was speaking to a friend who was complaining about how busy and tired she was
this summer. In addition to working full time on the evening shift she has been shuttling kids to
activities and summer camp. She has a seriously
packed schedule which starts early in the morning and goes all day..
can’t wait for the kids to go back to school,” she bemoaned. "The kids are out of school, but it's like I am in summer school."
schedule is such that sometimes it’s not worth her while to go all the home
between “pick ups” and “drop offs.”
had a long commute years ago where I worked 140 miles from home and only made
it home on weekends, I developed ways of occupying myself during the drive. I listened
to books on tape, MBA audio lectures and even studied lines for whatever community
theater play I happened to be in at the time.
bigger point is that down times, long commutes, or those annoying wait times can
be turned into opportunities for acquiring new knowledge and skills.
you have been placed on the night shift and have downtimes when you twiddle your thumbs, that’s a great
opportunity to study for an online degree or learn some new skill in another
laboratory department. If you work on weekends and have odd weekdays off, those
are the best days to pamper yourself, have alone time and run errands when most
of the world is at work.
to my friend shuttling the kids. She found a park close to the center where her
daughter does dance; so she often takes the opportunity to walk and get some exercise in. For some reason
she never learned to ride a bike really well, and has now made friends with a
lady who is teaching her to ride a bike, while her new friend’s teenage son is
teaching her to skateboard (!) in exchange for English lessons. It’s like she
is now in her own Summer school-and enjoying every minute of it. How cool is
are pretty simple examples. But you can always use inconvenient times to your
benefit. Just look around and see how you can fill those moments not simply
with with busy-work, but with something worthwhile; something that will add
value to your own life.
it and see the difference it makes.
are differences all around us: at work, in society, and even in our own family
or circle of friends. We tend to focus on the differences a lot. Just look at
the news and see how all of societal ills are being blamed on those who are different
weekend I have been catching up on my reading. I just read several Facebook
posts on MLS-related pages where several posts are recounting negative interactions with nurses and
doctors. As a profession we tend to make sport of the “stupid things” nurses
and doctors say and highlight how they think differently from us. It’s always “us
describe how individuals develop and act on biases based on the concept of the “in
group” (those like us) and the “out group” (those who are not like us). We
construct in/out groups for individuals, cliques, communities, organizations,
races and entire countries. Think of some countries which are like
America. Now think of countries which are unlike America. Then ascribe negative
and positive qualities (actions, expectations, morals, values) to each. See how we
place higher values on countries which are more like ours?
same thing happens in professions of course. It is especially tempting to make
fun of, and demonize, professions that we think exert some imbalance of power
just happen to be reading a book called “Us Plus Them” written by Professor Todd
Pittinsky. In fact, going back and forth between Facebook and this book is what prompted me to
write this blog. Pittinsky explains in convincing, if obvious, terms why
differences and diversity should be valued. We can capitalize on differences to
make interactions more effective. When individuals with varying points of views, or representatives of different professions, serve
on a team (in a lab, in an organization, for example) we can draw on the strengths
afforded by the diversity.
reviewer has this to say about Pittinsky’s book, “Us
Plus Them upends the way we look at
relationships. No more zero-sum games; no more clever nuancing around human
differences. A key challenge of leadership is harvesting the gains that arise
from the basic incongruities of our collective humanity. Pittinsky’s original
perspective is destined to create healthy controversy and healthier
continue to suggest that we draw in multi-disciplinary teams whenever we can,
whenever we want to get ideas or make changes. This way we build relationships,
build up relationship-capital for later, get different perspectives and ultimately arrive at better
outcomes. This is especially important in healthcare. where patients are the ultimate beneficiaries.
Each nurse-doctor/lab interaction which now forms the basis of a new
joke and ridicule on Facebook can become a teachable moment. It’s a natural
side benefit that we
learn and become better human beings as well, whenever we teach or listen.
Proficiency Testing (PT) is just part of life
for most laboratories. Laboratories are sent challenges (unknown samples) which
they test like patient samples and then submit their results. An agency like CAP then grades the result against
those submitted by peers using the same test system. Your lab is considered as doing a good job if your results are close to those of the peer
like standard deviation and SDI give the impression the results generated are
being checked for degree of accuracy. But are they? Well not really, the mean
is used as a surrogate for the correct value and the variation from that mean
is then regarded as the degree of inaccuracy (bias).
PT materials are not patient samples and often additional material is added to preserve
and stabilize the samples. How do these additives change how samples react? To assume
that closeness-to-peer indicates “correct” accurate results is to be overly
and even shipping and storage conditions- introduce matrix and other effects meaning the PT sample
used to give you that “atta boy” is in fact not directly comparable or
commutable to a fresh sample from your patient.
what if we just made allowance for that knowledge, knowing PT is not perfect
but it’s the best we can do right now? However that assumption raises another issue. How can
we be completely sure that our test system (say an analyzer with a certain
reagent) is in fact producing accurate patient results. Calibrators and quality control
material often have matrix effects as well. Then there is the additional issue of
comparability among various test systems.
research shows that a clinical condition has certain cut points or diagnostic targets.
Given the degree of uncertaintity and variation how can a clinician be
confident making clinical decisions based on such results? We are already
familiar with harmonization for cholesterol and with the use of INR (versus
PT) to guide warfarin anticoagulation.
In both cases there is much less inter-laboratory variation than there used to be.
brings us to the areas of accuracy and harmonization. Accuracy is “trueness of
result” while harmonization is a system of ensuring results for an analyte
are truly comparable; even performed by different methods, at different sites, on different platforms.
has recently introduced Accuracy-Based Surveys for various analytes like
lipids, Vitamin D, Creatinine, testosterone and Hemoglobin A1C.
is a totally voluntary process and laboratories might not want to subject
themselves to extra scrutiny and the possibility of “failing” even if results are
within the peer group. One advantage of the Accuracy Based Program (ABP) is
that manufacturers can re-evaluate their products (reagents and test system)
and even revisit their calibration traceability.
it be wonderful if your PT results indicated how you were doing in an absolute
sense, and not simply compared to your peer group who may have the same bias? Wouldn’t
it be great to have tests systems giving equivalent results across platforms
and laboratorians and clinicians having the confidence that their “numbers” are both
accurate and comparable and can be used to confidently guide patient care
you ever found someone very difficult to work with no matter how
you try? On the other hand you find others who consistently seem to adjust, cooperate and understand
even if things don’t go as planned.
all have different personalities and behavioral styles so it is probably unrealistic
to expect all personalities to mesh. However in our increasingly diverse workplace it is
important to at least learn how to have a collegial working relationship with a wide variety
of individuals-with many different personalities.
are various psychological tools for determining personality styles. One very
popular one that has been around for quite sometime is the Myers Briggs Type Indicator (MBTI) Test. Another
is the DISC Personality style test . DISC
stands for Dominance, Influence, Steadiness and Conscientiousness.
any communication it is important to recognize your own style: how do you perceive the world, where do you
get energy, how do you relax, what pushes your buttons, what do you consider important, what do you require
from colleagues and bosses?
the next step is recognizing the personality types of others you interact with
on a regular basis. Like a lock-and-key you then adjust your actions and
emphasize certain behaviors while minimizing others. In that way you can indeed work with a variety
of personality types and have a harmonious, productive working relationship,
even if you are not personal buddies.
look at the DISC personality style more closely, as an example of leveraging personality types.
D (Dominance) is typical of a
go-getter who relishes fast-paced activities and is task oriented.
that type of person you want to engage them by being more fast paced (matching their
style) and direct. They might not want to chit-chat about personal events in
your life. They are the “just the facts” types and like executive summaries
with the bottom line clearly stated. They eagerly take on challenges. They want
deadlines and respect those who set and stick to deadlines.
I (Influence). This is also called
the Promoter type. They like a fast pace but are very people-oriented. They like
working in teams and will probably preface each interaction by discussing their
family or asking about yours. Relationships are important to them. They enjoy a
compliment or a good joke and will react favorably to either. While deadlines are important they will understand
if a family emergency impacts a project temporarily. The Influencer employee craves recognition.
S (Steadiness). This type, also
called the Nurturer, tends to operate at a slower, more deliberate pace and is
very people oriented This is the typical
laid back, congenial individual who will seek input, try to get consensus and
consider the impact of change on all stakeholders. Consistency, dependability, honesty
and incremental change are important to them.
C (Conscientiousness) or Examiner type
enjoys a slow pace and is task oriented. This person is likely to create lists
and pore through data. They will analyze before they come to a well-reasoned conclusion.
You impress this type most by proving competency, discussing statistics, data,
trends and research. If you direct this person you might have to rein them in,
because they will tend to research and re-analyze all the way up to the
you work in a team (and everyone does to a degree) it can be useful to know the
various personality types on that team. Depending on the task at hand it might even be
useful to select certain personality types for a particular project. The good colleague
or manager plays to the type of the other individual in order to have a more
effective, productive and harmonious
It is important to remember that this
is not about being fake or changing your natural personality. Rather it is learning
a valuable skill that will pay off handsomely
both in your professional and your personal life.
are used to being regulated. It seems they are always preparing for inspection by the state, CLIA or
some accreditation agency-or two. Very often laboratories think inspectors are being too
hard, or picky, or even plain wrong in the way they interpret the standards and
grade the laboratories.
last blog discussed a
very harsh critique of the laboratory profession written by a journalist. One
of her claims was that not only was it near impossible to get access to
specific accreditation records, but the accreditation process itself may be flawed. In
that regard some laboratorians might agree with her.
have been a member of several laboratory inspection teams and I observed several differences in approaches, thoroughness and (yes) even interpretation of the standards.
One big area of difference is the subjectivity of determining whether certain
documentation does indeed prove adherence to, or fulfilment, of a certain
of the reason for the difference as I have also discussed previously is the fact that agencies like the Joint Commission
and COLA use professional inspectors while CAP uses volunteer peer-professional
inspectors. It’s logical to think the use of part-time volunteers might increase variation
between visits -and even during a single accreditation visit.
accreditation is voluntary, licensure and certification are mandatory. Under CLIA, CMS has
granted most accreditation agencies deemed status which essentially means CMS
will accept the accreditation visit/finding in lieu of conducting its own
visit. State agencies will often perform the role of CLIA inspector.
how can a laboratory be sure that its accreditation agency is being not just
fair, but accurate as well? CMS does routine validation of a subset of
inspections. CAP indicates that CMS will routinely re-inspect about 80-120 CAP-accredited
labs per year. They then look for differences in findings. Such differences are called disparities
how much of a difference is considered acceptable? In the last round of summary
reports produced by CMS they found a variation of about 17 percent for
CAP-accredited laboratories. A disparity level of 20 percent is the benchmark
at which CMS takes a closer look and reconsiders its deemed status. In fact
they perform a “deeming status review.”
are validation visits more likely to find “something missed by CAP or another
inspection agency,” or are they more likely to overturn an adverse finding?
Details are hard to come by, but it appears the former is more common.
discrepancies more likely to show up in some standards than others? Yes, it
seems the following 5 areas are the primary source of disparities: test
validation, proficiency testing, competency, personnel records and
responsibility of the medical director. Given this knowledge and the fact that
a validation is more likely to mark you “down” these should be considered areas
of high concentration for your lab.
A little while ago I wrote a blog in which I referred to a great, balanced, intelligent article written about the medical laboratory and printed in The US News and World Report. That article was remarkable by its rarity. I asked my readers to respond directly to the writer, thanking her for a positive article. Many of you contacted the journalist by email and Twitter, much to her delight.
This morning, another article crossed my desk. This one is a hatchet job written by a journalist for the Journal Sentinel. It is an indictment of the laboratory written using sources who have been harmed from inaccurate results generated by laboratories. Everyone from accreditors to MLSs/MLTs are assigned blame. Reference is made to shoddy habits like the use of expired reagents and mixing up samples.
To read this article it seems like there is no standardization, there is no quality assurance, and every lab test has the potential of leaving ruined lives in its wake.
Some of the "experts" who commented for the article are laboratorians and I would like to think they were misquoted or their words were taken out of context. It's disheartening to think fellow laboratorians would allow such a biased and unbalanced piece to see the light of day.
There is a lot of buzz on social media about this article: mostly hurt feelings and righteous indignation. But as I pointed out on Facebook, commiserating among ourselves is not going to educate the journalist or the public; and will not change anything.
I strongly suggest you read the article and weigh in here. Feel as indignant as you want to, but , more importantly, respond by contacting the journalist ( reached at email@example.com or (414) 224-2071) and her editor.
it seems like those of us in healthcare just love to hold meetings. We seem to
even hold meetings simply to figure out how to plan more meetings. Not
surprisingly, as busy professionals, always on some sort of deadline we hate
attending meetings as much as some people love holding meetings.
reason that meetings are so dreaded, other than the sheer volume of them, is
that they are often not very productive.
Since some meetings are in fact necessary, it’s important to know a view
hints that can make your meeting more productive-and less dreaded.
Get clear about the
reason for a meeting.
This seems like a no-brainer, but too often
we think about the reason to meet in vague terms or try to squeeze too many
subjects into one meeting, “While I have everyone together” is a common
justification. Big mistake. Some attendees will be totally disconnected and the
presenter will be less focused if the agenda is too loaded.
State the purpose of the meeting simply and
clearly in the invitations. That way invitees can start thinking about the
subject. Their contribution is likely to be more considered and thoughtful that
Set a time. I mean set a time literally and figuratively.
Yahoo’s CEO Melissa Mayer is known for holding 10 minute meetings. Some studies
show that 15 minutes is the ideal time for a meeting if the goal is to be
focused and productive.
have found that even for a staff meeting where you might discuss several items
and solicit feedback from various individuals, a 1-hour time frame is the maximum.
In any event set a timer and wrap up quickly (no matter where you are on your
discussion list) as soon as the timer goes off. Meetings are not the time and place
to do research and in-depth thinking.
extra detailed work to a subgroup. If discussions are running too long,
schedule another meeting later on. You will get more accomplished in four15 minute
meetings than you will in a rambling 1-hour session. Say goodbye permanently to long
drawn out gatherings unless the goal is to leave everyone feeling numb, uncommitted
Ban phones. This seems to be a
no-brainer but we all know how distracting it is when someone’s cell phone goes
off, they break the mood, apologize and turn it off. Then it happens to someone
else. Some of us “live” on our smart
phones so it becomes a habit for many to
constantly check their phones even during a meeting.
a basket or bucket to “check” phones that made it to the meeting. It is not
enough to just ask that they be silenced. The tradeoff for a long meeting is a
much more focused meeting while actually engaging all the stake-holders'
Assign A Directly
Responsibility Individual. If a task has to be
followed up on, assign the responsible individual publicly in the meeting. The DRI (another trendy term) should know
exactly what to do and be given a deadline for getting it done. Don’t be vague
and don’t assign to an entire group (unless it’s for the group to meet and work
Don’t abandon tips
that have worked up till now. It is still good practice to have an agenda, send
out the agenda before the meeting, send out a draft of the minutes and ask for
corrections before distributing the final copy of the minutes, use email rather
than distributing hard copies if at all possible. All those habits still make sense.
big danger with unfocused untimed meetings is that any activity tends to expand
to fill the time allotted. If there is no drop-dead time, discussion just goes
on much longer than necessary. If you can make just one of the changes above in
the short term, I suggest setting a time-limit and sticking to it. Over time
your attendees will learn to come prepared to work and get out. Your staff will
be grateful and you will surprise yourself at how much more productive your
An ongoing debate within the medical laboratory science profession for several years now has been the idea of patients having direct access to the laboratory.
A new law recently passed in Arizona allows patients to order their own laboratory tests legally. This law goes the farthest, that I am aware of, in terms of explicitly empowering patients to order tests cafeteria- style and get the results themselves.
In our traditional paternalistic model where big brother knows best and doctors always know best, the conventional wisdom has always been that laboratory tests should only be ordered by providers (never patients) and the results should be sent to the doctors (never directly to patients). Many states, in fact, have laws prohibiting direct access testing (DAT), or allowing DAT in very limited instances.
Going back as far as the Clinton administration, continuing through the Bush administration and finally in the Obama era, the Department of Health and Human Services (HHS) has suggested that patients should be empowered to have access to their own health information. In fact there is now a specific mandate that laboratories MUST allow patients access to results if the patient asks for them.
This new democratization of healthcare has coined phrases like The Empowered Patient and the Quantified Self Movement. Here we have the most educated, intelligent and tech-savvy generation in our history. So why should they not be able to access medical services without an intermediary? Why should their own information be withheld from them or doled out like candy to children? Why not take advantage of the available technology to access services, receive results, track and monitor progress?
The traditional approach has its place and will continue to be the norm for a long time.
This trend of patient empowerment, frankly, is not going away and will expand. States that currently limit DAT might find those laws challenged.
It is interesting that CLIA is silent on this issue. CLIA authorizes the regulation of laboratories that conduct testing, not the individuals who order the tests or receive test results. However most states either prohibit or severely limit DAT. It will be interesting to see how legislators in those states weigh the medical lobby against the inevitable consumer pressure.
One concern I have is that MLS practitioners have had a hands off attitude when it comes to patients ( I chose this profession so I don't have to deal with patients, I'll do whatever the doctor orders, once the results are generated I'll just pass it on and patients must discuss the results with the doctor.) The effect, intentionally or not, has been to minimize in the minds of the public and legislators the role of the MLS professional.
Labs might be looking at increased test volumes as consumers start ordering (and possibly paying for) their own tests. But lab professionals can be more valuable than ever in stating reference intervals, talking to patients about test selection, specimen collection/storage, factors that affect test results and when a result might indicate further intervention by a medical provider.
This might well be an opportunity to position the MLS practitioner more strategically-and appropriately- on the healthcare team. This could be a win/win situation for all stakeholders.
goes without saying that we live in the world of social media. I am not ashamed
to say (maybe I should be) that this not-so-young guy spends way too much time
online. Among friends of my generation, I am the go-to guru for interpretation
of social media terms and recommendation for the latest technology or app. I get lots
of news on social media. In fact my Twitter feed often beats the national networks
to broadcasting some event of national or international significance.
it is because of this wide exposure afforded by social media that many
organizations now have a Social Media policy. Such a policy generally addresses not just the access of social media at work and using company computers, but
also spells out what can be posted and what is prohibited.
organization wants to be portrayed negatively by a current employee. That is why certain posts can result in immediate termination. However, healthcare
organizations have a unique concern: that of privacy and security.
employers say posting pictures, patient-identifiable information are all
prohibited. Generally healthcare organizations are very prescriptive with their
policies directed at employees and even non-employee physicians.
of this comes as news, I am sure.
organizations often use social media to advertise or post positive news about themselves, should
they require employees to do the same? Should an organization “strongly suggest” that their employees post
at least one feel-good post per week reflecting positively on the organization?
What about requiring employees to “reach out to friends on social media to
raise X dollars” as part of a fund-raising campaign?
encountered a couple of those “requirements” recently and though the requirement odd at
best. What do you think? Does your employer require or strongly encourage you
to post on their behalf?
It's time of year again we celebrate and acknowledge Medical Laboratory professionals (technicians, scientists, specialists, pathologists and others).
The American Society for Clinical Laboratory Science (ASCLS) website has a very concise history of this celebration which, like the profession it highlights, has experienced many changes. It was started in 1975 as National Medical Laboratory Week under the auspices of American Society for Medical Technology (ASMT) which later became ASCLS.
Over the years several other laboratory organizations signed on as co-sponsors. For example, this year there are 14 organizations cooperating in the effort to salute the nation's estimated 300, 000 medical laboratorians.
In 2005 advocates from ASCLS spearheaded a change to rename it NMLP Week, with the "P" standing for Professionals. This was a deliberate attempt to emphasize that the celebration was for actual, real, live, talented, educated, hard-working professionals and not simply a room (the lab). This change was small but significant and evocative.
Traditionally each year a group of professionals selected a catchy slogan as that year's theme; often a catch double entendre. In 2010 it was decided to brand the celebration with a permanent recurrent theme, "Laboratory Professionals Get Results."
Then in 2012, the word "national" was dropped from the name to make the title less unwieldy. So here we are many years later celebrating the latest iteration: MLPW.
Much has changed over these 40 years. We have seen regulatory changes, emergence of disruptive technology, nanotechnology and healthcare reform. But one thing has not changed: the skill, knowledge, competence and dedication of a cadre of medical laboratory professionals who work diligently, often behind the scenes, to advance the health of this nation.
To all my colleagues, I say: take a bow. You deserve it. Happy MLPW!
recent College of American Pathologists (CAP) Q-Probe investigated the level of
physician satisfaction with what the laboratory has to offer. I always find
satisfaction surveys instructive and this one was no exception.
Q-Probe is certainly not the first of its kind or scope, but is the latest. The study’s authors
Shannon McCall, MD and Larry Massic, MD
had a sample size of 2425
physicians from 81 institutions and asked 16 laboratory-service related questions.
overall satisfaction was 4.2 on a scale of 1 to 5 (this compares to a 2007 study in
which the score was 4.1)
-Physicians were most satisfied with quality of results,
test menu and staff courtesy. They were least satisfied with turnaround time
(TAT) for STATS (inpatients and outpatients), and esoteric tests.
in terms of what providers considered important to them, clinical report format
scored fairly high as a service category
69 percent of respondents were satisfied
with the ease of use of electronic order entry. This was a surprise; as ubiquitous as that function
is these days.
percent of physicians said they would recommend their laboratory to another physician.
are some of the takeaways?
are confused by the increasing amounts of data they must process and find it harder to extract
what’s significant and actionable.
in smaller hospitals tend to be more satisfied with laboratory service than those in larger settings. The
study authors theorize that this difference might be due to closer, more frequent
interaction between providers and the laboratory staff in smaller facilities
despite some degree of frustration on both sides, physicians are basically
satisfied with the lab, but would welcome greater interaction and “help” in
several areas including selecting and interpreting lab results
time rates low on satisfaction because it rates so high on the “importance”
scale. So whatever we can do to reduce TAT is welcome and is translated in a
physician’s mind to “better service.” We
could also do a better job of
educating doctors as to what is included in getting a test from order entry to result.
They do not necessarily understand all the steps involved, or the differences
for different tests. Again, that is where communication comes in.
McCall gives the following advice, “Pay more attention to order selection and
entry, as well as the method and frequency of communication of results in the post
analytical phase. Then maybe we will see an improvement in physician satisfaction.”
This is just the latest in a growing number of studies where doctors say what they need from the lab. It is not coincidental that "help" and "communication" are repetitive themes. To me, this represents a real opportunity for laboratorians to expand their scope, boost satisfaction and contribute to enhanced patient care ; all at the same time.
This is the time of
year when the major medical laboratory organizations hold their national meetings.
These gatherings are a great opportunity for laboratorians to get together with
their professional colleagues from around the country and also to listen to
major players in the profession and on the cutting edge of science.
The advantages of national face to face
meetings are undisputed: to learn new information, exchange information with
each other, to network and to interact socially. Many meetings are held in
interesting cities, so attendees also take advantage of what the host city has
to offer; with many partying or getting much-needed rest and relaxation. Some even take this opportunity to have a
family vacation. Most meetings have a vendor exhibit or exposition (ranging from
modest to gargantuan) of some sort associated with the meeting. This offers a unique opportunity to talk to
vendors, to see and touch advanced technology.
thing is, it has become more and more difficult for the average bench MLS/MLT
to attend national meetings. Most organizations do not offer financial sponsorship
for meetings and, increasingly, laboratorians have to use their own money and often
utilize vacation time or PTO. What’s a laboratorian to do?
highly structured meetings are important for the reasons above, the reality is
that organizations must offer alternatives for those laboratorians who cannot reasonably
attend a meeting in person.
Communication technology has advanced to a great degree to offer several
where an individual could pay to “attend” one or more presentations
streaming of presentations and vendor exhibits
of CDs after the meeting
to a password-protected website for audio and visual presentations
of social media like Twitter and Facebook for some presentations where individuals
can participate and ask questions in real time from wherever they are
presentations of keynote addresses and high-interest topics
of technology available on smart phones like the recently launched Meerkat application
CEUs as appropriate for participation through these virtual means
of these options can be monetized ( I hate that term) of course. It is possible
to charge so that laboratorians would pay a sort of “fee for service” cost. These
charges would defray costs for the organization or, more likely, be a nice
source of revenue for the presenting organizations. Even if the cost was higher than the meeting
registration fee, it would still be a cost savings because the individual would
not have to pay for travel, meals away from home, hotel etc. and the other typical go-to-meeting expenses.
every organization has the wherewithal to offer all these services out of the gate,
but it would be nice to see an incremental move in that direction.
Vendors have a vested interest to subsidize some of the
cost, by the way. Here is a likely scenario: Vendor A allows a virtual tour of their expo booth,
ability to have a Q&A online and then allow the viewer to see one
presentation for free (could be a big keynote or a scientific session). The vendor bears all the cost. I can even see a situation where the exhibits
are less gigantic, with some of the savings being used to facilitate virtual
attendance and participation.
to face meetings are hard to beat and will not go away any time soon. However,
the reality is that they are inconvenient and expensive to attend. Luckily technology
offers many convenient, affordable alternatives. It is time to take advantage
of this technology. I know many meetings
sell CDs, I know some offer some CEUs after the fact, but I am suggesting
something much more comprehensive, bold and overarching. .
technology is there and the laboratorians are there. It’s time to bring them together.
disease is one of the most significant chronic ailments affecting Americans. Renal
disease is often a sequela of one of several maladies that plague Americans:
diabetes, hypertension, glomerulonephritis, autoimmune disease, polycystic
kidney disease and others.
estimated 20 million Americans have chronic kidney disease (CKD) some managed by
diet, exercise and medication alone, while others need regular dialysis.
of life can be adversely affected and impacted by kidney disease.
laboratory plays a crucial role in the diagnosis and treatment of renal
disease. One of the ongoing challenges for providers is the variation in tests
performed by different laboratories on different platforms using different
reagents. There have been several
attempts to create harmonization to standardize results and make it easier to
interpret results from various labs and even from visit to visit.
late 2012 some guidelines called the Kidney Disease Improving Global Outcomes
(KDIGO) Clinical Practice Guidelines for the Evaluation and Management of CKD
guidelines were developed through the collaboration of many international experts
and build significantly on lessons learned from previous guidelines. One very important
aspect of this guideline is that it contains strong recommendations for
laboratory input and involvement in the process of care. It only makes sense
that the experts who provide the information used in decision making should
understand the recommended best practices and the rationale for such practices.
surprisingly, laboratory involvement will require a more active participation,
rather than the typical passive behind the scenes “just do what the doctor orders”
the “Key Factors for Laboratorians” required by the 2012 KDIGO Guideline are the
good communication between laboratory professionals and relevant clinicians,
such as nephrologists and primary care doctors.
for common laboratory practices in a region so patients receive the same care
with comparable results from visit to visit, regardless of location where the testing is performed.
creatinine results are aligned to an isotope dilution mass spectrometry
an appropriate glomerular filtration Rate (GFR) formula for your population.
should use the same units, number of significant figures and clinical decision
points for both serum creatinine and eGFR reporting.
should understand, and provide information on, their creatinine method, including
any limitations and interpretation
should provide measurements of urine albumin and urine creatinine using traceable
assays. These tests might be part of a periodic monitoring protocol in a high-risk
population such as known diabetics.
should provide Albumin/Creatinine ratio (ACR) and do so in a clear, consistent
manner to help clinicians make correct decisions regarding declining renal
function in any one patient from site to site and visit to visit.
of these recommendations make good sense and offer yet another chance for the laboratory
to be an active participant in patient care. This involvement should provide
job enrichment as the laboratorian assumes a greater proactive and professional role. However,
these are recommendations, not mandates.
If laboratorians are hesitant and acquiescent then
another player will step forward. Then once again, someone outside the laboratory, perhaps
with limited knowledge of MLS, will direct “the lab” on what to do. It’s our
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.
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.
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
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.
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.
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?
would be interested in hearing your opinions.
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.
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.
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.
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 survey, doctors
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.
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
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
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.
like these are far too rare. Sometimes it takes others to remind us of our
value. Please share with your friends.