The Past, Present, and the Future: Department of Pathology and - - PowerPoint PPT Presentation

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Lydia Pleotis Howell MD Professor and Chair Pathology & Laboratory Medicine

The Past, Present, and the Future:

Department of Pathology and Laboratory Medicine

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My second five-year chair review

• A valuable opportunity to:

– Reflect – Shine a light – Advocate – Get feedback – Become better than ever

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In this presentation, I will share:

• Vision and plans from 10 years ago.
• Accomplishments today – a few examples among many!
• How we have achieved these.
• Future directions and plans

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10 years ago: Chair Search and Vision Presentation

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Vision is important to leadership

“Good business leaders:

• create a vision,
• articulate the vision,
• passionately own the vision,
• relentlessly drive it to completion.”

Jack Welch, former chairman & CEO, General Electric

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The chair is the CEO of a major enterprise

• Academic pathology is a $120+M business at

UCD Health:

• $8M grants/contracts
• $8.2M professional fees
• $4.3M purchased services for medical directors
• $100+M clin lab revenue
• Priceless: Education and community service contributions

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Vision then -- and now

To be acknowledged nationally as a department of the future In other words: a department that:

Is at the cutting edge of its discipline, anticipates and leads the future thru its research and creative work, prepares others for the distant as well as the immediate future.

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Being future-oriented is our inherent obligation:

As a land-grant university:

• Discover and share knowledge to

improve the lives of the people

Fits the Chancellor’s vision to “boldly go” Fits our role as a core department with a major role in every mission.

This Photo by Unknown Author is licensed under CC BY

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If chosen as chair  my duty is to be sure we meet this obligation by:

Facilitating research and discovery:

• Future-oriented and multi-disciplinary.

Providing clinical care:

• Efficient, high-quality, and cutting-edge
• Brings innovations to the bedside to the benefit all members of our

community.

Educating trainees and practitioners:

• Emerging methods and trends.
• Critical thinking about the future.

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Departmental activities/themes: Derived from major forces of change in medicine

• Tests for personalized risk assessment,

prevention strategies, treatment, monitoring.

Proteomics and other Biomarkers

• Digital and in-vivo imaging on gross and sub-

anatomic and cellular level

• Quantitative image analysis

New imaging technologies

• Integration of clinical and research info
• Data-mining
• Availability across wide geographic areas

Informatics and AI

• High quality, innovative, efficient care
• New delivery sites: POC, home
• Diminishing workforce, growing needs

Healthcare economics & reform

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The national context: NIH priorities

Example: NCI’s 2010 Professional Judgment Budget Request

• Clinical proteomics & other resources: $75M
• New imaging tools: $150M
• Biomedical computation: $45M
• Oncology tissue banks: $30M
• CaBIG & BIG network: $100M

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NCI Budget Proposal 2021

• Many similar themes today
• Opportunities specifically noted in the report:

– Microbiome – Artificial intelligence – often combined with imaging – Implementation science

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The national context, con’t

• CAP’s 2010 Campaign to Transform Pathology

includes:

– Investigation in emerging technologies – Better integration across disciplines: laboratory, clinical & basic

science

– New best practices & standards – Education not just for now, but for the future, too.

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Fits my own experience

• My leadership in American Society of Cytopathology and their focus
• n the future:
• Vice president (at that time – later president)
• Past-president, ASC Foundation
• Executive Board member x 5 years in 2010 – 10 years total.
• Discussion facilitator at ‘09 ASC Future Summit

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Focus on innovation is especially important for today’s leaders

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Have we achieved the vision? Are we an innovative and future-oriented department?

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Research accomplishments:

Discovery of new knowledge drives innovation  improve clinical care

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NIH funding and rankings

10 20 30 40 50 60 70 80 $0.00 $1.00 $2.00 $3.00 $4.00 $5.00 $6.00

NIH Funding and Ranking, 2010-present UCD Dept. of Pathology & Laboratory Medicine

NIH Funding, Dept. of Pathology & Lab Medicine Ranking, Pathology & Laboratory Medicine

• NIH funding:

– $4.2M as of July 2019 – Higher today

• NIH rankings:

– #68 in 2011  #42 in 2018 – Mid-30s predicted for 2019

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Areas of strength

• Neuroscience group: $16+M in NIH grants over past 5 yrs.
• Vice Chair of Research Yvonne Wan:

– Top 15 funded PIs at UCD School of Medicine – $7.5M total awards in the past 5 yrs.,

• Anticipate more growth

– New research-intensive faculty recruitments in progress. – On-going work by our current faculty

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Not all about rankings: We are acknowledged leaders of major multi-disciplinary programs

• Multi-center personalized medicine studies: NIH-funded All of Us and WISDOM

– Site PI: Sandy Borowsky MD

• Neuropath Core, $13M NIH R01 “Oldest Old” Dementia study

– Lee-Way Jin MD PhD

• Microbiome Program, Cancer Center

– Led by Yvonne Wan PhD – Recent collaborative seed grant program

• Clinical trials, largest site for Roche Diagnostics

– Nam Tran PhD

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New technology: Cool new tools for pathologists

• Imaging: MUSE (Levenson/Fereidouni)

– Involved lots of faculty and students

• Awards

– Astellas C3 Technology award – Chancellor’s Innovation Award – Innovation of the Year, Optical Society – 2019 Power List, The Pathologist

• Validation as a lab-developed test is

underway

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More cool tools – James Chan and colleagues

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Even more cool new tools: Artificial intelligence

• Artificial intelligence/Machine Learning

– Rashidi – Graff – Dugger

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Our research role is not just about us:

• We support research across UCD Health

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Leaders of inter-disciplinary seed grants

2015- 2016

• Inter-dept seed grant program  Pathology.
• Expanded from 4 to 8 departments: $80,000

2016- 2017

• Pathology leadership continued
• Expanded from 8 16 departments: $160,000

2017- 2018

• Collaborative for Dx Innovation: $370,000
• Gift + 11 depts, 3 Centers, SVM, PMB, OOR
• 9 Pathology faculty involved in 10/17 projects

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Support research in the clinical lab

Clinical Research Oversight Committee

• Purpose:

– Create an effective “front door” to foster research in our clinical laboratory. – Ensure:

• Capacity (instrumentation and staff)
• Workflows to protect turnaround time of clinical work
• Appropriate pre-analytic specimen preparation
• Compliance with CAP and other regulations
• Payment for services rendered

– Minimize tension and conflict.

• Outcomes (as of 12/2018)

– 223 projects supported – Serves 108 principle investigators and 30 departments. – Improved satisfaction and attitude among clinical investigators and lab staff.

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Education accomplishments

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Undergrad programs Medical Laboratory Technician Clinical Lab Scientists Cytotechs

Medical students Residents Fellows

Continuing Education for Practitioners

Educational breadth spanning the professions and level of learners

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New in education over the past 5 years

• 2nd year med student course (PMD410):

– #1 rating in pre-clinical curriculum:

• New electives for med students:

– 3rd yr elective – Acting internship in AP – Increased capacity for 4th electives

• New lab professional training:

– Med Lab Tech – Cytotech – award-winning grads!!!

• Clinical Informatics Fellowship

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Highlight: Two educational programs

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Residency program

• High ratings in

ACGME annual survey

• Above nat’l average

in recent engagement survey

• Thanks to hard work

by many after an external review.

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Award-winning residents

• George Gao

– Best poster, USCAP – Two leadership awards: ASCP, USCAP

• Ying Liu

– Certificate of Congressional

Recognition for volunteerism with ACS

• Ananya Datta Mitra

– UCDH High Value Care Competition

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Outcomes, con’t

Instituion Fellowship(s) City of Hope Hemepath Emory Molecular pathology Johns Hopkins Gyn pathology MD Anderson Cancer Center Surg path San Diego Coroner’s Office Forensic pathology Stanford Transfusion Univ, of Alabama Molecular pathology Univ, of Massachusetts Dermpath UC Davis Cytopath, Hemepath, Surg Path UCLA GI path UCSD Neuropath, Bone/soft tissue

• Univ. of Washington

GI path

• Outstanding

fellowship placement

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Edmondson Summer Research Internship: ~35 yrs

• Encourage careers in science,

pathology, lab medicine

• Develop diverse pipeline

– Prep Medico partnership x 3 yrs.

• Survey for 2002-17

– 93% strongly agreed/agreed:

“Important to career development.”

– 25%: Doctoral degree (PhD, MD, other) – 10%: Masters or other health

professional degree

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Faculty: National leaders in education

• Test Development Advisory Committee, American Board of Pathology

– Hooman Rashidi (Hemepath) – Max Fung (Dermpath)

• National Executive Board, Alpha Omega Alpha Honor Society

– Regina Gandour-Edwards

• Test Material Development Committee, United States Medical Licensing

Examination (USMLE), National Board of Medical Examiners

– Regina Gandour-Edwards

• 2015 Excellence in Advising Award (Faculty Advisor category), Region 9
• f National Academic Advising Association

– Hwai-Jong Cheng PhD

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Education innovators

• PMD 410A&B:

– Techniques from humanities education:

Essay questions

• Artificial intelligence applications

– Histology education – For early identification of students

experiencing academic difficulties

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Clinical Accomplishments

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Our clinical role: Testing for our region

• We enable care for an underserved region.
• Sacramento County
• Moderate access to health coverage
• San Joaquin County
• Lowest access to health coverage
• Life expectancy 69 years for poor vs. 90+ years for all others
• Higher percentage (23.4%) of uninsured nonelderly adults ages 18-64

compared to state as a whole

• High incidence of cancer in the surrounding

counties

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Our clinical role: Make care available to all in our region

Cost-effective lab tests More patients served

• Including those who can’t pay

Healthier community and region

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Points of Pride: Financial stewardship

• $11M savings, 2015-16: Negotiated capital equipment expenditure for

new automation line

• $1.1M savings, 2015-16: Converted four reference labs to 3rd party billing.
• $660K new revenue, 2018: Created new billing codes for opiate testing.
• New Lab Utilization Committee, to be launched in 10/2019:

– Chaired by non-pathologist physicians – Charter and P&P created by the department to get multi-disciplinary provider buy-in on

test menu and controlling use of expensive send-out tests

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Points of Pride: New, better, faster tests in the Clinical Lab

Earlier treatment

Better workflow in Emer Dept. Early dx

• f fibrosis

and cardiotox

• Among 1st labs

nationally to implement high- sensitivity troponin (hsT)

• 2 hrs faster!!
• More sensitive

for myocardial damage

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New better, faster, more efficient tests: mPOC for sepsis detection

mPOC for high-risk pts (burn unit)

Early dx (28.7 hrs) of meth- sensitive S. aureus infections Reduced unnecessary empiric vancomycin tx 35% decrease: Vanco-induced acute kidney injury

• UC Davis Health: 1st in the nation to implement molecular

POC pathogen detection in this high-risk group.

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Anatomic Pathology: Department’s biggest challenges

• Non-automated testing -- dependent on human effort and subject to human

variability.

• Lack of automated quality monitors in LIS:

– Manual data collection is required – Custom builds required

• Critical shortages of lab professionals  negatively impacting recruitment

– 2 year vacancies for AP manager and pathologist assistants

• Requires continual work on relationships

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Anatomic Pathology: Points of Pride

• In-sourced renal pathology: Kuang-yu Jen MD, Mingyu Cheng MD

– Better service, education, clinician satisfaction – Grew volume

• Digital pathology:

– Implemented in 90% of all tumor boards in 2018 – Telepathology for frozen section and consultations

• Key to accreditation of the new Rectal Center of Excellence

– Special commendation from site visitors

• Frozen sections:

– Low discrepancy rates: ~0.50% since 2014 (nat’l benchmark =1.10-3.25%) – Fast turnaround time

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How have we achieved so much?

• 2 strategic plans – but it takes more than just a plan

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Advice that has resonated with me for many years

• #1: Surround yourself with good people
• Am J Med 2012; 125:315-319

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So proud of our great people!

• Lots of new recruits – 2/3rd of faculty are new in the past 10 years

– 21 new faculty in the past 5 years!

• 13 replacements
• 8 new positions

– Retention rate better than AAMC’s national average

• New faculty section leaders in the past 5 years

– Nam Tran PhD: Chem/POC/Tox – Anna Romanelli PhD: Microbiology – Grace Monis MD PhD: Apheresis – Sarah Barnhard MD: Transfusion – Dorina Gui MD PhD: Surgical Pathology – Kuang-yu Jen MD PhD: Renal Pathology

• Lots of great new admin and clinical lab staff on our team

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Celebrate our staff and faculty, and honor each other

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Advice, con’t

• #2: Serve the interests of the faculty
• Am J Med 2012; 125:315-319
• Faculty come here

because UCD is a great university  they expect to have great careers here.

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Supporting faculty research

• Seed grants

– Department-initiated and leadership in collaborative grants – Department-only grants

• Continual attention to our administrative services

– Mandatory PI effort confirmation in Cayuse. – Improved monthly budget reports – Continued training of Business Office Staff in research admin. – More staff: Added part-time effort from Gabriela Lee MBA – Open houses to build relationships with Business Office.

• Advocating for space: 2000 sq ft. deficit.

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Faculty Development

Development Program Participants (Year)

ASCP Leadership Institute Barnhard, Jen, Tran, Romanelli (2018) APC Pathology Leadership Academy Vali Betts, Dugger (2019) Rashidi, Olson (2017) Wan, Gui (2016) USCAP Course for Emerging Leaders Barnhard (2017) UC Women’s Initiative for Professional Development Olson (2017) UCD Health Mentored Clinical Research Training Program Graff (2017-19) Grimsrud (2016-18) AAMC Minority Leadership Program Martinez-Cerdeno (2019)

• ~1/3rd of our

faculty have participated in development programs

• Almost all were

Assistant or Associate Professors

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Outcomes: Success in academic advancement

• % of successful actions:

– 90% promotions – 95% merits

• % of actions with Step Plus or

Accelerations

– 30% promotions – 20% merits

• Why so successful?

– Strong mentoring – Good advice – Resources and opportunities

5 10 15 20 25 30 35 1 1.5 2 Denied Accelerated

Faculty Academic Advancements by Step, AY1516 - AY1819 Pathology & Laboratory Medicine

Merit Promotion

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Advice, con’t

• #3: Perfect the art of compromise
• Am J Med 2012; 125:315-319

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• Reflects our values

– Collaborative

environment

– Importance of

relationships

• Compromise means:

– Negotiation – Partnership

This Photo by Unknown Author is licensed under CC BY-NC

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Compromise, negotiation and partnerships: Examples

• Improvements to billing and

collections

– Dept billing  central billing unit – Outcome: More $$ to the

department.

• Partnerships with

Radiology and Academic Affairs for shared services.

• Off-loaded responsibility for

core research services:

– EM lab  Anatomy & Cell Bio;

$300K savings

– Flow cyto core lab  Med

Microbio; $50+K savings

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Advice, con’t

• #4: Be transparent
• Am J Med 2012; 125:315-319
• (for all the things that aren’t

confidential!!)

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Transparency

• Regular updates:

– Financial – Council of Chairs – Association of Pathology Chairs

• Finance Advisory Committee:

– Rules-based compensation plan

• “Lunch with Lydia”

This Photo by Unknown Author is licensed under CC BY-SA-NC

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Advice, con’t

• #5: Give others responsibility and authority
• Am J Med 2012; 125:315-319

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Divide the work and conquer -- get more done!!

• Delegation of authority to lab directors:
• Vice Chairs:

– Modelled after Dean’s office structure – Requires formal reviews

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Advice, con’t

• #6: Never accept the status quo

– “If a day has gone by without a threat to the

well-being of your department, you probably have not been paying attention.”

• Am J Med 2012; 125:315-319

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Avoiding threats  Planning for the future

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Future: Research

• Keep our research programs growing!

– Address areas of current scientific interest and need.

• Opportunities:

– Complete recruitments for 3 tenure-track research faculty:

• Stowell Chair in Experimental Pathology
• Microbiome
• Neuropathology

– Leverage new recruits to expand dept-based collaborative programs,

especially immunology.

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Future: Research, con’t

• Be a leader re: new diagnostic technologies

– Develop, evaluate, implement – AI, imaging, and more – Create new pertinent quality programs, too.

• Support translational pathway  establish a Center for

Diagnostic Innovation (CDxI)

– Organize, brand, and market our activities under a single umbrella – Refine our plan based on feedback from external reviewers. – Submit to Dean and Vice Chancellor for support – Seek funding: internal and external.

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CDxI: Clinical Validation Laboratory

Clinical Implementation

(including provider education)

CLIA/FDA Regulated Validation Method Development Cost and Value Analysis

CAP Accredited Biobank CLIA and CAP accredited Lab

Feedback from clinical practice

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Future: Education

Undergrad programs Medical Laboratory Technician Clinical Lab Scientists Cytotechs

Medical students Residents Fellows

Continuing Education for Practitioners

• Mature and sustain our many new programs.

– Medical student electives – Clinical informatics program

• New subspecialty focus for surg path fellowships.
• Curriculum reform for medical students

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A few new things to think about

• On-line continuing education for practitioners:

– CME/CE, SAMs for our Lab Best Practice blog and Case of the Month

• More use of educational technologies for training programs:

– Less “sage on the stage” – More on-demand delivery at the learner’s convenience

• Create educational programs within Center for Diagnostic

Innovation

– Grow cross-disciplinary literacy between medicine, computer science,

and engineers.

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Future: Clinical Service

• Partner with Radiology  Path-Rad

integration

– Integrated reports and more – New opportunities with a new Chair of Radiology

• Refine our AP subspecialty team model:

– New and better teams? – Integrate clinical partners into teams? – Frozen section “hospitalist” role??

• Quality programs

– Leverage LIS – ?Cross-dept monitors – Client satisfaction

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Future: New financial model

• How will new funds flow model influence:

– Faculty staffing in all subspecialty areas (AP and CP)? – Salaries and Z-payments? – Departmental funding for education and research programs

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Lastly, to paraphrase the Presidents

• Being a chair:

– “is a glorious burden”

• George Washington

– “is a splendid misery”

• Thomas Jefferson

– “has made every person who occupied it bigger than s/he

was -- and no matter how big, not big enough for its demands.”

• Lyndon B. Johnson

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But it’s the best job I’ve ever had!

• Thank you all for a great 10 years
• You make our department what it needs to be
• I look forward to your feedback during my review