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In this episode of “Lab Medicine Rounds,” Justin Kreuter, M.D., sits down with Dr. Bill Morice, professor of Laboratory Medicine and Pathology, chair of the Department of Laboratory Medicine and Pathology at Mayo Clinic, and president of @MayoClinicLabs, to discuss the laboratory’s role in health and equity.
A Mayo Clinic podcast for laboratory professionals, physicians, and students, hosted by Justin Kreuter, M.D., assistant professor of laboratory medicine and pathology at Mayo Clinic, featuring educational topics and insightful takeaways to apply in your practice.
(wondrous music)
- This is Lab Medicine Rounds,
a curated podcast for physicians,
laboratory professionals, and students.
I'm your host, Justin Kreuter,
the bow tie bandit of blood,
a transfusion medicine
pathologist at Mayo Clinic.
Today's a special treat,
we're rounding with Dr. Bill Morice,
Professor of Laboratory
Medicine and Pathology,
Chair of the Department of
Laboratory Medicine and Pathology
here at Mayo Clinic,
and also President of
Mayo Clinic Laboratories.
Also, really relevant
for today's conversation,
he is chair of the American
Clinical Lab Association.
Today, we're talking
about laboratory's role
in health and equity and
why it's so important.
So thanks for joining
us today, Dr. Morice.
- Oh, thanks for having me, Dr. Kreuter,
Justin, and thanks.
A really very timely topic,
so I'm delighted to be talking about it.
- Absolutely, so this might be
kind of a little bit
of a perspective shift,
something that we're not used
to thinking about as much
in laboratory medicine,
or maybe at some levels,
it's something that's been
very much part of the
conversation for some time,
but this is, the audience is very wide.
We've got clinicians, we've got students,
we've got laboratory professionals,
that tune into this podcast,
so could you start us off
with why is health equity
important for laboratory
medicine and pathology?
- Well, it's first of
all, why it's important,
I mean, health equity is an issue
that was a real boilerplate
issue prior to the pandemic,
but the way the pandemic,
the COVID-19 pandemic,
of course, has played out,
has really highlighted
the dramatic inequities in
healthcare distribution,
both within this country and in globally.
And so, the important role
of diagnostics, of course,
in managing and responding to the pandemic
has really highlighted
the role of diagnostics
as part of that equation,
which we can get into.
The interesting thing is
that it's not a new topic.
If you go back and look, one of the,
the person that many of us think of
as sort of the godfather
of modern pathology,
which is Virchow,
actually was very
passionate about this issue.
He did a study of,
I think it was a typhus
outbreak in upper Silesia.
part of Poland that
was more, was a miners,
coal miners, they were kind of
the lower socioeconomic group
and that country
had really dramatic
impact there because of
the living conditions
and their access to care.
And so he started writing about
this and becoming passionate
about this well over a hundred years ago.
So interestingly enough,
it might be the new topic right now,
but it really goes back to
the founding of pathology.
- I love how you tie this
in really to the birth
of our specialty, right?
So this is something that is entwined in.
And I like also you're
highlighting that it's really
this diagnostics effort.
So this has been around for a long time.
You're saying even before the pandemic,
this was a boiler plate issue.
The pandemic has really
heightened a lot of these issues.
So what are we learning
about how as a laboratory,
we may better advocate for health equity?
- Well, there's a few
really important lessons
that we are learning,
like many of the lessons taught
by COVID, difficult lessons,
but ones that we really
have to pay attention to.
So one is, and I actually
wrote a blog post
about this, in the T3 blog post,
I think on ASU's website,
Arizona State University.
But if you look by zip code
and in places like in Boston
and New York City, where
they've actually studied this,
you can see an inverse proportion
or an inverse relationship
between poor outcomes for COVID-19
and access to diagnostic testing,
'cause they were tracking by zip code,
the frequency of testing.
And you can see that in
areas that had poor outcomes,
there was less testing.
And of course those tend to
be lower socioeconomic groups.
Why this is so important is
that if you think back to when
we really were first responding to COVID
and thinking about tracking, testing,
tracking, and isolation as a
key public health approach,
imagining the pandemic,
what that meant was that in
areas that probably had closer
living conditions also had more
people in service industries
that couldn't work remotely.
You actually had less testing.
And so then you have
more spread of disease
and also in areas where they
had less access to healthcare.
So it really just showed
how the lack of good access
to testing was really
undermining what we wanted to do
to protect those who were
actually most vulnerable
to poor outcome from COVID.
So I think that has really
catapulted the whole issue
of testing and how we use testing back
to the kind of the forefront of
the healthcare disparities discussion.
- Now, if we unpack this a little bit,
it seems like this data
you're talking about,
it highlights the lack of
testing and then how that's
so central and it's such a driver of many
of aspects of health and equity.
Where do you, it seems like it's a,
I don't know if it's one
of those wicked problems.
It's very complex.
It's not just more testing,
but what's the nuance there that we need
to kind of grapple with.
Not just more testing, but
I guess better testing.
- Yeah, yeah, and access to testing.
I think there's really
two things that we have
to start thinking about
as a laboratory community.
That one is with COVID and
the big push for home testing,
just look at the last wave with Omicron,
and the massive investment
in angio testing,
is that and thinking about app based,
apps that you can use
and companies like Q,
where you can have a box in your home,
is that to really be thinking
about not just getting those
to where there's a cool business case,
but to where there's a social case
for access to those tests.
How can we start thinking about
it in a digital world where
there's more access to diagnostics?
It really falls on our profession
to be the voice of where
those, just like every
laboratory in the hospital,
we think about where we
need hospital clinical labs
to support care.
When we start thinking
about the digitization
and the building of remote diagnostics,
we need to be really thinking
about where those diagnostics
are gonna have the biggest impact
and really advocating for that.
Case in point, you think about those,
why do some of those
lower socioeconomic groups
have poor outcomes to COVID?
Because they have a higher
frequency of comorbidities,
like diabetes and things that really could
be managed effectively if there
were better diagnostics early on.
So you didn't have patients
with end stage disease.
So really thinking about
what can diagnostics do
to help people as we go forward,
in terms of prevention and wellbeing,
becomes them really important
because we have to advocate
for that for our patients.
That's number one,
the other is just really
understanding why people wouldn't
wanna use a test.
And again, and that means
how that information's used,
because what we found is
that even when some of these
testing clinics were set
up and we've seen this both
in the US and globally, as
I've been participating.
And the other thing I did,
I actually worked with
the World Economic Forum
on a group looking at access
to COVID diagnostics globally
in low and middle income countries.
And you talked to a lot about, hey,
we could use these tests to
keep people from going to work
when they're sick.
Well, if they're people that depend on,
they might have a whole household,
depending on them going and
being able to drive a truck
across the border, they're
not gonna wanna get tested.
So really also thinking about
how do we influence policy
in a way,
and that's where the American
Clinical Lab Association
is important for me.
So how do you think about policies
that can help support people
wanting to actually get access
to the test?
Because it's a whole milieu
but going full circle
is our profession is really,
it's not just about doing testing,
it's about thinking about all
these issues that surround testing.
- You bring in a lot of
really neat opportunities.
You've been able to see
this problem from a couple
of different perspectives.
You're talking about changing
this from a business case.
And I think that's what a lot of us
are typically thinking about.
'Cause we're justifying our actions,
to switching ourselves
to thinking about it
from a social case.
That that might be kind of
new for some of these efforts,
I guess, are there other,
are there examples of
how we can do this better
from other professions
that we can learn from?
- Well really other professions and other,
really other groups, right?
So like one of the things that
was really gratifying for me
was Walé, from our Diversity
Equity Inclusion Group,
Elegbede, I was gonna,
I didn't wanna mispronounce his last name,
actually is very active,
I think even leads the
local chapter of the NAACP.
So getting out there
with community groups,
as a laboratorian, talking
about how tests work,
what they can tell you, what they can't.
So really actually I think
a real opportunity for us is
to think about community engagement,
which is not something
we typically think about
in lab medicine, right?
There's a lot of groups that
are really good with this
because it's really A, understanding,
what in those different
communities and cultures,
how testing is perceived
and then being able to help
advocate for that.
So I think that's one area.
And of course, actually your
area transfusion medicine,
probably any area in
DLNP with blood drives
and other things,
it kind of, that community
engagement's more part of
the fabric of your division.
We have to start thinking about that,
not just for transfusion medicine,
but really for laboratory medicine.
And how do we do that?
I think that's a really important one.
- So switching also to the policy,
you mentioned to really kind
of untangle some of these, you,
I love the take on the take
of that negative perspective
on that of like,
why wouldn't somebody do a lab
test and then how that really
gets to some of those policy
challenges that we have.
Is that something that's kind of,
you feel like that your
previous experience as
a pathologist, as a hematopathologist
has kind of prepared you for, or are these
additional skills that
you've kind of picked up
along the way?
- I think a little bit of both.
I mean, I think in essence,
it really all derives from
what drew me into lab medicine.
And that is how do we create
information that's accessible
and actionable for patients and providers.
That's really the mindset.
And how do you make sure
that's high quality?
How do you make sure that it's understood?
That part is natural.
Now thinking about how people outside
of our profession,
and we spend a lot of time just
in medicine explaining this,
even to people that are
using the labs that are other
physicians and providers.
So then you have to take that and think
from an even bigger scale,
how do you make that
understandable for people
that aren't in healthcare?
It's a big challenge.
So I think things like your podcast,
things that, thinking about how you
communicate issues outside of healthcare
is an acquired skill and
one that you can learn.
And you can learn by doing.
So that's probably the new skillset.
Everything in life is,
one thing I've learned in leadership,
it's all about timing.
The timing is critical.
'Cause for the first time,
really there's an awareness
in the highest levels
of policy makers of some of these issues
and a desire to address it.
So they're looking for,
their ear's attuned
to a voice.
Case in point, going back,
there was massive investments.
There have been massive investments.
You read in the papers
about the White House buying
500 million anti tests.
And I read that and think
about what difference
is that really gonna make?
I mean, if it's just people
that can afford to go
to Walmart and buy the tests
and know what they wanna
do with the results,
it's not gonna get us where we need to go.
And I think there is a
frustration from policy makers
about why isn't this making a difference.
I think going back, I mean,
we've always been about the why,
we just have to make sure we're helping
with the right questions,
but we're the right people to do it.
I'm convinced of that.
- I love this.
So what are these,
you've mentioned a couple
barriers that kind of
have been in the way.
Can you kind of take
the listeners through,
what are two or three ways that we here
are trying to navigate this
for increasing healthcare equity?
- Yeah, well, I think one,
there are a couple ways.
One is some of the community
engagement work through Wale
and others, it's just getting out there.
I mean, and I don't wanna say it really
is listening before talking.
So really listening and understanding.
I mean, that's goes back
to our Franciscan values.
Of course, St. Francis was,
that was his, it's better
to understand than be understood.
So I think getting out there,
hearing voices of people
that maybe aren't showing up
to a Mayo Clinic,
aren't showing up to
healthcare facilities,
understanding why, understanding what some
of those barriers are.
I think that's one thing that we're,
a lot of us in Mayo are doing,
a lot of people in healthcare are doing.
I think that's really first and foremost
because it's really,
we have to be just like
when we're in the lab,
we are really thinking about the patient.
We're the person in the
lab and at our microscope
or in getting a product ready,
that's thinking about what
does that patient need?
We're the voice for the
patient in that process.
And now we have to be the
voice for the community
in this process, too.
So that's one thing that we're doing.
The other is that through, with Mayo,
is really one of the things
that we've been very active with
is actually forming partnerships
with diagnostic manufacturing industry,
with companies like
Thermo, because ultimately,
the manufacturers of these products have
to understand how they're
gonna be used or not used.
And again, if we are,
don't have a great sensitivity to that,
many of those companies even less.
So I think it being, stepping
outside of our offices,
stepping outside of our walls
and really starting to think
about a whole ecosystem that has to exist,
from digital tools to the right test,
to the right kind of follow
up actions that are needed,
we have to do all this.
And there's different
areas of lab medicine
infectious disease has always had.
And clin micro always
has had a strong presence
in public health.
So thinking about the things
that are natural connections
and how do we start to amplify them?
I think that's the other thing
that we're really thinking about now
that we weren't a couple years ago.
- Unpacked, as you brought
up kind of partnering
with these, the industry
that's developing diagnostic testing.
How can we, what does that look like?
Can you kind of unpack
that for a little bit?
'Cause I can mention some
of our listeners might,
they hear you say those words, but
what does that look like?
What kind of feedback
can a pathologist provide
that helps them kind
of build a better test?
- Sure, a couple,
I'll give you a couple
real tangible examples.
So one of these things
that have been around,
really, I think started right around when
I started my job in 2015,
as department chair,
which is hard to believe
I've been in this role that long, but was
these things, the devices
that could draw blood without
a needle that you could
send to someone's home.
There are a few companies
that are out there.
Early on in the pandemic,
we thought about the potential
for serologic testing.
So we actually just talked
to the company, said,
can you send us some?
And we can test them.
And we had a group including Dr. Pritt,
and some others that
actually tested a few of them
and just found some things that would make
it really problematic to use them.
And you start thinking about,
especially if they're complicated,
you can give that feedback back.
And some of these companies
now are thinking about, wow,
you know, we can't just make this device,
we might have to have a call center.
We might have to have a video
link that can help someone
understand how to use it.
And then also saying what
you actually need from
a specimen type to be able to use it.
So if we need to
quantify, a dry blood spot
is something we have, been
around for a long time,
it's very difficult to get
like a quantitative serology
off of a dry blood spot.
So you start talking
about with those companies
about how you'd wanna use it,
and then they can start
a whole conversation.
And so those are some of the things
that I think, that's
kind of how that goes.
Like, but you'll find out that
oftentimes they just don't have a lot
of those conversations naturally.
So they're often very appreciative,
even if it's just like, we
wanna use this in our community.
Can we get some exposure
to the technology?
Can we talk to someone on your end?
Like if we wanted to roll it
out, say, to work with it,
a lot of this is again,
very, very specific.
So it might be like work
we've done in the past
with migrant workers.
So you start to think
about some of those things.
- It's really great.
I love how I think you're helping
our listeners kind of,
don't short change this
role of the pathologist,
where we have expertise, where
we got one leg, you know,
firmly planted in laboratory
and the other leg firmly planted
in the clinical practice.
And to understand that we often hear
what are those pain points on
getting a test accomplished.
And that's something that's
very valuable to manufacturers
and that collaboration
is what I'm also hearing
in your answer is, actively reaching out,
helping to develop this will
hopefully result in something
that's gonna be much better
for patients in the long run.
- Oh, absolutely, and thinking about that.
We have that expertise and
how do we start to apply it
for the long term?
So it makes a real
difference in these issues.
And I'll take you back
to one of the early days.
So it's probably late March of 2020,
and I'm sitting in my office
at SDSC right around midnight,
just trying to get through things
and get through my emails
'cause of the onslaught.
And one of the emails that I
get is from someone from a,
one of the native American tribes here
in the state of Minnesota
with a desperate plea, can
we get some COVID testing?
We have a lot of elderly.
We have a lot of people
with healthcare conditions
and we have a lot of communal
living and just really,
and no testing whatsoever.
And so I brought that back to Scott Beck,
we got really passionate.
John Heywood at Mayo Clinic
Labs has helped a lot with this,
but you realize it takes
us a sustained effort.
I mean, it's not something
that can be built over night
and we can't lose that now.
We're all gonna wanna forget about COVID,
but now it's been two years.
And everyone's burned out on COVID.
But the reality is for us in the labs,
we have our foot on
both sides, as you say,
and we know the issues and
it's just applying those
in a different setting.
And it's, I think it's
more long term work,
but overall all it's the right thing.
And it makes such a,
it can make such an impact for people,
even just simple tests
and having access to them.
So that's this experience
I'll certainly never,
that's really, after meeting. I was like,
wow, that's important.
And I think if there's
one thing I can share with
the listeners is that is making
that experience relatable for them.
'Cause it is easy.
It's easy to become sort of a immure to it
because we're two steps removed,
but we're so important
in terms of coming up
with the right solution.
- Absolutely, absolutely, right.
And one of the, what I'm
hearing in your answer too,
is this concept of it's
we don't just learn
from experience, but we learn
by reflecting on experience.
And I think what I hear
you say is, you know, yeah,
everybody's excited to
get past and hopeful
to get past COVID and to
kind of close a chapter.
But like you're saying,
there was a lot of
innovation that came out
of this period as well,
and lessons learned and it
would be a shame not to learn
those lessons and carry that
forward into the future.
- Yeah, I agree.
And yeah, I mean, just for the listeners,
just about everyone listening,
you probably know more than you realize
and have more to
contribute to the solution
than you realize.
Just, I mean, that's certainly, for me.
They're just very what
we would almost think of
as simple questions that
really need to be addressed.
So don't underestimate your
ability to really make an impact
on this, even though it seems like, wow,
lab testing and healthcare equity,
how am I ever gonna effect that?
That's such a huge problem.
So, and I think the pandemic means
that there's a receptive year
and there's a real chance
to make a difference.
- So let's just zoom out.
I've got one final question about
kind of based on what we discussed here,
like, taking this optimistic, future view,
what is the future of
health equity look like?
What does that laboratory support
of health equity look like,
in the coming years?
- I think that, well, how it will evolve
I don't know.
I think that the ideal
future state that we should
be working towards is that no matter
what community you're living in,
that there is enough
education and awareness of
the kind of tests that
you need to be doing
to understand your health
and the knowledge around that result
to help you turn it into
something actionable,
whether it's even something
as simple as you might have
pre-diabetes, here are some
healthcare choices you can make.
Here are some things you're
doing in your community.
Maybe even go back to
community groups and say,
we need more healthy
food options in this area
as a for instance.
So it's a system whereby an
individual can create data
around their health,
that's really actionable in
helping them lead healthier
and more fulfilling lives.
And at the same time,
we're taking all that
information and understanding
where we need to make societal changes
or policy changes that give people
a more healthy environment to live in.
- That's awesome, we've been rounding
with Dr. Morice on the laboratory's role
in health and equity.
Thank you so much for
being here with us today.
- Oh, it was my pleasure, anytime.
- So we're definitely gonna link,
Dr. Morice mentioned that he wrote a blog.
We're gonna be linking
that in the show notes.
And if you'd like to
hear more on this topic,
be sure to register for the
Phlebotomy 2022 conference,
Performance, Public Health,
and People In a Post COVID World.
Dr. Morice will be
presenting on this topic
at this year's virtual conference
that's gonna be on April
21st and 22nd of 2022.
And for more information,
please visit
MayoClinicLabs.com/2022Phlebotomy.
To all of our listeners, thank
you for joining us today.
We invite you to share your thoughts
and suggestions via email.
Please direct any suggestions
to MCLEducation@Mayo.edu.
As always, if you've enjoyed
Lab Medicine Rounds podcast,
please follow or subscribe.
And until our next rounds together,
we encourage you to continue
to connect lab medicine
and the clinical practice
through insightful conversations.
(upbeat music)