Pathology hospitalists in place at UMich

“A lot of pathologists just cover the frozen service,” Ellen says. “We definitely do more than that. We’re scheduled more often for intraoperative consultation, and we are invested in improving the frozen section service.” For example, the AP division has a digital strategy allowing pathologists to scan slides remotely, which has been helpful for frozen sections in certain situations, she notes. “We’re pioneering the use of digital tools in routine intraoperative consultation, which aren’t commonly used at many institutions.”

In addition, “We’re a constant face for the surgeons to see and, in that sense, we serve in a liaison role.”

At the research complex, the two hospitalists are about an eight-minute commute from the hospital, so their day might include shuttles back and forth. “But I think we can pilot a way to be a liaison and a chief communicator with our surgical colleagues,” Ellen says. “Having someone that the surgeons can see as a go-to person to say, ‘I’m having this issue with a case,’ or ‘There’s something I’m interested in bringing on,’ I think, will be sought out by other hospitals.”

The collegiality pathologists had with surgeons in many cases, because of proximity, went away when the laboratory moved off site, and Ellen sees their jobs as a way of restoring that collegiality. “The idea was that by having dedicated hospitalists, we would essentially provide the face for the department to the different technical teams. And that is already starting to take root. We’re getting to know the surgeons quite well, and we better anticipate their specific questions, their specific intraoperative needs.”

Frozen sections in most settings are covered by a mix of pathologists from varying training backgrounds, which she applauds. “But other places probably don’t have someone who takes ownership of the frozen section service and is interested in improving it.” Providing a diagnosis may be enough for most pathologists who participate in frozen sections, she notes. But being involved in process improvement and being invested in a service allows pathologists to improve their diagnostic accuracy and enables surgeons to make better clinical and surgical decisions. “And thinking of the AP hospitalist position as almost like a subspecialty allows us to do that.”

Avoiding fatigue in these settings—or, as Ellen puts it, “maintaining your optical mileage”—can be a challenge. “With frozen section it can be incredibly busy. You could get 100 cases a day or one case, or no cases. So you have to stay clinically active and mentally sharp” to match the pace.

David doubts anyone has used the word “hospitalist” in conjunction with pathology before, and he doesn’t want the AP hospitalist title to carry an implication of it not being a serious academic endeavor. “Part of our job is going to be to convince the pathology community that this is a legitimate need, it has legitimate academic applicability, we can do meaningful research from this vantage point, and it is also relevant and logistically feasible,” he says. (In fact, Dr. Kunju reports, the Drs. Chapel have already written four chapters for a book on frozen sections during their months at Michigan.)

The altered circumstances stemming from the pandemic did have an impact on the AP hospitalists’ roles, David admits. “The pandemic has decreased our frozen section volumes somewhat because the hospital has implemented limitations on the number and type of surgeries that can happen.” There were also fewer opportunities to get together with colleagues, “so I haven’t met all of the other pathologists or residents,” he says. That’s expected to improve as the pandemic eases, which he welcomes: “There’s no substitute for being there in person interacting with colleagues under the microscope.”

Having expert, energetic, and enthusiastic AP hospitalists on site has had a remarkable impact, Dr. Pantanowitz says. The two Drs. Chapel “have become a constant and welcome presence to our surgeons. Their days are action-packed, and like an ‘action potential,’ they are always available and ready to kick into action when needed.” David and Ellen are also helping to put a different face on pathology. “When we see them walking around they are almost always in scrubs.”

Dr. Pantanowitz himself is enthusiastic about how successfully the hospitalist experiment is proceeding. “It puts the pathologist into clinical practice, where they interact with patients or their physicians every day.”

As their new AP hospitalist practice model evolves, Dr. Myers believes eventually the hospitalists will be based entirely in the hospital rather than at the central laboratory. “So that’s where they would arrive in the morning and where they leave in the evening. And those who are now traveling back and forth to meet needs in the hospital won’t have to travel.”

More important, in his view, will be the hospitalists’ impact on pathologists’ relationship with clinicians. His first time in the surgeons’ locker room at a University of Michigan hospital was at a time when pathologists who worked in the frozen section lab didn’t wear scrubs. He remembers a head and neck surgeon who stopped and said approvingly, “Wow, we’re finally seeing a pathologist in the locker room.” “Those are simple, powerful things that kind of change the way we’re perceived and how we’re valued as a member of the team,” Dr. Myers says.

“We’ve gained from having a hospitalist there with constant presence,” says Dr. Pantanowitz. Operationally, with the AP hospitalists, “we now have a much more streamlined working team in the hospital, a team that is not chopped up,” he says. The other pathologists “also now start to appreciate the workflow much better so they can easily identify where the trains are going in the wrong direction. And that’s why the AP hospitalists have been part of our QA program.”

He compares the AP hospitalists to emergency department physicians. “They have to hustle with the frozen sections because there’s a patient on the table under anesthesia. So the hospitalists are kind of like ER doctors for pathology, out there on the frontline.” Like ER doctors, hospitalists won’t have continuity in their cases, he says. “They are only there for a short component of the life of a patient specimen, which is at the time of an intraoperative consultation. They come in, make an assessment, and then step away from the case and it ultimately gets signed out by someone else. So it’s kind of the same as an ER doctor when someone comes in with chest pain. You address the chest pain and then you move them along.”

While the AP hospitalist program has not yet been subject to a long-term evaluation, “the reactions inside the hospital are all positive,” Dr. Pantanowitz says. “We do know that they have improved satisfaction from surgeons, who are happy to have someone around all the time to help solve problems expected and unexpected. And we’ve had a lot of satisfaction from the faculty, who now don’t have to do this rotation all the time. Our SWAT team is happy they don’t get pulled away to do the frozen section work.” Beyond the Michigan Medicine system, he adds, “We haven’t broadcast outside our institution that we have AP hospitalists, but the few folks who have heard about this were amazed and gave us their approval.”

Dr. Pantanowitz says the hospitalists’ presence has made even crises easier to handle. “We’ve had several unexpected problems. For example, late last year the frozen section room flooded and we couldn’t do frozen sections there. We had to move the operation to an adjacent hospital, and that was a huge operation to coordinate with the surgeons and facilities, diverting the frozen sections to make sure no patient was compromised.” Without the AP hospitalists they would have struggled. But as it turned out, “the surgeons didn’t even notice the two weeks we took to repair the room.”

Similarly, during the pandemic, when staffing the autopsy and forensic services was difficult at times, one of the hospitalists was able to step in.

There are a few risks that another pathology department might wish to consider if contemplating the addition of AP hospitalists to the staff. “We are learning that harmonizing this practice model with a subspecialty-based culture has its challenges, and that’s a lesson in change management,” Dr. Myers says. “I think also identifying meaningful opportunities for professional development that may be attached differently to our traditional ways of thinking about advances in organ-based subspecialties is a challenge. And I don’t know that anybody has the answer to that just yet.”

As other AP departments or divisions face similar potentially disruptive moves away from hospitals, the pathology leaders at Michigan hope their hospitalist experience will provide a template that others can employ to keep pathology an integral part of clinical practice in the hospital.

“Pathologists are important for inpatient hospital-based care. There’s a trend to move pathologists outside the hospital, which will leave this gap in the workforce,” Dr. Pantanowitz says. He’d like others to know that with AP hospitalists, “We have a creative solution. We believe it is an actual career pathway.”

He envisions the department one day creating a fellowship to train future AP hospitalists. “We would like people to consider this as a future new area of subspecialization. We believe it is a major contribution to the field of pathology that can benefit any department having this problem. And just as it did in internal medicine, the AP hospitalist program will be taken seriously and recognized for the value it brings to the field.”

There is a risk, Dr. Myers notes, of someone saying that the Michigan approach is an anachronism, in the belief that with digital solutions all of this work will be done remotely. But that increasingly remote practice through telepathology is not the way to go, he says, and he warns that pathology needs to avoid what has happened in radiology.

“The way I’d like to think about this experiment is eventually it would address all kinds of hospital-based opportunities in our discipline, on the clinical pathology as well as the AP side. So that maybe a pathology-trained hospitalist would be comfortable with autopsies and with rapid on-site evaluation for cytology specimens and frozen sections, and maybe with emergent needs in the blood bank. To me, that’s the kind of scope and scale of the challenge and the opportunity.”

Dr. David Chapel considers the AP hospitalist job a way for the pathology profession to shape its future in clinical practice. “The reality,” he says, “is that given spatial constraints and with the increasing ease of applications of telepathology or digital pathology, it’s almost inevitable that an increasing number of academic institutions will have their pathology facilities off site to some degree or another. And that raises the question of how pathology retains an active role in hospital clinical affairs, making that invaluable personal connection with our surgical and clinical colleagues.”

“I was excited about the opportunity to essentially blaze that trail.”

Anne Paxton is a writer and attorney in Seattle.