Pathologists Providing Direct Patient Care in Thoracic Transplant: Same Objective, Different Scope Open Access

Organ-viewing encounters (Figure 1) are held in a specialized viewing room that facilitates an interface between outpatient/clinical space and laboratory facilities, located adjacent to our on-campus autopsy laboratory. With the assistance of transplant coordinators, appointments are made between patients and the pathologist who had dissected and signed-out the explant specimen, at mutual convenience following the completion of the pathology report. Patients are generally permitted to bring family members or friends for supportive purposes.

Given the proximity to the autopsy laboratory, autopsy technologists are responsible for preparing the room and 3-dimensional specimens (see below), and escorting patients into the viewing room from the elevator lobby. Upon entering, a curtain is closed to the laboratory space, such that the pathologist can prepare the patient for the experience with a verbal description of what to expect at the onset of the appointment.

All 9 of our thoracic pathologists (5 women, 4 men) participated in these sessions during the study period, including discussion of relevant pathology, pathophysiology, and potential implications to the first-degree relatives (as applicable). The role of the pathologist in patient care, as well as a discussion of normal organ function, was included. Patients and their guests were encouraged to don appropriate personal protective equipment and handle the fixed tissue if they so desired. A “normal” example organ (derived from our educational collection) is available for comparative purposes (Figure 2). Whole slide digital imaging is incorporated into the experience on an ad hoc basis. The patient is subsequently gifted the printed 3-dimensional model of their explanted organ, a card with the pathologist’s professional contact information, and the final pathology report of the explanted organ. The interaction is then documented by the pathologist via a note in the electronic medical record.

These sessions have been branded and marketed by our institutional teams as On My Path medical appointments. Demographic patient information, appointment date, and diagnostic information were tracked from the inaugural On My Path visit in December 2017 through December 2022.

Specimens are placed in formalin following accessioning and subsequently held for weekly specialty dissection teaching conference. A subspecialized staff pathologist leads these conferences, wherein residents, fellows, and pathologists’ assistants perform the dissection. Routine dissection methods that optimize evaluation and clinical diagnosis of the expected underlying pathology are used.

During organ dissection, a representative short-axis section or single coronal slice of the lung explant is scanned via photogrammetry (3-dimensional Thyng Medcreator 1.0 Scanner). Three-dimensional scans are printed via PolyJet Material Jetting technology (Stratasys J750 Digital Anatomy Printer, Stratasys J5 Medijet) (Figure 3, A and B). Funding for this initiative was provided through institutional common funds, in conjunction with the Anatomic Modeling Laboratory and Department of Radiology. Following the scanning process, anatomic tissue is returned for archiving in our Tissue Registry.

Transplant coordinators are in the unique position of having facilitated both the aforementioned prior experience and the On My Path appointments. Their daily interaction with allograft recipients provides deep insight into the usefulness of the program. Thus, their perceptions of patient response and the program overall were captured via a survey (see supplemental digital content at https://meridian.allenpress.com/aplm in the July 2025 table of contents) to evaluate the patient experience in the pre–On My Path and post–On My Path environments.

One hundred fifty-eight appointments were recorded between December 2017 and December 2022. Of these, 96 (61%) were cardiac allograft recipients, 54 (34%) were pulmonary allograft recipients, and the remaining 8 (5%) included patients undergoing combined heart and lung transplants. Ninety-two appointments were done in the same year as the explant surgery, 66 in a subsequent year. Overall trends in thoracic transplant viewing experiences (compared to thoracic surgical specimens) are provided in Figure 4, A.

The 96 appointments involved 94 individual patients, with 2 representing repeated visits from patients who wished to view their organ more than once. Thirty-one (32.3%) were women. The average age was 43.2 years (range, 3–71 years). Sixteen cases were from pediatric patients.

Fifty-two of 94 patients (55%) underwent allotransplant for cardiomyopathy (including dilated [38 of 94], hypertrophic [8 of 94], and arrhythmogenic [5 of 94] types, and eosinophilic endomyocardial disease [1 of 94]). Ischemic heart disease represented 9 of 94 cases (10%), while congenital heart disease was present in 16 of 94 individuals (17%). Four individuals underwent transplant due to cardiac amyloidosis, 5 for myocarditis (including 4 cases of sarcoidosis), 3 each in the categories of valvular heart disease and retransplant due to primary graft failure, and 2 for radiation-induced heart disease.

The total number of viewings increased from 12 in 2018 to 25 in 2022 (Figure 4, B). The overall percentage of cardiac explantation viewings peaked in 2019, before the COVID-19 pandemic.

Fifty-four patients took part in the pulmonary explant On My Path appointments. The average age was 60.9 years (range, 23–74 years), with 19 women (35%) within the cohort. The primary reason for allotransplant was interstitial lung disease (33, 61%), with 14 undergoing transplant for emphysema. Three patients had transplants from pulmonary veno-occlusive disease, and 2 each in the categories of constrictive bronchiolitis and cystic fibrosis. Thirty-six represented bilateral lung transplant, while 18 were unilateral.

The trends in patient viewing experiences and percentages (per pulmonary transplant volumes) are demonstrated in Figure 4, C and D, respectively.

Patients with combined heart and lung transplants represented the smallest cohort of patients in this study (n = 8), in line with our overall transplant patient population. Four patients had pulmonary hypertension, 3 had congenital heart disease, and 1 had a history of interstitial lung disease with right heart failure. The overall numbers are too few to reliably deduce trends, though viewings appear relatively stable (1 in 2018, 2 each from 2019–2021, and 1 in 2022).

Ten of 11 transplant coordinators (91%) completed the provided survey. The population was divided into those who specialized in pretransplant, posttransplant, or both populations. If individuals participated in the prior design for organ viewing (before On My Path), those individuals were asked to compare the patient experience. In the pre–On My Path environment, a patient understanding of disease process after viewing an explanted organ was ranked on a scale of 1 to 5 (with 5 being strongly agree), resulting in an average score of 3.5. This parameter increased markedly in the pathologist-led post–On My Path environment rating at 4.88. Patient emotional closure from the experience was also considered in the pre-environment and postenvironment, increasing from 3.33 to 4.75, respectively.

Twenty percent of the respondents (n = 2) reported that more than half of their patients independently ask them about the program (Figure 5). Selected comments are listed in the Table.

Several academic endpoints were unexpected advantages of the On My Path program. This included a peer-reviewed article featuring the 3-dimensional printing process and its application to the On My Path program.¹⁰  In addition, a formal divisional-level presentation (“Anatomic Pathology Grand Rounds”) was provided by 2 of our thoracic transplant pathologists. This presentation featured involvement by a patient and patient family member discussing how impactful it was to have had the experience. The event was attended by 149 individuals and received 47 evaluations. Free-text comments are provided (see supplemental digital content). Quotes from the 2 individuals who were recipients of the organ-viewing experience are included in the Table.

Patient access to private health information has seen great advances in the era of the electronic medical record, with rapid acceleration after passage of the 21st Century Cures Act. Curiosity organically stems from this access, with patients’ desire to better understand their disease processes and help with interpreting what they have learned on the internet. These patients are engaged and proactively taking steps to understand their health care concerns.¹¹  This laudable investment has refined the doctor-patient relationship to one of a translator and guide within the movement of participatory medicine, in addition to direction of primary therapeutic care.¹²  Indeed, the nature of being a physician is rooted in this concept of educating and guiding: the word doctor taking root from the Latin docere—to teach.

Pathologists are ideally suited to play a role in patient education and meet this growing demand, the specialty having long been recognized for its contributions to medical education. The concept of the doctor’s doctor implies an inherent subject expertise and the ability to translate complex concepts. Such communication has historically been effective not only among medical professionals, but also with patients.⁹  Harnessing these skill sets of teaching and disease expertise can be viewed as a natural progression of the field.

This importance of pathology, and its potential applications in the realm of direct patient care, has been recognized broadly.¹³  A call for patient-facing pathology visits has been answered from national organizations and academic institutions. The College of American Pathologists (CAP) has been a staunch advocate for this change.¹⁴  Added to this, the American Society for Clinical Pathology likewise has established a Patient Champions Program.¹⁵  Duke University, Lowell General Hospital, and the University of Michigan have all reported successful pilots or initiatives into patient-facing pathology experiences.^16,17 

Previously described patient-pathologist experiences have typically focused on histopathologic findings. In contrast, our experience details a gross pathology–based appointment in a specialized transplant patient population. This group shows profound engagement in their own care.³  Moreover, the potential implications of heart and lung disease to direct family members through genetically mediated diseases increases the spheres of interested members who are invested in all available medical information.

Anecdotal experiences from patients have been profound. In our Anatomic Pathology Grand Rounds, 2 patient/patient family members who had taken part in the experience volunteered their impactful feedback: “I can never say enough good things about our experience here and how it has changed our lives.” Moreover, an increasing number of patients are proactively seeking this opportunity when enlisting for, or immediately after, organ transplant.

We have paired this experience with photogrammetry for digital rendering and 3-dimensional printing to provide patients with a tangible takeaway from this meaningful experience. Our patients have related that they have used this model to teach their family and friends about their disease and the importance of organ transplant. Such an experience may have profound impact particularly within the pediatric realm, wherein genetically mediated (and therefore heritable) conditions are enriched and thereby of increased import to blood relatives. This initiative is part of a multipronged initiative to advance technology into clinical, educational, and research spheres.¹⁰ 

The focus of this report is not only on the initiation of the patient experience, but also on the feedback provided by our transplant coordinators. Transplant coordinators responded at an impressive rate of 91% to our survey. Herein, we observed substantial improvements in patient perception to their care experience, both in knowledge of disease and emotional “closure” with their explanted organ.

Our experience in pathologist-patient interactions has been positive from the clinical perspective (as evidenced by our transplant coordinators’ reviews and impressions, as well as anecdotal feedback from our patients), and harnesses technologic advancements that enhance the overall experience and utility. We attribute our success to an engaged patient population, high volume of transplants, support from our laboratory technologist, and partnership with the transplant team. While some of these elements are specific to this institution, the tenets of this experience are certainly translatable to alternative academic sites.

Organ transplant is a growing program at our institution (Figure 4, B and C). As volumes increase, scalability of our current program requires thoughtful evaluation. The On My Path program is resource-intensive, without a currently applied reimbursement structure. Future directions include cost analyses with an eye toward accommodating increasing patient interest in this program, both in its current iteration with a thoracic transplant focus and for future growth toward other specialties within anatomic pathology. Recent changes in reimbursement structure make billing possible for these activities, which could further offset cost and possibly bring a new revenue stream to the institution. Patient feedback has been largely anecdotal to date, further limiting our review of this program. To this end, future directions include formal assessment of the program, including patient interviews and opportunities to improve the process.

The authors express gratitude to the numerous technologists, technicians, and pathologists’ assistants and leaders in anatomic pathology who facilitated multiple facets of the workflow described herein, including Emily F. Scharrer, MNM. We extend deep appreciation for the support from our clinical partners in thoracic transplant, including the physicians and transplant coordinators. We also wish to thank the staff of the Mayo Clinic 3D Anatomic Modeling Lab, who are instrumental in the development of this work. Lastly, we extend our immense appreciation and respect to the patients who have undergone thoracic transplants. The opportunity to interface with you has brought in immeasurable value to our work.