Amid COVID-19 crisis, pathologists fill a critical gap

“When this came up as an option, it was sort of a relief,” he says. “We can be of value clinically, but we’re not going to be asked to do things that are too far out of our comfort zones.” Nearly the entire team of 20 signed up immediately, he adds. “It was just an instinctive thing to do. We jumped in.”

Learning how to use the hospital’s EMR wasn’t easy, and the need to develop a working knowledge of acute respiratory care in an ICU setting was pressing, he says. “Previously, if I needed the medical history of a patient, I knew how to go into the chart, look up labs, look up the doctor’s note summarizing the history, look for chest x-ray results or radiology results.” But he had never had to write clinical notes in the system, or contact physicians using the system’s chat function, or wander into how ICU care is monitored and documented. But over the course of training, “it became clear how to use the system, how to look for information, how to create a list of patients so you don’t have to keep re-entering them. Basic stuff, but we had never before been trained.”

Many of the families Dr. Theise has spoken with have questions about the mechanics of ventilation. “As a liver pathologist, I don’t know the first thing about ventilation, so I had to learn quickly. And many of the patients’ families were becoming sophisticated very quickly and wanting to know details about the ventilation status.” On other occasions, families have wanted to understand what was going on in a more fundamental way. “And that’s one of my skills as an academic pathologist,” he says. “To translate jargon words and complex understandings in pathobiology into something people can understand at any level.”

The program has proceeded largely without hiccups, Dr. Hochman says. In its first few weeks, there were several occasions when uncertainty among the frontline providers, Family Connect team, and palliative care team about which group was responsible for a call led to confusion. “There were a couple of times where too many people were calling,” she says, “so that was one thing we had to work out when we were talking to the floor team during WebEx rounds.” They have since solved the problem, she says. “My philosophy is, it doesn’t matter to me who calls. Just someone has to call the family.”

Without the Family Connect program, the hospital simply wouldn’t be able to communicate with families every day. “I promise you, because I was on the wards myself, if it was up to the floor teams, we would be taking care of the patients first, and then at the very end of the day if we remembered or thought about it, we would call the families,” Dr. Hochman says. And if the frontline team made those calls, it wouldn’t be with the rigor of the Family Connect team, simply because the treating doctors and nurses are overburdened. “Now they can really focus on direct patient care,” Dr. Hochman says.

Using Epic EMR’s direct messaging system, the frontline team can relay information to the Family Connect team even after rounds have already been completed, so families can get updates throughout the day if needed. As Dr. Hoda puts it, “We’re a liaison between the families and the floor.” And that relationship maximizes and takes advantage of resources, Dr. Hochman says. One example: FaceTime connections between family members and patients. “If the medical team is speaking to a family and the family wants to FaceTime their loved one, the Family Connect team can speak to a Family Connect nurse,” who works on site and can enable a FaceTime connection. “That’s been really meaningful too.”

The program has improved the lines of communication within the hospital as well. Under normal circumstances, NYU’s patient experience office would field calls from families inquiring about patients, Dr. Hochman says. When the visitor restrictions were put in place, “there were a zillion calls coming in,” and there was no organized mechanism to relay clinical questions from families to the appropriate care team member. Now, she says, if a call comes in, “that message goes out to the Family Connect team, and they can address the question, or maybe if it comes in before rounds and they don’t know the answer, they’ll ask it at rounds.” In addition to making daily calls, she explains, the attendings in the program are responsible for responding to calls about clinical questions that come in during their shift. But as the program began operating, the number of incoming calls dropped dramatically. “People know they’re going to get that daily call, and they’re not getting as frantic.” In addition, the family has a number. “If they have questions, they can call back.”

Whether the program will continue after the crisis abates remains an open question. It will operate as long as the visitor restriction is in place, Dr. Hochman says. Pathologists’ workload will return to normal. But even after, “I think there will be lessons that remain,” she says. “We need to think more carefully about patients who are vulnerable and can’t make their own phone calls. And we do usually call families, but not as rigorously as we’re now doing with Family Connect. I think our practice will change.”

For Dr. Hoda, the program is something more: An opportunity for pathologists to get directly involved with patients, throughout the crisis and after. “I think pathologists want to get involved. But it’s hard to know how,” he says. Information about pathologists intubating patients or providing other forms of direct clinical care has been circulating online. “That’s one way to get involved,” he says, “but it’s not the only way. We do testing on every patient, so pathologists are already involved.” But the Family Connect program “offers an alternative, something outside the box.”

“I don’t want us to be invisible anymore,” he says. “I want to prove that kind of method brings pathology back into people knowing where we are. And we’re doing that. Every time I’m on these interdisciplinary calls with the people doing this, with radiologists and surgeons, I’m glad pathology is being represented.” The 20 pathologists on Dr. Hoda’s team have been surprised by their ability to deal directly with patient families, he says, “in a way that’s totally new to us.” He is proud of them, he adds, for “stepping outside their comfort zone to do this important work.”

He says he would like to get something similar off the ground for pathologists in general. “A patient clinic type of situation where the pathologists can discuss the patient’s diagnosis with the family,” he says. The same skills are useful in other ways, with patients in some health care systems getting surgical pathology diagnostic results through MyChart or hospital apps sometimes before the clinicians do, “just because it’s automated.”

“There may be a role for pathologists to communicate with patients directly by phone,” he says, rather than the patient receiving just a chart notification. As it stands, patients sometimes read their report with no one there to interpret what the results mean.

“I think it’s super important to push the lines a little bit,” to be bolder and a little louder, he says of pathologists. “I’m willing to get involved with something and do this or try this.”

Public perception is a big part of health care, he explains. “It allows for funding of departments, for better students to go into pathology, for better training programs.” It opens doors, he says, including to “better diagnostics for patients.”

Dr. Theise agrees, noting that for pathologists there are numerous opportunities to teach, which he calls “one of the great pleasures of pathology.”

“I think pathologists are headed for the possibility of increased patient and family contact. We’ve been shielded from that historically, but it may become a more routine part of what we do.” He acknowledges it’s tricky: “Are we prepared? How do we document it? What are the medicolegal aspects? The ethical aspects?” For now, though, he says, the Family Connect program “shows us we can do this, and we can do it very well.”

Charna Albert is CAP TODAY associate contributing editor.