In recent years we have heard a lot about evidence-based medicine (EBM). Many physicians practice medicine out of habit; doing what is familiar or what they have been taught. Evidence-based medicine, however, is based on doing what the research shows is most efficacious; despite popular or conventional wisdom. In reality, EBM has been practiced in various ways, such as instituting care maps whereby for example a  patient with chest pain is always given aspirin or clot busters on arrival at the ED, is given an EKG, has cardiac enzymes drawn stat and repeated every 6 hours, starts cardiac rehabilitation within 48 hours of admission and so on.

Laboratory tests have been an integral part of EBM from the beginning (consider HBA1C for all diabetics, using PTT and INR to guide anticoagulant dosages, for example). However, not much has been done in terms of investigating the efficacy of laboratory tests.

With major payers like managed care plans and Medicare trying to reduce cost at every turn, it is no wonder that they are starting to suggest that reimbursement should be tied to the proven efficacy of lab tests.

Congress is considering several bills that may result in an increase in federal funding for what is termed comparative effectiveness research (CER). If passed, this could have huge implications for how lab testing is used and reimbursed.

CER is an evidenced-based research tool, which compares different health services or treatment options for the same condition, so healthcare professionals can personalize patient care.

The possible upside is successful CER studies may well provide laboratories with important information for assessing tests and improving test selection. In addition, these studies may provide needed data for new guideline development. However, there are also potential pitfalls associated with CER, such as how payers use the data. Will they use it to restrict coverage or reduce payments for certain tests? If insurers choose this route, what will it mean for clinical laboratories and test developers?

What's in a name? Does a rose by any other name smell just as sweet? In the very first regular column I wrote for ADVANCE in 1991 (September 30), I posed that question and proposed that our image as a profession is affected by the name we call ourselves.

The name "medical technology" as commonly used literally refers to the equipment, technique and state-of-the-art practice of medicine. It conjures up images of robotic arms, magic pills and surgery more than it does anything having to do with the clinical laboratory. The ambiguity inherent in this term has largely been responsible for the need to constantly answer the question "What exactly does a medical technologist do?"

I am amazed at the ongoing confusion of the term medical technologist with emergency medical technicians (EMTs) and the like in the public's mind. Even after many reminders, some of my friends and family insisted on calling me a lab tech, if for no other reason than (they claimed) it's a common term they didn't have to explain to others.

If you think that situation was frustrating, the umbrage was unbelievable when as a new laboratory supervisor, the "MT" on my brand new business card was interpreted as "massage therapist" by an innocent, if unsophisticated hostess at a party I attended.

With the increasing adoption of the preferred and more accurately descriptive terms clinical lab science/scientist by many, how much has changed?  I still hear laboratorians refer to themselves as "techs" and perpetuate the use of the same generic descriptions often used by nursing and others such as "someone from the lab," "lab person" or, simply, "the lab." 

Another interesting observation is that laboratorians who move on to careers outside the walls of the laboratory will often gladly dismiss their laboratory background as one would a seamy past: "back then I was a lab tech." Others, on the other hand, like doctors and nurses in executive positions, will often wear their doctor/nurse credential as a proud badge of honor, a value-added qualification, an asset, not a liability.

Using a strong descriptive moniker for ourselves will not increase our salary or give instant recognition, but it certainly will be a step in the right direction.

As a student, one of my professors prided himself on being a CLS historian of sorts. He would regale us with tales of old tests, methods, instruments and innovative efforts to make do under trying circumstances. In our eyes, he was the McGiver of CLS! When we did our clinicals at the local hospital he showed us the tank out back where they used to keep frogs for doing pregnancy tests. He had an old Natelson blood gas instrument, a colorimeter with removable glass filters, and insisted that we do methods manually to comprehend the principle before we took the "easy route" of automation.

Most recent grads today cannot even fathom taking all day to perform fecal fats or doing a batch of enzymes with stopwatch and a water bath.  If you talk about the need for producing a protein-free filtrate, you would most likely get a "huh?" In fact, now watching an instrument take 15 minutes to churn out a result is way too long! I am fascinated by details of old tests, old instruments and making do in the early years of your practice.

Please share some of those old stories with us here. I know there are some old-timers out there still practicing medicines who find it hard to relinquish an old test that has outlived its usefulness.  In an article I read recently, expert laboratorians, not surprisingly, gave the boot to LE Cells, Schilling Test, FTI, Bence Jones Protein and others.

They also fingered more controversial tests like ESR, LDH, AST and even CKMB for being superseded by more specific tests in recent years, What do you think?  I am also interested in hearing what is your "favorite" (or most annoying) useless test requested in your lab currently or fairly recently?

This year National Medical Laboratory Professionals Week (NMLPW) will be observed April 20-26. The theme this year is National Medical Laboratory Professionals: Delivering Today's Results for a Healthier Tomorrow.

Sponsored by 10 laboratory organizations this year (it's remarkable that any organizations can agree on anything) NMLPW is designed to highlight the importance of the nation's more than 260,000 clinical laboratorians. 

Started by ASCLS (then called ASMT) in 1975, the week has been anticipated by laboratorians over the years because it is an opportunity to celebrate and toot our own horns a bit. In the Fall of 2005, the word "professional" was added to the title to emphasize that the celebration is about living, breathing, smart, dedicated individuals and not simply a room--"the lab."

One of the things most laboratorians look forward to during lab week is all the cool stuff--magnets, t-shirts, lunches and breakfasts courtesy of administration or one of the few vendors that still offer such perks.

That's all well and good, but the week is about way more than hanging banners, wearing cool t-shirts and celebrating in the lab. For one thing, this is no time for false modesty or insularity. Sing your own praises and loudly applaud each of your colleagues. By all means, provide tours and free testing, but also take time to educate healthcare colleagues and the public about the training and important role of the clinical laboratorian.

Who are all these people in the black box called "the lab?"  What do they do to produce a valid result? What's their educational preparation? What are the relative roles of phlebotomists, customer service reps, lab assistants, CLS/MTs? What's the difference in training, role and specialties?

We have a real opportunity that we mostly squander each year by looking inward way too much. We can wear cool t-shirts, eat good food and educate all at the same time.

The problem is that many organizations view a mission and vision as something to be written down and trotted out when convenient, not a vibrant honest pledge that has to be lived daily. Organizations must work to change their culture so that employees feel actions match the "words on the wall." Engaged employees are those who feel proud, empowered, excited and a part of the organization.

There is a story about President Johnson visiting NASA and stopping to say hello to a janitor mopping the halls. The janitor introduced himself and proudly said "Mr. President, I helped to put a man on the moon."

That employee was engaged!

Lab managers often feel that as middle managers they can do little to affect employee morale. They even sometimes hate the mantle of being seen as representative of management. They do, however, have the ability and obligation to create employee engagement. They can do this by listening, walking in the shoes of their employees, encouraging employees to feel empowered to create solutions. Most importantly they can model  and reward desired behavior.

Previously, complications could be used to increase the weighting of a diagnosis related group (DRG) over and above the diagnosis given to the patient on admission. For example, if a patient is admitted on a ventilator, with a central line and develops hospital-acquired MRSA, Medicare will no longer pay for treating the MRSA.

Initially eight commonly-encountered conditions have been targeted by CMS. These include blood/crossmatch incompatibility, pressure ulcers, injuries from falls and infections such as blood stream infections secondary to wounds or catheter contamination. If not present on admission, these complicating conditions will not be reimbursed.

This is all designed to improve patient safety-and to reduce Medicare spending. It is very likely that this list "unreimbursed conditions" will be expanded as time goes on. Because so much of medical care is dictated by the results of laboratory testing, the laboratory staff will play an increasingly important role. Laboratory data will be useful in documenting, for example, that a condition was present on admission (POA) and therefore reimbursable-or the converse: no lab results on chart, not reimbursable.

Under this regulation it is very possible going forward, laboratory data can be considered in other ways as well. What about a wrong diagnosis resulting from an incorrect test, delayed results or incorrect results. Might the lab be inducted into controlling preanalytical and postanalytical phases of testing more than is currently done?

Bottom line: the lab will continue to play a pivotal role in ensuring safe patient care.

A nurse calls from the oncology clinic wanting to know how long she would have to wait to get the results of a CBC in order to start the patient's chemotherapy. The lab assistant answering the phone stumbles and says something like "we are really short staffed today. We are working on it and will get out a soon as possible; I can't give you a time."

She does not tell the hematology technologist about the call. Ten minutes later, the nurse calls again, the tech realizes the smear is still in the stainer and says simply "It's on the machine and will be off in about 10 to 15 minutes." The nurse says sarcastically "You all need to get faster machines" and hangs up.

Fifteen minutes later, the physician himself calls and is really mad. He berates the laboratorian who answers the phone and asks if she realizes how important it is to get results back in a timely manner. He says he is especially interested in the platelet count and seeing if there are any blast cells.

This time the tech says, "I am sorry about the delay. The automated part of the CBC is ready and I can give you the platelet count, WBC and H&H right now. The smear has just been stained and I am about to take a look at it microscopically. It should take me about 5 minutes or so, but I will be happy to call you back if I see any blasts even before I do the entire differential. Would that help?"

Which conversation do you think is more useful and powerful? Not only did the tech provide valuable information to the physician, she used language indicating she was aware of the lab's role in patient care. The lab assistant was dismissive and vague. The first tech made the lab seem like a bystander, simply passing on automated results generated by instruments.

This is a very simple example of how laboratorians can either play into negative stereotypes or how subtle choice of words can present a more positive, progressive view of the laboratory's role in patient care.

I was speaking to an older physician recently who bewailed the fact that his younger colleagues do not seem to believe in the benefits of society membership. Most physicians are concerned with the cost of doing business: malpractice insurance, continuing education, licensure fees, and do not feel a need to belong to professional organizations for camaraderie or social benefit.

They see society membership simply as unnecessary added cost. I found that really interesting since I had never heard that before about physicians.

I have, however, noticed that many laboratorians think membership in a professional association is an unnecessary (and expensive) luxury. I happen to disagree and even wrote a column about it a while back. Here is part of what I said:

I would submit that organizational membership is definitely good "bang for the buck," especially in these changing times. When selling the benefit of membership, we often talk generically and globally of the importance of networking and being part of a larger whole. Members have direct access to their peers, including leaders in their field-an inner circle of colleagues who provide support and motivation. New members to the profession are guided and mentored into maturity by more seasoned professionals who offer experience and (hopefully) wisdom. It is not uncommon for this interaction to translate into new jobs, an expanded scope of practice, increased knowledge, skill coping with professional challenges and the opportunity to grow as a leader. This is all very good and noble, but membership offers so much more.

If you have dismissed organizational membership as a luxury or totally without value, I urge you to reconsider. If you ask, "What has (pick any professional organization) done for me lately?" my answer would be: "A lot, and they could do much much more--with your help."

As a proud dues-paying member of several professional clinical lab science organizations, I can say I benefit from networking, attendance at meetings with stellar educational offerings, the opportunity to lead, the privilege to serve and the satisfaction of being a guiding force in my profession.

As laboratorians, we often bewail the disunity in the profession. Not only do competing membership organizations tout their relative superiority at the expense of others, but there are also competing certifications. Many Human Resource departments think (incorrectly) that only ASCP certifies laboratorians. They sometimes require, totally without any foundation, that a candidate "must be ASCP certified."

I am still mystified when even  some in the profession get confused. I  hear people say "I am ASCP." Really? You are an organization? I see credentials listed as CLS/ASCP, BS(ASCP) or CLS(AMT). There are no such credentials. I have also heard  " I have my ASCP license." Passing a one-time examination which is not required by law is not a license. Paying dues to remain on a roster is not a license and does not prove current competence.

Only states with personnel licensure are mandated by law to hire laboratorians with a particular documented set of skills. Everything else is voluntary and based on preference or personal prejudice. ASCP has prided itself on being the premier organization simply because of age and its pathologist connection.

One drawback has been one-time certification, with no need (until recently) for continuing education. Also it's essentially certification of one profession by another. NCA was born of this weird anomaly and represents itself as "certification of the profession by the profession."  Also, until recently, it was the only laboratory certification agency requiring continuing education to maintain certification.

Suffice it to say that multiple certification organizations in clinical lab science have resulted in much confusion inside and outside the profession. It has caused fractious competition and dilution of efforts to advance the profession. I was thrilled to hear of talks between the two biggest certification agencies: NCA and ASCP.

It seems this effort is already losing steam. It is in all our interest to continue down the road of unification, in my estimation. I urge you to write to your certification agency and let them know your thoughts regarding the creation of one certification agency as all other professions have. We can only benefit individually and professionally from such a move.

The acute coronary syndromes (ACS) are a continuum of ischemic heart disease that spans the entire range from unstable angina, associated with reversible injury; to frank myocardial infarction with large areas of cardiac necrosis. Here are some facts:

• The acute coronary syndromes are the biggest killer in the western world, accounting for approximately 500,000 deaths annually in the U.S. alone.
• Until recently, the magnitude and impact of this disease on women was largely under appreciated. However, the acute coronary syndromes by far account for greater mortality among women than any other cause.
• The economic impact of acute coronary syndromes is estimated at between 3 and 10 billion dollars annually. CHF costs another 30 billion dollars.
• Because of high risk of death and morbidity, ACS must be identified among the estimated 7 million patients with non-traumatic chest symptoms presenting for emergency evaluation each year in the United States. Better testing will also identify many more women at risk when interventions can be instituted.

There has been a lot of discussion recently about the "best" cardiac marker and which of the many newer tests will prove to be the gold standard. Recent guidelines from the National Academy for Clinical Biochemistry suggest Troponin is the most sensitive and specific.

CKMB falls faster than troponin, so is useful in identifying a re-infarction, for example. Myoglobin is an early but very nonspecific marker and should be used only in conjunction with a more specific marker. It is pretty much agreed that total CK and LDH do not provide much useful information.

Because of the financial and human cost of ACS (including MI) it is important whener possible to measure cardiac risk before a heart attack occurs. Probably the most commonly used pre-test is highly specific CRP ( hs-CRP).

Microalbumin, homocysteine and BNP are also used by some ED docs and cardiolgists. Promising new tests of cardiac risk include Ischemic modified albumin (IMA) and Cystacin C among others. What's the current thinking in your lab?

We have all at some time or the other had a "boss from hell." I for one have had my share. In one company I worked for executives who seemed to try to outdo each other for toughness and would even brag about, and recount how successful they were, at driving employees from the company.

To think someone could be proud of that. "Not on my watch," one vice president was fond of saying as she explained how she humiliated someone.

Several studies have shown many employees give as much importance to their relationship with the boss as they do with a spouse or close friend. That means a rocky relationship with the boss can cause untold stress, low productivity, lead to clinical depression and contribute to absenteeism and the like.

In an article in Psychology Today, Brad Gilbreath of Indiana University indicated his studies show a well paying job, a rewarding job or even good relationships with coworkers cannot completely compensate for a bad relationship with a boss from hell.

Gilbreath and others say a bad boss is the No. 1 reason for staff turnover.

Bosses identified as noncaring and abusive almost always have their own take on employee behavior, work ethic and  turnover. For example, they almost universally absolve themselves of responsibility for employees' departure.

I have heard:

• "They weren't the right fit."
• "They didn't want to work or change or conform."
• "It's just the nature of the  business that we're in."
• "I can't believe they wanted more money, a different schedule, etc."

Tell us your accounts of your experiences with a boss from hell; you can be anonymous if you like. Or you can use the "a friend of mine" literary license to protect the innocent. 

I am also interested in hearing from bosses who think they have been unfairly called the boss from hell or who otherwise think employees slack off too much and expect to be coddled by bosses. I would like to hear from both sides.

When I was in medical technology school in North Bay, Canada, I had lots of friends in the nursing program of the same college. We would often compare the programs in terms of workload, difficulty and our perception of the wisdom of choosing our respective professions.

As I recall, the nursing program had a course called "Nursing Seminars: The Profession of Nursing." This was a mandatory one-credit course that involved spirited discussions on the contemporary practice of nursing in Canada: opportunities, challenges, controversies; warts and all!  They sometimes had guest speakers or discussed journal articles; other times they would talk about some current topic.

One of the most disappointing aspects of stepping into a lab as a new graduate, many laboratorians say, is being hit with the reality of the practice of clinical lab science compared to what they had envisioned in school. Many in the profession do not feel connected or engaged.

Students and new grads cannot see the value of professional society membership, attending meetings or professional licensure. Is there an inverse connection between "disengagement" and job fulfillment? Of course there is! How about a sense of empowerment? Absolutely!

One way in which educators could prepare students for "real life" and  full participation in the profession is to engage them in discussions of topical issues while in college-not just academic subjects, but the politics, legislation, bugaboos, challenges and hot topics in the news.

I highly recommend using resources like columns in ADVANCE and this blog as jumping off points. I bet students would enjoy them and become more engaged, savvy, loyal and empowered laboratorians as a result.

The bill mandates the first increase in federal standards for automobile fuel efficiency in 32 years. By 2020, all automobiles must meet a standard of 35 miles per gallon up from 27.5 mpg for cars currently. Note that SUVs and trucks will need to meet that 35 mpg standard as well up from only 22.2 miles per gallon today.

Other requirements are for more efficient appliances and electronics from dishwashers to computers. Gone will be that old energy hog—the 100-watt incandescent light bulb so familiar to us. In its place will be energy efficient fluorescent bulbs. There will also be more ethanol use.

To put the energy savings in perspective: by the year 2030, we will save 4 million barrels of oil per day or roughly twice our current consumption from the Middle East.

There are also specific labeling requirements to clearly indicate energy efficiency of appliances and the like. This bipartisan law was very long in coming and went through a long process of debate and compromise before it hit the President's desk.

Many individuals are trying to do their part to reduce the country's dependence on foreign sources of energy as well as contributing to the conservation of energy globally. Labs with their instrumentation, air conditioning (or heat) and bright lights are massive users of energy 24/7. What types of measures would you recommend for your home and laboratory to play a part in the push to becoming more energy efficient?

A few weeks ago, I wrote a blog discussing the relationship between low pay and female-dominated professions

As is typical with blogs, the subsequent discussion from readers touched on several indirect subjects including nurse/patient ratios. Bernd from New York then mentioned the concept of patient abandonment and referenced the New York State situation regarding patient abandonment.

That particular point got me thinking about the abandonment concept. As a hospital COO, periodically I heard charges of patient abandonment hurled at nurses by other nurses. In the profession, abandonment is considered the crudest, most unprofessional act. After all, nursing is supposed to be about caring and always making the patient No. 1. 

While some cases could be conceivably considered abandonment, in most instances, the accusations were just empty charges designed to embarrass and malign a colleague. In nursing, abandonment ranks right up there with sexual harassment and patient abuse. Stay with me here, this is convoluted, but I am getting to the point.

Although clinical laboratorians do not have individual patients, they certainly work for the good of patients and perform an essential role that impacts on life and death. Should there be a similar concept in the CLS profession? Are there instances in which laboratorians can be credibly accused of job/patient abandonment? What sorts of actions would qualify?

Some scenarios: A Microbiology CLS is pulled to Transfusion Services to help because of several traumas in the ED. When the sole TS tech repeatedly asks her to perform tasks she is uncomfortable doing, the Microbiology tech leaves rather than (in her words) "kill somebody."  

A CLS/CLT who has worked a double shift leaves when his/her relief does not show up on time. What about if there is a bomb threat in another part of the hospital and a CLT leaves the hospital against her supervisor's instructions because she thinks self-preservation is the first law?

With the holiday season approaching, most people are swamped with shopping, planning and simply surviving the commercial onslaught. It is widely believed that this is the worst time of year to look for a job because all hiring stops. However, some HR and recruitment experts point out that those who continue the search over the holidays often have the edge.

First, employers are really scrambling to replace employees who left and possibly hire replacements under the current year's budget. Second, those employers with plans for new programs, business expansion and the like will gladly interview likely candidates now so they can make decisions soon and be up and running early in the New Year.

Whether looking for a job across town or moving to an entirely new city, this is a good time to touch bases with a prospective employer and get at least a preliminary interview. A recent article in Career Journal discusses this entire strategy in more detail.