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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Should Every Laboratory “Clinical Problem” be Handled by a Pathologist?

Published November 1, 2014 10:52 PM by Glen McDaniel
 

It seems that experiences always occur in groups. Recently I had 3 separate but similar experiences that made me decide to write this blog.

 

Laboratorians on an online forum were discussing recent issues that their particular labs faced with nursing, such as specimen draws above an IV, many hemolyzed specimens, abuse of stat; the usual. In each instance several respondents said, “Tell the pathologist.” The same sentiment was echoed for a physician over-ordering uncrossmatched O negative blood.

 

The discussion continued with each example apparently designed to show an even more ridiculous "pathologist issue"  that laboratorians are confronted with.

 

“One so called doctor wanted to know which hepatitis B test to order. Another genius asked me what was the difference between a PT and anti Xa test”

 

“What do you do when a doc insists on ordering a bleeding time for his pre-op patients?”

 

"Check this out, one doctor asked how could the current b-HCG be less than the prior result when the patient is still pregnant as confirmed by ultrasound." 

 

Some questions were tricky. But there was also a fair amount of agreement that even the most casual question regarding selection, use or interpretation of a test should be referred to a pathologist.

 

“I am just a tech.” said one comment. “The pathologist gets the big bucks,” said another. “I did not go to medical school,” said a third.

 

This discussion made me think about a coupleother recent experiences I had regarding essentially the same issue. About a week ago, an MLS around my own age was opining to me how lax and unsupportive pathologists are these days. I asked her for more details. She gave me a list of annoyances, mostly breaches of common laboratory practices, such as frequency of ordering the same test, ordering boutique tests from private laboratories and insisting they be sent out, or demanding that specimens be retrieved from storage for add-on tests long past the recommended time period. One physician realized that specimens were discarded after 5 days and now demanded that “his specimens” be maintained for 7 days for add-ons.

 

"In the old days, a pathologist would just call and set them straight," she says. "Not these young guys who just want to do quick biopsies, a little histology and nothing else. They are friends with the doctors and don't care about the lab."

 

That piqued my interest so I asked for more specifics. “I have told our pathologist about these problems and he does nothing,” she said. Have you talked to the physicians yourself and pointed out that these are violations of laboratory policy? Have you had your technical manager attend a medical staff meeting and educated doctors? Have you shared your Test Utilization Policy? Have you involved Quality Assurance or Risk Management? No, no, no she said.

 

“Have you told the pathologist the extent of the problem?” She admitted she had talked to him once, giving him examples and she expected him to act if he really cared. It is not really within the purview of a laboratorian to talk directly to a physician, she said.

 

The other example I was told about was even more baffling. In a community hospital a  group of MLS/MLTs were assigned to review procedures that were long overdue for review. Their review policy called for a biennial review but some had not been looked at in close to 5 years. They wanted to do the right thing. They went the extra mile of verifying best practices with local sister hospitals, checked with specialists in the hospital about cut points for troponin, use of glucose tolerance test for gestational diabetes and updating the glucose range from 70-110 mg/dl which is what the current procedure listed. They also developed a list of critical test ranges based on physician input.

 

A new pathologist on staff objected to any change in procedures despite the fact the change would reflect current best practices. They provided justification, but he would not budge. It was unclear why he was resistant to changes that were clearly justified, but he made it clear he had the final say.

 

I cannot fault anyone mentioned in any of the examples above for consulting their pathologist in his/her role as medical laboratory director. However, does every annoyance, breach of policy or question about laboratory practice have to be referred to a pathologist?  As professionals is there a point we can decide it’s within our scope (and body of knowledge) to answer questions or resolve problems. It should not be difficult to re-state what current policy is or to explain the principle of  a test or give guidance on selection of a test.

 

A couple of months ago, I wrote two blogs: What do doctors want from the laboratory? Parts 1 and 2

discussing a major study which found that clinicians really do want more from the laboratory. Furthermore providers think we are more than prepared (educationally and intellectually) to provide answers and give guidance but we hesitate to do so.

 

The pathologist certainly is one tool in our arsenal, but should not be used as an excuse for not stepping up and offering answers or resolutions to problems that are fully within our capability. 

2 comments

I dont know your age or that of the woman who thinks her pathologist  does not intervene, therefore he doesnt care. I am older and I find that we were taught to hand over all issues except instrument-related stuff to the pathologist. It was just drilled in us from day one that the pathologis was in charge and had to make any major decision.

Over the years I have found that thinking kind of useless and often just wasted time. They would not act because they did not know enough about the subject or they would make decisions and promises to doctors that we could not live up to because of scheduling issues or how the lab was run on a daily basis.

We had pathologist offering to send out tests for some doctors when we did the test in house, or offering for us to collect, spin and send out some specialty tests to some lab like Mayo or in California  beacuse a sales rep had sold the doctor on some tests.

Technically I have had pathologists who had a senior Hematology tech read his slides and then just sign off on it. Path-review sometinimes just meant  a pathologist signature.

I have had pathologists who wanted input on every new instrument and others who just wanted to be updated but the superviors, technical director and techs chose the new instruments.

So this new younger pathologist mentioned above is probably just realizing the reality of the game and giving more freedom to the techs. Maybe he DOES care, but thinks the techs should be able to handle some issues. I actually prefer that approach. I dont wnat to be spoon-fed and controlled, especially if I am being told the wrong thing or have to act on a bad decision that someone else made.

As we retire, I think you will see the younger kids will take more of  a proactive role in the lab.

Patsy K, MT November 3, 2014 2:25 PM
Chicago IL

I am an Administrative Lab Director and I take a proactive stance in talking to  doctors and Administration. Some doctors do get confused when they call they expect to talk to a pathologist. But once they see I am knowledgeable and willing to help, they are not just OK but actually happy and appreciative.

To be honest my staff and I are much more knowledgeable about day to day  operations, procedures, policies and test menu than the pathologists.

We really need to step up and do more for the sake of doctors, patients and for the reputation of the profession.

Jonathan, Lab Director November 2, 2014 10:39 AM
Pensacola FL

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