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