Journal of Clinical Pathways spoke with Bryan McIver, MD, PhD, Deputy Physician-in-Chief; Chair of the Pathways Steering Committee, Moffitt Cancer Center (Tampa, FL) about his views of and experiences with the clinical pathways program at Moffitt. Dr McIver has over 20 years of clinical experience in the care of patients with endocrine diseases, specializing in the evaluation and treatment of patients with thyroid nodules and thyroid cancer. He has a particular interest in the management of patients with advanced and aggressive forms of cancer and the role of genetic and molecular techniques to improve the accuracy of diagnosis and to guide treatment. Prior to joining Moffitt, he was employed as Professor and Consultant at the Mayo Clinic and Foundation in the Division of Endocrinology & Metabolism, where he was appointed as a member of the Endowed and Master Clinician Program, recognizing his excellence in patient care. He is also a founding member of the World Congress on Thyroid Cancer, an international conference held every 4 years and the largest meeting in the world dedicated to improving the care of patients with thyroid cancer.
As deputy physician and chief for the cancer center, can you detail your relationship with the clinical pathways in the disease states that you treat, and what is your role in designing, implementing, evaluating, and measuring adherence to these pathways?
In my role as Deputy Physician and Chief for the cancer center, I am responsible for facilitating a single standard of care across the center for patients with cancer. We use our clinical pathways to help us define that single standard of care.
My enthusiasm for pathways began when I first arrived here in the cancer center about 5 and a half years ago to lead the endocrine/oncology program and has grown since then. What we had in endocrine/oncology at that time was a group of endocrinologists, oncologists, and surgeons who had fundamental disagreements about how to manage a patient with thyroid cancer. If you had put 5 of those people in a room, you could have received 10 different opinions at any one time about how a patient should be managed. Using our pathways as a reference, we were able to create an environment in which we could have collegial discussions, where personal animosities and unsubstantiated opinions could be squeezed out of that conversation. I used our pathways to facilitate a conversation to uncover areas of agreement and disagreement and to dig into the medical literature and actually learn about where people were either misinformed or had ideas that didn’t gel with the evidence. With this approach, we can have a very rigorous evidence-based discussion around the decision-making process across the spectrum of thyroid cancer, from the moment of diagnosis all the way through to the end stages of the disease. Discussions like these have allowed us to develop an institution-leading approach to creating a single standard of care in our pathways.
That success in using the pathways to bring together a group of physicians who, in the past, were sometimes at odds with one another and now could communicate collegially and agree on a single standard of care was recognized by the cancer center and used as a model for other departments and clinical programs as they developed their own disease-specific pathways. Throughout my time at Moffitt, I have maintained a deep interest in clinical pathways as a mechanism for defining a standard of care across all of the different cancers. I’ve continued to be a pathways advocate, and I also serve as Chair of the Pathways Steering Committee for the institution.
It is our understanding that patients are provided with a comprehensive, multidisciplinary plan as soon as they’re considered a Moffitt patient. Can you discuss the level of interdisciplinary communication and planning that goes into making this happen?
Patient preference and patients’ goals of care are always critical when it comes to implementing a plan of care. We believe the patient is a central element in any medical decision making. Our pathways really are designed to be patient-centric, outcomes-focused, and evidence-based. Let me take a simple example from my field of thyroid cancer: one of the big dilemmas is when is it appropriate to remove the entire thyroid gland surgically, and when is it appropriate to remove something less than the entire thyroid gland. This dilemma has many implications for the patient’s well-being and health, both immediately and in the future. The bigger surgery has more risk of complications than the lesser surgery, and yet, at the same time, you’re dealing with a malignant process, and the usual approach in the past has been to remove the entire thyroid gland. So in other words, these are tricky decisions that you’re making where the patient has got to have some input into the outcome, because, at the end of the day, it’s the patient’s life that we’re affecting by this.
What we’ve done through our pathways process is to gather together the best evidence from the medical literature along with insights from our very experienced surgeons and endocrinologists and pull together a set of recommendations that we can present to patients in a format that the patient can grasp and fully understand. By standardizing the language and standardizing that decision-making algorithm, I think it helps us to provide patients with clarity around the pros and cons of the decisions that they’re making. We can make a recommendation and provide the document that says, “Here’s the reasons why we’d make this recommendation for you to have one surgery vs the other,” or adjuvant treatment or no adjuvant treatment.
When I’m interacting with patients, I will often use the actual pathway diagram itself to walk a patient through that decision-making process and let them see where their path is headed over the course of their treatment, including monitoring and survivorship. For patients who are interested, we can even click on and access the individual research articles that demonstrate why that decision is so important or why that decision is the appropriate decision to make. Pathways are a very helpful educational tool.
One thing that is unique about Moffitt’s pathways that I don’t think exists in other pathways is that they really run from cradle to grave. They start before the diagnosis is made. We walk through how that diagnostic algorithm should work, through the primary treatment, through adjuvant treatment, through surveillance and monitoring, and into survivorship and beyond. These are truly comprehensive approaches to managing a patient.
Many of our pathways are also now integrated into our electronic medical record (EMR), which provides us with decision support at the time of the clinic appointment. For instance, when I’m going in to see a patient, I’ve already brought up that patient’s chart and brought up that pathways tool from our EMR, so I know where we are on this patient’s journey, and I know what decision we need to make next – whether that’s a decision to add in a treatment, to go back to the operating room, or to do a scan of some sort or do a blood test. That decision support helps me to provide consistent care for patients every day.
Now, I am considered a world expert in my particular field of endocrinology, so you would think that I would know exactly what decision to make at each stage of the patient’s journey. But I can tell you that, in my own experience, having that decision support tool keeps me disciplined during the decision making. It prevents me from making arbitrary decisions that might be less than optimal for that patient. It takes much of the emotional decision making—that contributes to so much of the variability of practice—out of the equation and provides a guiding structure that encourages objective decision making, which is good for patient care.
So you would disagree with individuals who think pathways take the decision-making privilege away from physicians?
I think that there is a concern among physicians that pathways limit professional autonomy. They may say that having a pathway, having a protocol, de-professionalizes us, and you’re then making it impossible for me to make a judgment and treat a patient the way I know they should be treated.
I’d push back on that very, very strongly. At the end of the day, decision making around medical care is an art form, but it’s an art form with a structure. It is analogous to painting between the lines. What the pathway tool does and what these kinds of protocolized versions of care do is provide us with external self-discipline that reminds us that we’ve previously discussed the role for treatment X, or scan Y, or we’ve made a decision around how often somebody needs to be followed. We’ve already discussed the evidence around that and developed a standard of care. And if we’re deviating from that standard of care, if we’re going what we call “off pathway,” then we have to be able to justify why we’re making a decision that is different from the decision we chose earlier when we discussed it as a group.
To be clear, I can be off pathway for 1 of 3 different reasons: I can be off pathway because the patient somehow is unique and does not fit on the pathway. That does happen, and we don’t expect 100% compliance with pathways; we expect roughly 80% to be on the pathway. It still leaves that wiggle room when a patient has a unique issue that doesn’t fit into our pathway.
Secondly, I can be off pathway because the pathway is wrong. Of course, pathways are living documents, but they tend to lag behind the best, the newest evidence. For example, if I’ve gone to a meeting, and we learned about a new treatment or a new drug, and the evidence is strong and we want to bring that drug to the patient, I’m going to be technically “off” the previously defined standard of care until we bring that pathway up to date. That’s an opportunity for us to say, “Hey, we need to update our pathway and modify the pathway,” and we do that on a routine basis, generally twice a year. But we also do it on an as-required basis when something new arises to update the pathway.
The third reason I can be off pathway is because I am wrong and the pathway is right. That’s why, if we’re making the decision to be off pathway, we require our physicians to document the reasons why. Tell us what is it about this patient and this circumstance that made you make a decision that is different from the decision we all agreed on as a group? The physician can certainly go off pathway and make a clinical decision based on their judgment, but they have to hold themselves accountable and explain why they made that decision.
To what extent does Moffitt examine physician behavior on the pathways? Are there on-pathway concordance thresholds for which you hold physicians responsible?
We have an expectation that the pathways will inform discussions at tumor board, and tumor board, of course, is the place where patients are presented and treatment plans are agreed upon by the multidisciplinary team. We use the pathways to guide those discussions so that we make sure, as a group, that we’re not deviating from accepted practice unless there’s a reason.
We employ a physician incentive to encourage pathway concordance in the form of a bonus payment if physician decisions are deemed at least 80% concordant with pathways. Of course, concordance rates are very challenging to measure until you have the pathways integrated and electronically recorded. What we’ve done for the last 6 or 7 years is perform manual audits of decision making around key areas. If you are below 80% compliant with the pathway, there needs to be a solid explanation entered as to why that was a justified decision. In this way, we were able to very quickly get physicians to be highly compliant with the pathways and to start documenting when they were off pathway and why.
As our pathways have been integrated into the EMR, we can get away from the manual audit, which is labor intensive and subject to human error, and move in the direction of electronic audit. Although we have not yet made concordance mandatory, we are beginning to record those data to recognize when we’ve got individual providers who may be doing things in a discordant way, and starting to have those conversations with physicians around the rationale for that. If somebody strongly disagrees with the standard of care that we have as a group agreed upon, then we need to get that person at the table and really engage in an understanding of why and either adapt the pathway or educate the team member.
I’m an enthusiast for the entire process of pathways because I believe that it does help physicians be better at what they do. This is not about getting in the way of professional autonomy; it is to augment professional autonomy by providing useful, relevant information at the point of care that can inform clinical decision making. In my own experience, I have been humbled to realize that certain areas of my practice in the past have been somewhat arbitrary despite being the so-called world expert. I think that having the discipline of the pathways tool helps me to be a better physician.