All right. Welcome back, sir. Thank you. This is the third part in a multi-part series on the diagnostic management team So I'm doing great. Thanks Chris. Excellent. Wonderful. Well, let's go ahead and get right into it This episode is focusing on what seems to work and what doesn't seem to work in the diagnostic management team And that can mean a lot of different things. I think primarily we're gonna be focusing on different areas of medicine, but we may venture further afield so This is kind of get started Why is it that coag was sort of a natural fit for the beginning of the DMC concept? Many people have asked me that and it's a very good question It really relates to where coagulation was Around the time that the idea emerged in the early to mid 1980s. I Found myself as an MD PhD student in an awkward position in 1980 when I went to the chairman of hematology at Hopkins where I was a student and said I want to be like you and Do something in the field of coagulation benign hematology and He said you can't and I said why? and he said that hematology is going to merge with oncology And most of the people who finished that program are probably going to be oncologists Then I said what happens to hematology And he said to me it's going to go to pathology And I said what so you mean if I came in with a bleeding disorder I would see a pathologist and he said I think that's what's going to happen and I think you might be the example of Who does that work because you work like an internist But you have all the advantages of advantages of a pathologist you control the laboratory You can do this test that test you can take care of the patients get a diagnosis sooner, so he was right and as hematology benign hematology fell away from oncology Even the internist didn't know coagulation so sure enough We did develop a diagnostic management team. It was focused in coagulation serendipitously because that's what I knew and I was reading the literature and I could do it and And I was badly needed it ultimately ended up as a clinical practice for me when I was at the MGH Yeah, I had a practice people came to see me and they were referred from hematology oncology docs primarily Who didn't know the hematology part but knew that? I would probably be able to do it. So coagulation was very well received because Not only did the surgeons and primary care doctors really needed but even the internist themselves I had a conversation with a doctor who was A dean at Harvard Med School. He was former chairman of medicine at Stanford and he said I'm an endocrinologist and I might not need your help for endocrinology But everything you write about coagulation is valuable to me That's how it all started. That's fantastic. Yeah, I um, I kind of wonder one of the things that is interesting about coagulation is that it feels and maybe maybe it's just because I've been in the field, but it feels like almost like a tweener space, right? There's neurology and it's pretty clearly this is the diseases of the given organ system and coag has kind of a feeling like It's a subset of the disease processes of that given organ system and so as a result, it almost just feels like it gets short shrift like almost everybody kind of ignores it and It's not that it's not important a huge number of people, you know die from thrombotic causes And yet somehow they seem to not prioritize it appropriately And so I think that that that was an additional kind of area where or a reason why when he monks sort of merged It just feels like it got left behind. It was like the area of medicine that was just kind of left behind No, I think it's fair If you look at the liver in the spleen the heart, right you can pick them up. You can hold them What do you do with blood? It just blows over your hands, right? So it is an organ system and it's very complex and It's like many things in school that we didn't learn. Well nutrition is one Coagulation and all these lab tests certainly one and remember coagulation is one of those things that really has no Anatomic pathology component to speak of so there's no biopsy except to get a blood smear. Yeah, so different. Yeah, I wonder Is a Tool based specialty Not not originally but Certainly clinical pathology is a yeah based specialty. We think of ourselves as being chemists and microbiologists and To some extent that maps onto a disease process But to some extent it doesn't really it actually maps on to an electrochemical process some sort of mechanical process what you know, and so What what characteristics of Disease focused EMTs make them perfectly suited for DMTs or better suited for DMTs than say that Orientation. Yeah, I would say Remember what we spoke of earlier that DMTs were developed So that we could get a diagnosis. It's the principal nature of the DMT Yeah, exactly that we're going to narrow down a differential diagnosis look at tests ask for tests But ultimately we're going to say that's why you're sick So I Think we have to think about Where uncertainty and clinical risk are what areas? Yeah how we can contribute to reducing that and certainly in The time when we didn't have many tests the 1970s everybody knew what to do with a glucose It was high or low. We didn't have many tests think about the automation. Yeah, the 12 tests on an SMA 12 That's it. Yeah, there were a few extra tests, but not many but then here come the 80s suddenly a Lot of tests that are immunoassays get put on automated instruments and they're complicated Then we start adding more and more the 80s and 90s were such an explosion of lab tests So at first the reaction by the doctors who were treating their patients is yeah, I know that I know that don't bother right and Don't even think that I have uncertainty about it Are you kidding when you finally sit down with them and you say what about this? They don't know even though they've portrayed themselves as no so Even the routine tests as we went further along got complicated So the complete blood count got our red cell distribution with put in it. Are you sure you know what that means? Yeah, what about the immature platelet fraction? So at some point there's uncertainty in most physicians Even with routine tests for some of the parameters, but certainly beyond that level of routine tests People are guessing because they don't have a place to go If they had a place like a DMT and it was everywhere maybe in a diagnostic center that we've been talking about They could just say I don't know what this means to have a red cell distribution with that's so big in this patient What could it be the patient has been anemic for a long time? Oh, yeah, so that's a very important thing and you can't say I'm done here. Even though I don't know You have to find a way to get it and we have to create that place to go the diagnostic management team Maybe in a diagnostic center so that every health care practitioner who is facing a patient Doesn't say I don't know that but that's okay. That's not okay Where you're talking about the quality and quantity of people's lives here. So that's why it's so important and It's not embarrassing to say I don't know what an immature platelet fraction means Yeah in this patient for goodness sakes once we have all this set up just ask that's the whole purpose Yeah, I wonder it must be a challenge in our field It's much easier to be somewhat intellectually honest about the level of uncertainty that you have about a diagnosis Because there's nobody it's okay. No problem. I don't know. I just read a minute ago Yeah, that Apo E4, which is a risk for dementia serious genetic risk. It has subtypes There's an epsilon variant of Apo E4 And that is bigger for cognitive decline, holy cow I didn't know that until half an hour ago, so it's okay I don't know everything but I have to say I'm pretty good with looking up everything to find out what was found out yesterday How do you how do you see the role of diagnostic uncertainty? Driving the value of the DMT. Obviously what we what we've got is a clinical team Who are on both ends of it being forced to present? Their level of uncertainty at different amounts, right? So when you're speaking to a patient clinicians are less likely to Express how uncertain they are about a diagnosis and We can talk about whether or not that's appropriate or not But it is the way that the field has evolved. Yeah, and you know, we can even think about, you know procedural specialties being even more likely to not convey that. It seems to me like there's value in that discrepancy between uncertainty and you know The amount of uncertainty leads to more value from the DMT. How do you sort of enormous? Yeah, so what are the drivers right for saying? I don't know that but I'm gonna find out as opposed to just saying here you are That's what I know. And I'm not going to tell you what I don't I would say the number one driver is you care about the patient. I don't want that patient to suffer a Complication that could change their life or end it because I didn't ask the question Though those are the errors that are not quantified But somebody who takes somebody who's short of breath And says oh, I think it's asthma You give them a nebulizer to send them home And if it's pulmonary embolism and you don't anticoagulate them, they can die when they put their key into the car To go home, of course, and does somebody say gee, I should have known that Does that go to some medical review board? No What happens is the poor patient ends up with the well, there was an unexpected thing There was no way the doctor could have known oh, yeah There was a d-dimer test would have told you a lot. Yeah, but nobody is saying That's a problem. Now if you poke a catheter through the aortic arch, everybody knows But if you don't get that right and the patient dies, we've had a hard time Calculating how big a problem it is. But really through the 2000 teens we realized this is the biggest place for medical error so your insight Even even knock around in this in this field for a while. Yeah, I think that a lot of people Will get a lot of value not only historically understanding what has happened and and the obstacles that you've overcome But kind of the brass tacks like what do I do now? Right. They're talking to you. They say hey mike what areas of Medicine do you think lend themselves to a dmt and and kind of why? so I think the most important thing is If you want to be involved it has to be an area which you know So I wouldn't start a dmt right now in endocrinology endocrinology of the adrenal gland because Goodness, i'm at the very beginning of that. I know some some things some of the headlines about a pheochromocytoma But the reality is that i've signed up 50 000 cases of bleeding clotting disorders. So So for me first, how do you start? A dmt which one would you pick? It's the one you know and Pretty much all of us in pathology have some area that we just are more interested in and we read more about it and So if we have the diagnostic center concept think about how you could participate in a diagnostic center in what you know it could be that You are broad-based knowledge in a big specialty that is dominant in laboratory And uh, and I might say coag is one of those because it's so dominant in laboratory There are other specialties where testing other than a biopsy is pretty small Really everything in the gi tract is pretty much a biopsy. Yeah, so That's not as big an area for building a dmt So I would say there are two concerns to answer your question one is What do I know and would I like to participate in a diagnostic center? That's probably regional or if we're setting ones up here Um, which ones do we set up based upon the expertise that's in-house? You can't cover the waterfront completely. Yeah How do you think about so there's another sort of You know axis to think about in terms of the dmt And I think that coag kind of is on on the far end of that. So there's there's relatively rare disease processes That are extremely high impact And then there's run-of-the-mill Processes that are a little bit confusing, you know think like the management of chronic kidney disease is Really important because there's so many people And yet it's just a little confusing yes Um, but then obviously you've got rare genetic disorders that you know have very highly new ones So when you think about where the dmt ought to reside Where do you think it should reside in that sort of continuum? With regard to department No, I mean as as as i'm thinking about let's let's imagine that i've got three or four dmt's that are rattling around in my head Okay, I think You know i'd like to start here here and here. Okay Do you think that that continuum matters for starting a dmt? Do you think that it should be the rare disorders that are extremely complex or should it be more the frequent? But slightly confusing dmt's or does it actually not matter and that they're all needed? Yeah, I think they're all needed and we decide which ones we do based upon what we keep reading about. I have a good friend who um has been Probably the biggest contributor to understanding thrombotic thrombocytopenic purper at ttp The mechanism everything and the diagnosis That person could contribute immensely for a disorder that isn't that common, but he literally knows About everything there is to know about ttp So that's an example where at his university there might be a dmt On ttp that hopefully we could recruit into a diagnostic center, but I really think that If I were asked to start a dmt on something I didn't know it would be a problem um So i've i've had that happen before where people said you need to start a dmt on that And I said, you know, I haven't read five papers on that topic Yeah, it seems to me like as we Move away from the very local right your institution to regional and national that areas where you might have the highest impact become also the most financially viable, so Very rare disorders If you have a dmt on these it's almost like okay, so you're going to get one of those every couple of years You know what exactly right and so then you know your your billable codes your department chair whomever says you aren't billing enough whatever right the practical get it And as we move more regionally, then that expertise in those rare disorders becomes more valuable, correct and so you sort of your natural intuition is to move towards the Very frequent and just slightly difficult But the fact is those are the kinds of things that are going to be consumed by fairly simple ai systems Yes, and guidelines. Yes, and so it seems like If we really get the diagnostics international Then the more rare But highly impactful cases are going to be the ones that people are going to be attracted to the most No doubt about it. I'll give you an example. What about fennel keaton urea, which i've learned a lot about recently. Yeah because of people in the family and So what what has just happened in fennel keaton urea? um It was once something that you diagnosed based upon clinical observation of poor feeding in a newborn and you have to Identify it to be able to provide the right uh food and nutritional support That doesn't have fennel alanine in it or intellectual disabilities and a whole bunch of bad things happen, so What is it now? well Now there's a new treatment that has just been developed a small molecule and What you can do Is to alter the system so that fennel alanine can go to tyrosine Now you have to know the genetics which mutation is Present to produce fennel keaton urea. Well, let's see There's at least six genes that are important here and there are more than 1200 mutations So these small molecules that are used as drugs can Take somebody from this relatively rare disease to basically normal costs a lot of money. You have to know the mutation what's the likelihood that Even a gi doc who might be taking care of a somebody with fennel keaton urea is going to know all about this Yeah, right. So it's us. It's our it's our expertise in genetics, which is Not common among Practitioners because there's really too much to know And we explain it. We say what the mutation is we explain this is going to have Likely a good effect if you treat with a drug Or the drug won't work at all and so Boy, what could be more important? This is a life or death thing. Yeah, and it starts with birth And we know the answer to all of it. So Why should we fiddle around saying I wonder what this kid has if the If the newborn test suggests that's pku, please give us a sample We'll tell you the mutation and we'll tell you if it's suitable for drug therapy. Yeah. Yeah It seems to me like uh As we have more tests the percentage of Diagnoses that are made without a test Will just almost necessarily go down. Okay, you're just going to have more maybe to nothing. Yeah, and So right now there's a subset of diseases that are in one of three camps one is That it's not made with the laboratory value at all Some that it's made somewhat with a lot of free value and another that it is made primarily with the laboratory value Perhaps even exclusively Can you obviously in that environment? Primarily with a library value it lends itself to a dmt What other sort of general heuristics do you think in addition to your own preferences? Do you think about when? Starting a dmt what kind of areas what what helps you say? That would really be a good dmt anything else besides labs testing and your own preferences So certainly lab testing is the biggest one But let's take um, let's take alzheimer's So for years, it's just clinically diagnosed. We give you a test and see if you're in cognitive decline. That's it like Can't you tell five years ahead of time by doing a blood test? Yeah, so i'm looking at all the things that are out there that are really decreasing the quality of life or shortening life Uh and saying can we get a lab test and then we could can we put a dmt next to it? How about pancreatic cancer? Can't we get something for pancreatic cancer as opposed to I don't feel good and when you find it at stage four Yeah, and everybody dies and the average length of Of a time from diagnosis to death is just 90 days. I mean, yeah, really there's got to be a lab test And people are looking for those things. So Really blood tests are important. You can't biopsy the pancreas every year. Let's say you have a family history What are we going to do? Well, if you have a family history, maybe i'd get an abdominal ct once a year Wow, these are tough things as opposed to just getting a blood test and seeing if a marker is elevated. We did this with psa for prostate cancer, right you have a psa of of 60 Uh, we're concerned probably metastatic prostate cancer by that time But there was a blood test and before that time in the 1980s How did we know you just had a hard time with urination? Yeah, right. Yeah, how about How about different, you know alternative structures? Are there any dmt's that? You were surprised about their structure that maybe Kind of happened in a way. It's been really impactful, but you did not anticipate and it surprised you Yes, when we had those three national meetings in galveston on the dmt There was a group I believe it was a group in amary in uh, georgia that Had a dmt created for a very specific issue related to platelet refractoriness uh, and uh And so they used hla testing and some other things and I wondered is that really a dmt because We're doing a few tests But in fact if we're getting to a diagnosis platelet refractoriness, yes or no, which has an impact on clinical decision making Sounds like a dmt to me. Well, it certainly has yeah, it's remarkable. Um because sometimes our blood management especially platelets, especially during covet and shortly thereafter, um Can have every bit as big of an impact on a health system as anything else because you are now dealing with a fairly limited resource Your logistical, you know acquisition of platelets might be really impacted. It certainly was for us We were getting platelets from wisconsin and so it took us days If you waste, you know a couple platelets because you've got a refractory patient and then now it's just Being put in the garbage can That hurts the whole health system. I mean hundreds of people are impacted by you not having platelets on the shelf So yeah, it's it's kind of an interesting model that that in particular i'd forgotten about that example Um at the time I remember thinking the exact same and then as i've been doing a lot more blood banking. I thought oh, man Every every one of those bags matters. Yeah It's it's funny thinking about dmt's as as handling logistics and resources Um, and that's one where I think that their focus was on something very different than a disease diagnosis per se But managing that resource was pretty pretty impactful. No question. Have you ever had a situation where? Anybody forced the dmt that kind of failed have you ever had a situation where? Somebody forced it kind of lingered along. I might have been administrators that sort of forced something that we really got to have this You know up and running it just kind of never really worked because maybe There wasn't enough lab testing the expertise wasn't there anything like that. Uh, I would say that most of the things that have not worked were Originated by somebody who worked in a specialty area Wanted to get a gold badge for doing a dmt. Yes, sure, but in reality Couldn't put all the pieces together to solve that problem um As you know, we're very interested in a dmt that would focus on is there a fatty liver But you have to put all the pieces together and will the resources allow you to buy the equipment to see? Uh an image that shows the presence of fat in the liver without cutting it open and doing a biopsy Cutting the skin that is so you have to come up with some non-invasive things So I would say that idea has been around for a while but only now is it coming to fruition because um You have to have enough money to buy things and you have to have enough support from people above you to purchase them. So Those are the ones that tend not to go but I have to say nobody ever said hey You need to do a dmt on Crohn's disease Dug on it. What are you going to do? I mean I could put together some laboratory tests associated with inflammation some other things maybe um but but it's not um It's not something that was ever forced on me But it's worth mentioning what we did with covet here at our institution because there was a lot of uncertainty about uh The interpretation of the lab tests around covet there was pcr Standard tests and everybody said well if it's positive you have it and if it's negative you don't Well, that didn't turn out to be true because you can't put the swab down Far enough in some patients to get virus on the swab if you stick it in the nose because the infection's in the lung So there were a lot of false negatives when you actually do it clinically because you're not getting the virus It's in the body. You're just not getting it in your test and then I saw what they were doing with antibodies to see if you have antibodies to to the SARS-CoV-2 that produces covet and I saw it on the news and I thought oh my god Those lateral flow assays are probably picking up antibodies to the flu not just To SARS-CoV-2. So you're getting positive tests for antibodies that don't reflect the COVID. So what we did was We wrote 75 comments that turned out to be 150 comments And then we taught epic to look at all the lab data the antibody response and the pcr test and sometimes the rapid test and Pick one of those That made the most sense and then we gave an interpretation that was patient specific It was expert driven because it was looked at by one of us And then it ended up in the chart. We really didn't know what's going to have an impact until you Actually looked at the big numbers and showed that for our patient population The number of people who died especially in the early stages of the illness was way lower Now the only thing we had that everybody else didn't have was the interpretation We didn't go back and do surveys and say what did you do after you got this this narrative report? They must have said, you know what? There's some uncertainty about whether or not I have it or not. I'm not going to the family reunion I might be giving it to everybody. So we had fewer deaths and we had quicker time to getting better So we were uncertain about the benefit of that and it turned out it was really valuable. Yeah. Yeah it was an interesting area where I I was somewhat even skeptical initially when you had proposed it and I thought how much value Is it really going to have and so that's actually why we did that because I think we in the group Um Peter did a ton of great work here. Dr Peter McCaffrey did a ton of great work Building out the automated solution himself, you know coding everything himself and obviously Alex Rapp Um did a fantastic job shepherding all of the work that you did to Make it happen and so I think there was Healthy skepticism on its impact and it was remarkable. I mean There was remarkable. There's a lot of people who are walking around this island Yeah, this is not a big island, right? There's a a bunch of people who are walking around this island that would not be walking around this. No question No question. It's incredible how impactful that was one of the I think that's actually a fairly good example of where Dnts might Stop as well. So so traditionally we haven't had a situation like that where A dmt has a natural Sunset phase right it starts it stops. We're done. Okay and I i'm curious to know if you Have any sort of way to think about What measures you might want to have for ending a dmt? There haven't been a lot of them that have actually gotten the momentum started up and we've decided we wanted to end a dmt But I think that for people who are listening out there, that's a great concern right because I don't necessarily want to bite off more than I can chew So when do I know? Hey, this is actually something that we could go ahead and sunset or turn off or change the frequency or do something like that So people push back on the dmt for covet after four years or so here Um, there was a modest charge for the interpretation. It wasn't much Talked to insurance companies along the way who said very valuable. We pay a lot more for surgical pathology, for example But what you're giving us for the covet is Valuable and we believe our patients are reading it because it's in my chart so no trouble with the insurance paint so we responded because uh the Folks said well, there's treatment you get a positive test. We're going to give you the drug Maybe pack sloven for example And then we don't have to worry whether there's a false positive or negative because they push back I said, okay If you don't want to do it, we won't do it Now what what is me as a doctor and a scientist think? Is omicron the end of it? We went from alpha to omicron. Yeah, so So the next the next greek letter is pi Yeah, and so will there be a sars covey tube? That's pi that has more variations in the spike protein and ramps this baby right back up again Well now we've disengaged from the dmt. I don't think it's a good idea. That said Response to political pressure is sometimes what you do. Yeah, but I think it's I think it's fair. I I do um I do wonder though For other dmt's, you know, you can imagine that From a volume standpoint perhaps the impact isn't there Maybe you did an initial study and you thought it was going to really be impactful and it just wasn't as impactful as you thought um, I can also see a scenario where You actually teach the physicians at your institution how to perform And then they figure it out that would be great, you know, I think that there are a lot of areas where Learning actually does in fact happen right we're a bit cynical on our side because we're so analytical but Learning does in fact occur. Oh, I saw it I saw it at the mgh because that was the closest we were with the Physicians who received the reports and I was surprised but all my friends in vascular surgery They knew all about the hypercoagulability panel. Yeah, right because they've read so many of them Yeah, and that is the goal really it's to bring up the knowledge. You can't learn it all in med school Yeah, I always say how much time was spent on Description of the thrombin time and how to use it. Yeah, and what the results mean And if it was any time it was a nanosecond and it was done once. Yeah So there's too much you can't fit it all in there So you learn mostly when you practice? So this is an element to bring everybody up to up to speed and you know because you were the one who implemented it but in our reports For a while we were putting chain of reasoning That is we are going to tell you why this patient is likely to have lupus And there it was. This is the ana. This is the immunofluorescence There's this and all these things happen and there were these clinical pictures and bingo done. That's what you have lupus Yeah, it's helpful. I think In particular the chain of reasoning is valuable for scenarios where Again to go back to this unknown unknown concept our biggest obstacle with the dmt I think Is clinicians believing now that they know more than they in fact do know And so the chain of reasoning is helpful because it essentially raises the floor of their performance When they go away from you if they don't do a dmt with you Then they are likely to not miss at least these kinds of cases. They might still miss some other cases That haven't been covered by your rationale in your chain of reasoning but at least Now they know that in these kinds of scenarios you can do this sort of thing or this interpretation makes the most sense And it helps them understand and have fewer gaps in their knowledge I'm i'm still a little bit nervous about The trend where clinicians say i've done 20 of these and therefore I know everything mike's going to say Because the 21st Could be all different. It could be totally all the patients are really different in some way Let me tell you that the chief medical officer at vanderbilt where I was between the mgh and here Said to me that we're worried about coagulation because You give them the answer you tell them what it is. And the fact is it's on their internal medicine boards So he said is there any way you could make it so that when they read it They understand why you said what you said And so I told them yes, and in fact we're going to do that And when he saw that he said this is phenomenal. That means every case they have is a full teaching case In the moment with the patient they're thinking about now And he said that's much better than saying now i'm going to figure out why immunofluorescence differences tell me between Tell me the difference between lupus and rheumatoid arthritis Because that is a month later when you're sleepy and you're sitting in your chair here and you're just oh So mrs. Jones says rheumatoid arthritis not lupus and that's why yeah, that's when you want to learn it And he said you're now providing that information So dmt is a major teaching role for the internal medicine residents Yeah in addition obviously for internal medicine residents is a teaching tool for really any intellectual Level, right? Yeah, your your patients Can have the exact same chain of reasoning now with llm's we we have been changing the change of chain of reasoning for different reading levels knowledge levels whatnot and so it's actually fairly useful in that regard because If you take your report and you give it to an ai Assistant and then they summarize it for the patient There may be context That is is lacking And so when we do it on our side And then give it to the patient we read it over and we say yes In fact that is correct or no It has been oversimplified to the point that it's not as useful and therefore we can modify it. So Being able to give that chain of reasoning As educational tool for not only medical students and residents But also patients, you know makes it a lot more valuable. The the patient can take better care of him or herself Yeah, I I totally agree. I I'm curious One of the dmt's that has happened At our place and has somewhat Diminished in its overall impact over time Because we've built in other systems has been High cost testing so we for a period of time we were analyzing high cost tests. We still do that I still do that um, but it seems to me like From a Hospital administration standpoint there's always going to be interest in the reduction of the number of high cost tests There's always going to also be an interest in the reduction in volume of high volume tests It's just a thing that they're going to do and they're going to always think it because You know the proverbial beam counters are going to always think oh, hey see that look at that mike's group. They blah blah blah so It seems to me like The use of a dmt in those spaces makes The use of that testing more justified because you're now looking at you know, I don't know there's a test It's ten thousand dollars. Well You know sally and jim took a look at it and it was Reasonable and here's the report based on that Do you do you agree with that sort of general idea that dmt's in that space would be valuable? What a great example and I have a good story for you. Yeah, so when I was at the mgh there was a Committee that we created and it was called click clinical laboratory utilization something And we looked at the high price tests because administrators one of us so When you get cancer, there can be some neurologic effects So there were some tests for and they were very expensive and our neurologist Was they were very interested in these tests? and so I approached the neurologist because I was friendly with them and said Look, here's the test that we do at the mgh the number of these tests. Here's what they do at another hospital. They said That's the difference between us. We're way better than them And they said I said well You know, there's 19 kinds of ataxia and the tests you're doing are trying to look for like eight of them So even if you find the eight if you're one of the eight, that's great But what if it's one of the others that we don't have a test for? They said Well, at least we know the eight that's why we're better than the people who don't do anything at all for figuring out the type We're better than ataxia And then they said how many papers have you read about ataxia? I said, I don't know probably a textbook 10 years ago. Yeah, so we read it every day So why are you questioning us? So that's when I realized the way to do this Is you create something like ataxia you have people who are your colleagues who want you to help everybody else because They're surely not seeing every case of ataxia and they help you craft it. Yeah, and so Once we got credibility doing coagulation at the mgh as we wanted to build others Then we started saying what would you put in there? How would you do this and I would stand up with a marker in front of a whiteboard and draw this as an algorithm You do this test if that's positive you did and worked it out with them. Yeah, and so the reality is that Gosh, if you take a look there's the neurologist in the middle of this Then there's us who know a little bit about medicine and a lot about testing and then there's somebody who never had background in medicine who's Worrying about how much we spend and to make some doctor Not do a test that they think is valuable for the outcome of the patient where it's uncertain, but they believe a certain way Really not fair. I mean we really have to understand Yes, it's expensive, but this is what it'll accomplish Really if you just take a look at all the things we could do i'll take pharmacogenomics So there's one test you could spend two to four hundred dollars for it. You would know how you respond to The 280 or so drugs that are affected by your genes wouldn't you want to know that from the time you're a baby so that when you get an Antibiotic or later when you get a statin or later when you get an antidepressant that you get the one that actually works for you Yeah, of course, and wouldn't that be less expensive than if people suffer with depression for 16 years because yeah, but nobody wants to pay for pharmacogenomics. Yeah. Well, that's that doesn't make sense financially So somehow we the doctors have to be credible enough With the people who pay our bills here and everywhere else that this is well spent money. Yeah Yeah, it does. It does feel as though What you're mentioning is an expanded but also really? Limited role in the dmt here's what I mean, you know, um I think administrators Oftentimes are have a health background, of course some um, but some of them don't and anything that improves Their hospital value whether it's clinical value financial value, whatever If it's good, then more is better right, and so if the dmt is useful Could it then be applied to? scenarios like You know financial scenarios could we optimize our finances? Sure. DMT the structure and yet to some extent It's hard When doctors are being forced to think about both things at the same time And so there's there's somewhat of a limitation to the dmt because you can't really apply it everywhere Because doctors are focused on finding the diagnosis and then treating the patient And so the dmt itself while it can be useful for You know cost savings and whatnot. Its real value is in the diagnosis of the patient and showing value in fast diagnosis. Yes, not in cost-cutting and reducing the number of cdc's you do Absolutely. I think the big problem is How do we count how much we saved when we prevented a blood clot, right? I've had many patients on my own referred to me after they've had a blood clot and One I remember Who started using oral contraceptives and fine, but never got even a good history taken about clots in the family Just here's your oral contraceptives, right? um And so there are blood tests that you could do if you Have a story like that coming from a patient do a hypercoic panel look for factor five liven and Prothrombin 202 one of those kinds of things know them in advance So when you present that to somebody who doesn't have a health care background, they don't understand that one test relatively inexpensive in this whole thing Could solve a problem where they get a blood clot and now they're on a blood thinner for the rest of their life It would have been way better way cheaper if you just would have done the test first And that's why these patients come in and say why didn't they do these tests at a time? Why is it I go see my doctor and they do a complete blood count every time But they don't come in and do a test to see if i'm going to get a clot when I fly in an airplane Yeah, it is interesting um how What is measured is the current focus of an administrative Team, you know, like for example, if you've got You might look at yourself and you benchmark your your institution against some other institution and There might be a thousand ways to measure the financial health of an institution it could be things like length of say for a given diagnosis or tests or procedures or whatever the zillion of these things and your natural inclination Is to look at the outliers high and low and then if they're high to really work on that thing and So therefore you might look at Our lab testing volume for example and say hey, that's high. Therefore. We better work on that thing and reduce it and You might Increase your length of stay even just modestly because you've reduced the lab testing But of course That length of stay number matters way more than the lab testing volume, you know, because you know in most institutions like ours The relative budget of the laboratory is in the single digits right, it's like it's like A nap about yeah about three percent. Yeah. Yeah, and so when you compare that to Pharmacy or surgery stay in a day in the hospital. Exactly. It's it's not it's every single test ever Versus one day in the hospital and it's like, okay We could have just done them all at vander belt. We shorten the length of stay for pulmonary embolism by two days Yeah, it's hard to eat. We did some more tests. I want to buy that but Two days for all the pees think about how much that is Well, we did the you know, we did the heparin news from beside opinion. Oh a good example that Really had almost no financial viability if left on its own And yet we showed that not only did it save pharmacy money overall so against But then we reduced the length of stay at our institution by More than two days. That's $2,000 a day for a thousand it's for a lab test that might have cost 50. Yeah Millions and millions of dollars we've saved since we enacted that test And I remember when you wanted to bring it in and I thought i'm not sure that it's going to make it any sense financially And you said we're going to do it anyway, and we did and now it's been extremely valuable. Yeah. Yeah. Well, so I um We've gone long. It's been it's been fantastic, but I do kind of want to ask a couple, you know Sort of final up question. Um So if someone's considering a dmg What is the first question they should ask themselves about that process first thing is commitment I had a person at the mgh Who loved interacting with the residents taking the cases, but he didn't want to commit to doing it every day I said well, well you're in a hospital. You're in our department. You have the most knowledge about this area Yeah, you have to do it monday through friday People are still going to make themselves sick in your area on thursdays. So you can't say well, I don't feel like it So commitment is the first and once you start it you started it. That's it You don't want to start it and stop it. So that's first second thing is do I actually know enough? And the third maybe what happens when i'm not here who will do it? So it was wonderful having you in coagulation because we never Faced the gap so I would say commitment having enough people to do it Being able to do it. Well I would say that's really all Excellent. Is there anything else we should know about starting a dmt that that you've learned over time that I didn't ask about I think it would be intriguing if everybody in our field looked at what they know best And said how could I standardize this? What could I put in it? So it's not just the biopsy of a prostate But it includes the psa and maybe the trend of psa Over a period of time and some other variables that might say more about a prostate cancer um just as an example, I think that There could be so much benefit by putting all these tests together and making an integrated diagnostic report Instead of handing pieces of paper over and over again relative to that prostate cancer to the primary care doctor who Has to put together a 500 piece puzzle on everybody. Yeah, I think it's our job to put the puzzle pieces together And that makes us valuable that makes it That makes us so valuable that when we're absent Somebody would say where the heck is that pathologist? Where's mike? Where's the Report for three days. Yeah, right because right now the way we work Nobody knows when we're gone. Yeah, and there's no other specialty except Clinical pathology lab medicine. I think where you could be gone for weeks at a time and nobody would know That's it. Well, thank you very much, sir. I'm looking forward to the next one. All right. Thank you. Chris. Yes, sir. Bye
