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Press Start: Lead an Empowered Life as a Clinical Laboratorian

Laboratory Inspectors: Using Peers Versus Employees of the Agency
February 15, 2015 3:39 PM by Glen McDaniel

I  was speaking to a group of laboratorians including a pathologist, and the conversation turned to laboratory inspections. At first everyone was on the same page: inspections are a necessary evil in the sense that it is important to have some neutral measure of quality, but the inspections could be very stressful.


Each person recounted horror stories of overly-picky inspectors or citations that were just arbitrary or inexplicable as far as they were concerned. The pathologist was very adamant that medical directors should be exempt from such scrutiny. One older scientist told the group stories of lowered practice or low-quality practices being adopted at the urging of medical directors who in fact had the real power in the lab. The pathologist insisted, quite rightly, that such occurrences were probably few and far between.


I then asked the group should inspectors be practicing peers drawn from sister- laboratories or should they be professional inspectors employed by the agency or the state.  I have witnessed both practices-Joint Commission , State, CLIA and COLA professional inspectors  on the one hand, and CAP peer-inspectors on the other.


The group was about evenly split. The pathologist liked the idea of peer pathologists (doctor to doctor). A couple of scientists insisted it takes someone in current practice to be  knowledgeable and realistic enough to “judge” their colleagues. They suggested professional inspectors were often retired individuals “ who had not seen the inside of a real lab in years- except during inspections” They might not understand current medical laboratory practice and their expectations were often unrealistic, for example.


Interestingly, the younger members of the group unanimously thought it would be better to have only professional inspectors instead of peers who only volunteered from time to time. Why? They thought professional inspectors  would be better trained, more current on the standards and would adhere to interpretation of standards in a more objective way. Peer-scientists tend to be more subjective and tend to “judge” laboratories more in comparison to their own experiences. In short, they were more rigid and there was more variation among visits and among inspectors, they thought. Interesting.


I guess there are advantages to both models. But since most laboratories are CAP-accredited, using volunteer peer-laboratorians it seems, the issue is of more than academic interest. Do you prefer being inspected by a team of practicing scientists who are just taking time off from their own labs, or would you prefer a team of professional full-time inspectors, who do nothing but laboratory inspections?


I would be interested in hearing your opinions.

The Laboratory: Operating Behind the Scenes
January 31, 2015 1:01 PM by Glen McDaniel

The mantra of most laboratorians is, “We get no respect.” The wrenching truth about that is that it is a self-fulfilling prophesy. We provide the majority of empirical data used to make clinical decisions, we are among the most educated of healthcare professionals. Yet the truth is we are under-recognized and often underpaid, as compared to our healthcare colleagues.


I am not sure what medical laboratory education is like these days, but when I was in school, our studies were heavily scientific. We studied the biochemistry of human functions, the anatomy of the body and a good deal of time was spent “diagnosing” based on laboratory data.


Then we graduated, interned in an actual  medical lab and found that our knowledge and critical thinking skills were grossly underutilized. To make it worse, burnt-out laboratorians slapped us down (figuratively) whenever we dared to be audacious enough to think we could offer an opinion.


I have written several blogs discussing research that indicates that what physicians want from the lab is accurate, timely results. In fact, they are lost without that. That’s a given. But they also want consultation. They want help selecting and interpreting tests. When they call they want to speak to a professional laboratorian to have their questions answered, someone who will help them solve their dilemma. Plus they want to do this without too much trouble. In one CDC surveydoctors said they often just hung up as they were transferred from person to person when all they wanted was something as simple as what swab to use and why one specimen was acceptable and another not. They wanted “why” not some snide comment  like “that’s just what we use” or to be told “ask the pathologist” for just about every technical or clinical query.


I call the “no respect” prediction self-fulfilling  because as we get disillusioned and shut down or don’t bother to keep up with clinical and technological advances, physicians and nurses trust us less and assume they know more than we do. Even about OUR body of knowledge and our scope of practice.


Articles written about the lab often reflect the same dumbed down narrative of who we are and what we do. A few days ago, I was very heartened to read an article in US News and World report that talks about the value of the laboratory and the fact that, despite our pivotal role, we still operate largely behind the scenes.


The article accurately describes the roles of laboratorians, even using the correct title of medical laboratory scientist, and walks the reader through some common scenarios in which the laboratory’s actions make a difference in diagnosis and treatment.


The author of that article, Lisa Esposito is an RN by training and in an email to me she reminisced on how, as a nurse, she often waited anxiously for critical lab results or blood for a transfusion. “Without the work you do, we would have been at a standstill in patient care," she says.


Articles like these are far too rare. Sometimes it takes others to remind us of our value. Please share with your friends.

Happy MLK Day
January 17, 2015 3:37 PM by Glen McDaniel

Martin Luther King Jr.  was born in Atlanta, Georgia on January 15, 1929. Best known as "the slain civil rights leader" his mission was fighting for civil rights through nonviolent means.  His birthday is now a federal holiday celebrated in all 50 states, although with some reluctance, on the third  Monday in January. This year it will be observed on Monday the 19th.

MLK's life was one of service and in recent years the emphasis has been on celebrating the holiday through some act of community service.  The idea, as someone said, is to have " a day ON and not simply a day off."

Our profession is by definition one of service. It is no surprise that on Monday, while many Americans will be celebrating a day of rest and relaxation,  many of our colleagues will be at work providing healthcare as we do 365 days a year, 24/7. But for those who will not be working, what will you be doing? This is a perfect day to volunteer to help someone less fortunate or who can benefit from your expertise, knowledge; or even your physical effort.

Service is always about the other person, not us, but it is still an opportunity to teach others who we are and what we do. I have met many friends and professional contacts through volunteering, which is something I enjoy and feel compelled to do.

A simple pleasantry like "Where do you work?" or "So what do you do?" is always an opportunity to educate and to advocate for the profession.

The primary function of service is to GIVE, but one can always do well (and derive some benefit) even as one does good.

Whether you are at work or not, I urge you to make this MLK Day a day "on" and not a day off.

What Has Happened to the DCLS Degree?
January 11, 2015 5:12 PM by Glen McDaniel

 For several years now there has been talk about a doctorate in Medical Laboratory Science (DCLS). This idea was advanced by ASCLS to support the idea that medical laboratory science has a unique, distinct, significant body of knowledge that MLS practitioners  should be able to practice independently as do other professionals with similar education and training.


ASCLS developed and published a substantial toolkit which serves as a reference for educators wanting to craft and offer a DCLS program. Professional groups worked with NAACLS, the agency that accredits MLS programs, to develop standards and guidelines for accreditation of DCLS programs 


In recent years many professions that contribute significantly to patient care have asserted their right to have their own doctorate, with pharmacists being the most well-known non-medical “doctor” in the healthcare setting. Others like physical therapy have also advanced the idea of a doctorate as an entry level practice degree.


Despite the hard work that has gone into floating the idea of a DCLS, very few schools have made the leap to actually offering such a degree and enrolling students. I suspect it might even be difficult to convince universities to  authorize a new program without a clear return on investment for the university.


I think there are several reasons for this lackluster response to the DCLS:


-Many MLS practitioners still think of themselves as “only techs” and do not believe there is a viable option for advanced practice or a more significant role in health care for “lab techs.”

-The contents and goal of a DCLS curriculum are not clear. Even those who support the idea of a DCLS describe the ideal program in several very different ways. Will a DCLS focus on clinical research, advanced practice, clinical consultation, directorship of a medical laboratory? All of the above? Will there be the option to specialize in one area, as pharmacists often do, for example?

-With no clear or reasonable assurance of a niche in healthcare, few want to expend the time and finances involved in completing a doctoral program

-Neither healthcare administrators nor pathologists are advocates of the DCLS role. Healthcare administrators are concerned about increased labor cost, while pathologists might fear competition and usurpation of their role as “the lab doctor.”

-Entry requirements for DCLS programs seem very rigid. One program says “Only those with an MLS(ASCP) will be admitted.”  A successful program, especially one that is largely experimental should be more flexible, offering online options, allowing specializations and so on. This can be done while maintaining academic rigor. Just look at the flexibility of many advanced practice nursing programs.


While I continue to be an advocate of the DCLS idea, I feel more needs to be done to clarify the role, to market the benefit to employers and regulatory agencies, and to make the degree more attainable.


It is unlikely that the DCLS will catch on as a first professional degree (as the MD or PharmD) needed to enter the profession.  If folks balk at the idea of professional licensure (for professionals who already meet the requirements for licensure) they are unlikely to go for a higher entry-level degree.


The DCLS is much more likely to be an advanced practice degree, gained after a first degree (and some experience) where the practitioners assume roles over and above that of the “typical” bench MLS/MLT. The question remains “What roles?”


The DCLS is unlikely to gain popularity until that question is answered satisfactorily and all the players (MLS practitioners, clinicians, employers, regulatory agencies and even the public) can see some benefit for themselves.

Know the Difference Between Cost and Value
December 31, 2014 2:38 PM by Glen McDaniel

In casual conversation we use the terms cost, price and value almost interchangeably. That might seem to be just semantics, but I think we send mixed messages or act inappropriately when we start believing these concepts are identical.


Anyone who has a teenager probably knows all too well how they are guided by peer pressure. All the girls tend to wear the same fashion. Young people of both genders hanker for the latest “trendy” shoes, gadget or new toy. To many the cost does not matter and the sellers (knowing the demand) over-charge accordingly.


A friend of mine told me his  son who is unemployed borrowed $200 to acquire a pair of sneakers because they were the “it” shoes of his generation. I have driven a luxury car for the past few years but as it aged the repairs became never-ending and very expensive. So I traded it in for a sturdy, dependable Japanese car and am shocked at the many comments I have received. You would think condolences are in order because I have been “reduced” to a non-luxury car with much less status.


OK, so that gets me back to the various terms I started this blog with. I am writing this not only because of recent experiences, but because I believe they have significance to all our personal lives and also our professional lives. How do you value yourself, your colleagues and your profession?


Let’s just define those key terms simply, instead of using the formal economic definitions.


Cost: is whatever is spent to produce goods and services. So it might be what Toyota spends to make a car, how much Apple pays a worker in Asia to make an i-phone, or how much your employer is out of pocket to have you work for them (recruitment, salary, benefits etc).


Price:  is the what is charged or received by a seller. Again, using the car/employer analogy, it’s what someone pays the dealer for a Camry, or what your employer pays you to do a job as a phlebotomist, MLT or MLS  for them.


Value: is whatever the customer believes a certain good or service is worth. Value is a much more subjective quality, but it is what really drives the price.  The perceived value of "it" sneakers or an I-phone have very little to do with their respective cost of production. You can look at various professionals and realize that pay is not commensurate with education, work ethic, competence, service provided and so on.


My teenaged neighbor was willing to go into debt and pay hundreds of dollars for a pair of sneakers because of the value he assigned to those shoes. Employers will pay certain employees more because of their perceived value in the organization.


We tend to regard anything with a high price tag as being valuable, or more significant and important. The converse is also true: if we can convince a customer or employer that we are valuable, important, critical, crucial to their success, then our value increases.


These might appear to be subtle differences, but not knowing the difference often results in being undervalued and underpaid.


Here’s to recognizing and explaining your value (and fetching an appropriate price) as you move into the New Year

Expand Your Network by Bridging Structural Holes
December 28, 2014 3:30 PM by Glen McDaniel

Think about the people you know professionally; and most likely the majority are also laboratorians. That seems logical because you interact with colleagues at work. Maybe you belong to a local professional group or even a national membership organization. You might even know the majority of medical laboratorians in your city. That makes sense.


But think for a minute about the many professionals you know who may help in your career or who you can use as a resource from time to time.


Research conducted by Ronald Burt at the University of Chicago School of Business finds that our personal and professional lives are richer and more productive if we build bridges with others who are different and with whom we would not normally interact. This is called bridging structural holes.

Certain individuals and groups seem naturally connected to certain others; often comparing similarities and exchanging thoughts, ideas and even support. Burt says social capital, on the other hand,  is created by brokering connections by otherwise disconnected segments. All parties benefit from this symbiotic structure.


By the way, this is not the same as networking which is a deliberate strategy of expanding your list of contacts so that you can call on them periodically if needed.


You can deliberately bridge structural holes by creating associations outside of the laboratory: in your organization, at church, in a volunteer organization and even online.  Sometimes  it takes someone with different experiences and frames of references to bring a new perspective. They can identify strengths, weaknesses and even holes in your logic that you cannot see. In return you can garner support and even borrow ideas of how to solve a problem you are grappling with.


The great thing about bridging structural holes is that it is mutually beneficial. Many processes or lines of thought which are traditionally connected with scientists can be beneficial to those in business, social science and other areas. The reverse is also true. I cannot count the many times I have been complimented on my ability to analyze complex material or  my keen attention to detail. These traits come naturally to scientists, but not necessarily to my friends in business, some clinical disciplines or even journalism.


 When you adopt (or adapt) someone’s ideas you don’t even have to tell them, and you can avoid the sense of obligation of having to constantly ask for favors.


Here's the take-away. Deliberately court relationships with others “not like you” and observe how they think, the logic they use, they tools they have, the resources they draw on. Learn from them as they learn from you.


Chances are you will find something useful that will benefit you in your personal or professional life.

Time to Reflect on 2014 and Plan for 2015
December 26, 2014 12:36 PM by Glen McDaniel
The year is winding down and it is traditional to start looking forward to the next year. This is the time of year when we traditionally start thinking about what changes we will make in the New Year.


Some have already started penning their New Year's Resolutions. May I suggest that before you jump into crafting the year ahead, you review the current year. Get pen and paper and be brutally honest. It might take several sessions. If necessary, leave your list and come back to it after some hours (or a few days) of contemplation and memory recall. Analysis of personal and professional successes and challenges often come up with similar issues; a theme if you will.


What worked well? What did not? What issues kept popping up? What challenges were there? Those should be the areas on which you focus your attention. Is there a theme? You might find, for example that both personally and professionally time management or life balance were challenging. If so, how can you commit to doing things differently in 2015?


I am not a big advocate of lists or promise-to-do resolutions. I have blogged about those previously.


Since areas that we want to work on or goals we want to achieve tend to have a theme, I suggest (as I did last year)

that we concentrate on a vision for the new year.


Holding that one grand idea helps to focus attention and keeps you in check as you  measure significant actions against that vision, “Will  this action (move, job, school, relationship, expenditure etc.) move me closer towards my grand goal or not?"


I received scores of emails from individuals who have found this concept useful, so I submit it to you as well.


Here’s wishing you a very happy, prosperous and successful 2015, and please share your insights and successes with us!

Person of the Year: The Medical Laboratorian
December 21, 2014 1:48 PM by Glen McDaniel

As we come towards the end of the year several publications generate lists, perform annual reviews and select the most newsworthy items for that year. One eagerly anticipated “contest”  every year is the Time Magazine Person of the Year (POTY).


This year Time chose “The Ebola Fightersas their POTY. “They risked and persisted, sacrificed and saved,” says the preamble to the declaration. They even waxed poetic by adding, "Not the glittering weapon fights the fight, says the proverb,  but rather the hero's heart."


I totally understand this choice given the focus on Ebola this year, and the fact that for the first time in the history of the disease Americans were affected in a real way. It is human nature to attach more importance to matters that affect us than those that occur far away.


However, if the POTY needs not be one individual, and if the honor is to recognize those who have made a real impact on the world, then I nominate (and select) the Medical Laboratory Professional.


These professionals-scientist, technician, specialist, pathologist-work  tirelessly all year to be medical detectives, ferreting out the cause of disease, monitoring the effectiveness of treatment and helping to maintain health. This might not be a showy endeavor that makes the news, or even attracts the attention of patients and other healthcare providers, but it is vitally important work. In fact it is essential.


I suggest that the real heroes are those who not only perform yeoman duty every day, but continue to do so despite the lack of public recognition or even compensation commensurate with the value they contribute to the public’s health. It is not the "glittering weapons” of analyzers and “toys” in the laboratory, but the talent, competence and heart of the laboratorian that really make the difference.


Like everyone else I read the annual lists and honors, but I choose to salute you, my fellow laboratorians, individually and collectively, as The Person of the Year!


Soon an Entire Lab on a Chip?
December 11, 2014 10:29 AM by Glen McDaniel

Bigger is not always better, it turns out. It seems our appliances, gadgets and instruments are getting smaller; or at least coming in smaller versions, even as they have more capability.

I was watching an old crime movie this past weekend and burst out laughing when a detective pulled out a cell phone the size and shape of a brick. That was state of the art technology in communications back then. Over the years cell phones have gotten smaller even as their sophistication has increased. The typical smart phone is not just slim, but has the memory and capability of a full size computer. In fact the cell phone in your pocket most likely has more computing power than the computers that first put man on the moon.

The entire Point of Care Testing (POCT) arena has been growing by leaps and bounds as many tests traditionally performed in the laboratory on large, complex instruments can now be done on small black boxes or test kits close to the patient.

One new development in the news is that of what has been dubbed by some the Theranos Miracle. California-based startup company Theranos under founder Elizabeth Holmes is threatening to revolutionize the field of medical laboratory testing. Theranos has developed a proprietary phlebotomy process that is self-described as “a painless micro-needle that draws a few drops of blood, enough to perform 70 assays per sample.” 

The company is now offering blood draws in Walgreen pharmacies, offering not just convenience, but patient comfort and fast turnaround time. But lest you think this is just a small niche market, or that the claims of revolution are hype, look at the following

- The Theranos lab in Palo Alto is CLIA certified

-They are highly capitalized with millions of venture capitalist dollars

-They intend to expand nationwide

- They want to act as a reference lab for smaller labs and even larger hospitals by being competitively priced, offering a large menu, small sample size and rapid TAT

-They use cutting edge testing technology like ELISA and nucleic acid amplification

-They are in the process of obtaining FDA clearance for all of their tests

-They are highly computerized, so there is positive identification and specimen tracking from collection all the way back to the ordering provider

Laboratorians traditionally love technology. But here is a development that could revolutionalize the way we practice-and even who performs testing.  How do you feel about this sort of new development?  We have seen that technology tends to grow exponentially rather than incrementally so ventures like Theranos are likely to become more common with more bells and whistles pretty fast. Technology tends to be exponential, even as organizations change more slowly or logarithmically. Will your organization be ready to capitalize on this sort of modified lab-on-a-chip?

 Do you feel threatened in your role as a traditional laboratorian and how do you think these changes will affect the profession as a whole?


Happy Thanksgiving to You
November 24, 2014 1:03 PM by Glen McDaniel

In a few days the country will be celebrating Thanksgiving,but this festive holiday means different things to different people. To many it will be a day off from work, a time to spend with family, to over-eat and drink too much. It will be a time when family members get to show off their favorite recipes, critically assess relatives they haven't seen all year and, if lucky, enjoy a long weekend. To others it signals the start of the Christmas shopping season and an opportunity to start eagerly stimulating the econmy!

It is pretty easy to forget how Thanksgiving started as a celebration of a successful harvest by the Pilgrims, that over the years there have been different days of thanksgiving based on historical milestones, or  that the day itself was not always a permanent national holiday.

Many incorrectly think of Thanksgiving as a uniquely American holiday. I once mentioned to a colleague that I  was headed to Toronto to celebrate Canadian Thanksgiving with family and friends. I told him the celebration was on the 2nd Monday in October.  He replied in utter consternation, "Why do Canadians celebrate Thanksgiving? What are they grateful for and why are they celebrating on the wrong day?"

So the idea of giving thanks on a particular day has a checkered history; but reduced to its basics, it is a time to be grateful for all the blessings we have individually, as a nation, as a family, and as a profession. It is formal recognition of the gratitude we should feel all year long.

As a profession we should be grateful for the opportunity to serve, the ability to make such a valuable contribution to the health of this great country. We have a long way to go in terms of  recognition (pay, independent practice and licensure, for example) but we have also come a very long way, especially technologically.

While many can kick back and enjoy a long weekend of feasting, fellowship and foootball, many of you, my colleagues, will be away from family and friends; working as you do all year long. You will be supporting the health of the country. For that, I am personally grateful. You will be using your expertise, competence, knowledge and critical thinking skills to make crucial decisions that often mean life or death. For that, I am immensely grateful.

Whatever you are doing this Thanksgiving and however you choose to celebrate it, enjoy it and be safe. And, please take  a moment to acknowledge those achievements, qualities, individuals and blessings for which YOU are grateful.

Happy Thanksgiving!

Has Ebola Suddenly Gone Away?
November 15, 2014 6:03 PM by Glen McDaniel

Just a few short weeks ago, Ebola was the talk of the town. Both the lay public and healthcare professionals seemed consumed with the topic. Entire cottage industries were born to supply Ebola-proof personal protective equipment (PPE) and to teach Ebola safety.


There was a CDC conference call almost daily to update (and modify) guidelines. Hospitals diverted lots of resources to train their staff and to provide PPE in emergency departments and many patient care areas. The nation’s largest airports started screening visitors originating in Western Africa.


Several very enterprising merchants ramped up production of Tyvek-looking full body suits in time for Halloween.


Now, Ebola is rarely even mentioned-at least on the online sites that I visit and the healthcare organizations that I work with. So what happened?


First, the cases in the USA seem to have got less and those being treated in the US (except in one Texas hospital) have all had favorable outcomes. They were all released, essentially cured.


Conversely, why the earlier panic? Again it’s conjecture but there are several possibilities:


-This decades-old disease was now infecting Americans so it suddenly became new, serious, significant and important to Americans

- The media pushed the fact that it was largely fatal, and as much as they explained how it was spread through intimate contact with body fluids, the public chose to concentrate on the fatality rate and the fact that PPE use as described  by the CDC might not be 100% fool-proof

-There was an election looming and this was too tempting a drama not to exploit for political purposes. Who would be best at coping with this “foreign disease?” How tough should sanctions be: travel bans? Quarantine? What would each candidate do to protect you?


Now the election is over, the US has an Ebola-czar and there are currently no patients being treated for Ebola in the USA. So Americans have tended to turn away as if bored with a prime time melodrama and its drawn-out plot.


But the battle continues elsewhere. According to the World Health Organization (WHO) more than 14,000 have become infected and over 5,000 have died since the 2014 Ebola outbreak in March.


One doctor infected in Sierra Leone is on his way to be treated at the Nebraska Medical Center’s Biocontainment Unit, which  like Emory University in Atlanta and National Institutes of Health have a perfect record of treating patients using appropriate infection control protocols and targeted treatment by dedicated medical lab scientists, doctors and nurses.


There are 3 principles that come to mind. In healthcare, actions should always be based on science. We should be concerned about healthcare issues regardless of who is affected. Finally, healthcare delivery should not be politicized or overdramatized for political reasons. The Ebola scare is instructive because the public reaction violated all 3 rules.


This is a shame.

You Work for Yourself, No One Else
November 9, 2014 7:39 PM by Glen McDaniel

My dad was so proud of the fact that he worked for the same employer for 40+ years. He was never late, was rarely sick and sometimes went to work despite the fact he was under the weather. He thought he was indispensable and that his employer really valued him. To him loyalty to one employer was huge.


He received a small pension - not even the metaphorical gold watch, or a cake and punch party - when he retired riddled with aches and pains.


How things have changed. It is now very clear that employers have no loyalty to employees who are typically viewed as “elements of production” and therefore costly and replaceable.

Several years ago, the American Management Association (AMA) conducted a survey of 6,000 participants across the United States. The survey asked employees 2 questions:
1) Do you get enough recognition at work?
2) Would you do a better job if you got more recognition?

There was no equivocation in the answers.   Over 97% of the respondents said "no" they didn't get enough recognition at work, and 98% replied "yes" they would do a better job if they received more recognition. This means that employees think recognition is very important, but that they don’t receive nearly enough from employers.

The typical employee (inside or outside of healthcare) will have several jobs in their lifetime, sometimes even changing professions.  Laboratorians are no exception and have come to realize that employers have no loyalty to them, and will gladly cut an employee loose for a variety of reasons including preserving the bottom-line.

That does not mean that the employee-employer relationship has to be adversarial. However it is important to realize that you work for yourself first and foremost.  In every job you should learn as much as you can, develop new transferable skills and keep your resume current. Consider a reasonable work-life balance.

A flexible, nimble employee is a good employer of him or herself. To be a good self-employer, you should be open to change, cross training, taking on new projects and practicing constant networking. Learn as much as you can, and acquire skills that no one can take from you. Position yourself as a valuable individual professional, not merely as an employee of ABC Laboratory.  It is easy to get comfortable in a job, but at least once a year, update your resume with any new skills you have acquired. Look at job ads and decide, in an ideal world, which one would you go for. Practice writing a cover letter. List the professional colleagues you would like to act as your professional reference if necessary.

This exercise is as much a matter of psychology as practical preparation. If you suddenly have to make a change (voluntary or not) you will have a leg up if you are prepared, sale-able and have a current resume.  Faced with change, you will then have real options to make the move that is right for YOU. Your employer will be OK and will move on without you.  Trust me.

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

Get Back to Basics: Ebola and Other Things
October 22, 2014 5:46 PM by Glen McDaniel

It is extremely important to get back to basics in whatever we do. This simple edict is so often ignored because- well, because it is so basic. We tend to go for the complicated and glitzy. I thought about this truism when the CDC issued its new more rigorous guidelines this past Monday.

There is nothing really complicated about the guidelines at all. What is remarkable is that these guidelines have been used with thousands of Ebola patients for years in Africa. The group Médecins Sans Frontières (MSF) or Doctors Without Borders has treated hundreds of Ebola patients under horrendously primitive conditions for years with very few cases of provider-infection by using very basic guidelines similar to these finally adopted by the CDC.

We like to think we have the best healthcare system in the world, the most sophisticated  equipment, and the most knowledge. We are reluctant to modify our more high-tech rituals; we certainly do not like to borrow ideas from less developed countries. CDC first issued Ebola guidelines in 2008 and again as recently as August of this year.  But we have a situation where 2 American nurses using CDC guidelines became infected on American soil. The CDC admits they have not been able to identify any specific breach in protocol so it’s possible the problem was the ineffectiveness of the protocol itself.

According to CDC Director Dr. Thomas Frieden, the new, MSF-type guidelines are based on 3 principles:

-healthcare workers should be rigorously trained in both donning and doffing PPE

-there should be no skin exposure at all

-each episode of donning and doffing should be supervised by a trained monitor

Looking at the protocol in more detail, consider how basic certain steps and concepts are

1.     Full coverage of the body, no neck or face exposed as in previous guidelines

2.     Use of face shields versus goggles that leave skin exposed, fog up, and may be adjusted inadvertently with contaminated hands

3.     Decontaminate gloved hands and soiled  PPE with a virucide during and after removal

4.     Use extra covering such as aprons if the patient is producing excessive body fluids like vomiting and  diarrhea

5.     Use a “buddy” monitor to observe, coach, and correct in both the donning and doffing of PPE to ensure there are no shortcuts or violations of protocol

6.     Hand washing, hand washing, hand washing

7.     Staff should be trained, practice and be familiar with the protocol before they have to actually use it

It is worth noting that as scientists with highly sophisticated instrumentation at our disposal, specimen processors, auto verification and the like we sometimes give up autonomy and abandon critical thinking. Nothing is a substitute for ensuring the right specimen is collected from the right patient, the right test is performed, the result makes sense, and the correct result gets back to the right decision maker in a timely manner.

 No matter what our instruments say, we can over-ride technology and should still go with the basics whenever there is doubt. Or if there is a problem of any sort. Or as part of troubleshooting. Or if we have a gut feeling.  

Technology and established protocols are great helpmates. But I cannot think of one instance in which going back to the basics is not a sound principle by which to operate.

Is Your Lab Prepared for Ebola?
October 10, 2014 7:21 PM by Glen McDaniel

Just a few short months ago Ebola was a disease in a far away continent. The greatest fear was that with our internationally mobile population a case or two might slip into the USA. Then 2 Americans in Liberia contracted the disease and were flown back amongst great fanfare to Atlanta's Emory Hospital where they were treated for several weeks, during which they obtained  various experimental treatment. They both recovered and were discharged from the hospital.

But then there was another case in the US, and then another. The CDC has also been receiving calls from emergency rooms all over the country. Epidemiologists and health scientists assess symptoms on the phone and advise whether patients should be hospitalized and isolated, hospitalized and treated supportively, or treated and sent home. Sometimes specimens are drawn and tested for the  Ebola virus, sometimes not.

A man who traveled from Liberia to Texas, presented to the emergency room with flu-like symptoms. He was misdiagnosed and sent home. A few days later he returned to the hospital, was admitted and died of Ebola several days later.

The World Health Organization (WHO) estimates there have been over 4,000 deaths from the current Ebola epidemic, and has called this the biggest epidemiological challenge since AIDS .

Several countries including the US have started assessing travelers at the larger airports and denying them travel if they appear to have been exposed to Ebola (or have flu-like symptoms and are traveling from certain areas).

The US hospitals that have treated Ebola patients tend to have entire isolation suites, often with a dedicated care team. In one hospital I know of, specimens were handled exclusively in a point of care lab, samples for further testing were specially bagged and sent off to the CDC. Equipment was sterilized and samples were incinerated or specially disposed of. That is great for a couple of patients, but how will the typical hospital handle suspected Ebola cases coming through their emergency rooms? It is conceivable to have more than one patient at a time.

Laboratories need to know what tests to perform for diagnosis and retrospectively on someone who might have died suspiciously.

Infection control practitioners and risk managers might be building protocols right now, but is the lab involved in the planning? How would your lab handle the sample of a suspected Ebola patient sent for a CBC and electrolytes and crossmatch, for example? 

I would like to hear how you personally feel as a scientist in terms of your own comfort level and how well prepared do you think your lab is to handle your first case of Ebola?



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