lead on this because we are the ones who are in a position to see the big picture. As more coordinated care comes to our communities and medical home teams begin to form, we need to make sure we are members of those teams. This has to happen soon and at the grassroots. It’s a challenge. But if pathologists follow through on the opportunities the patient-centered medical home provides, we may someday conclude that health care reform was a blessing in disguise for pathology.