Lablogatory

CDC Press Release–Passenger Notification

CDC and Frontier Airlines Announce Passenger Notification Underway

On the morning of Oct. 14, the second healthcare worker reported to the hospital with a low-grade fever and was isolated. The Centers for Disease Control and Prevention confirms that the second healthcare worker who tested positive last night for Ebola traveled by air Oct. 13, the day before she reported symptoms.

Because of the proximity in time between the evening flight and first report of illness the following morning, CDC is reaching out to passengers who flew on Frontier Airlines flight 1143 Cleveland to Dallas/Fort Worth Oct. 13.

CDC is asking all 132 passengers on Frontier Airlines flight 1143 Cleveland to Dallas/Fort Worth on October 13 (the flight route was Cleveland to Dallas Fort Worth and landed at 8:16 p.m. CT) to call 1 800-CDC INFO (1 800 232-4636). After 1 p.m. ET, public health professionals will begin interviewing passengers about the flight, answering their questions, and arranging follow up. Individuals who are determined to be at any potential risk will be actively monitored.

The healthcare worker exhibited no signs or symptoms of illness while on flight 1143, according to the crew. Frontier is working closely with CDC to identify and notify passengers who may have traveled on flight 1143 on Oct. 13. Passengers who may have traveled on flight 1143 should contact CDC at 1 800-CDC INFO (1 800 232-4636).

Frontier Airlines Statement

“At approximately 1:00 a.m. MT on October 15, Frontier was notified by the CDC that a customer traveling on Frontier Airlines flight 1143 Cleveland to Dallas/Fort Worth on Oct. 13 has since tested positive for the Ebola virus. The flight landed in Dallas/Fort Worth at 8:16 p.m. local and remained overnight at the airport having completed its flying for the day at which point the aircraft received a thorough cleaning per our normal procedures which is consistent with CDC guidelines prior to returning to service the next day. It was also cleaned again in Cleveland last night. Previously the customer had traveled from Dallas Fort Worth to Cleveland on Frontier flight 1142 on October 10.

Customer exhibited no symptoms or sign of illness while on flight 1143, according to the crew. Frontier responded immediately upon notification from the CDC by removing the aircraft from service and is working closely with CDC to identify and contact customers who may traveled on flight 1143.

Customers who may have traveled on either flight should contact CDC at 1 800 CDC-INFO.

The safety and security of our customers and employees is our primary concern. Frontier will continue to work closely with CDC and other governmental agencies to ensure proper protocols and procedures are being followed.”

Internationally Safe

With the serious and concerning news about international contagious disease, it’s always appropriate to remind ourselves of safety, both personal and protective. What laboratory professional has not donned the gown, the mask, the gloves…in an effort to protect ourselves, and also protect the patients we serve? We all have…but we all have also occasionally been cavalier about it.

In these times of viruses and antibiotic-resistant strains of microbes—and who knows what iterations of the above are in the “evolutionary muck” of the future—we stand in the cautionary shadow of the devastation they can cause. The invention of the microscope only served to give us a view of our un-seeable enemies, and they are countless.

I travel extensively, internationally and within the USA, and the risks of contagion are all around. It helps to keep yourself personally prepared by encouraging a robust immune system, eating/sleeping and hydrating well, and staying as healthy as is possible—but as we all know that is not always enough. It will also serve us well, as laboratory professionals, to both practice and teach personal protection in compromised situations. When at work, it’s obvious…but when in someone else’s lab, or hospital, or clinic, or even railway station, we must be diligent and alert to the unseen dangers of contagious disease contamination. Laboratory scientists are trained to treat every single action, specimen, and encounter as if it were a threat to health and safety, and yet…do we?

Life is short, disease is inevitable, and safety precautions are a must…but also a choice. Choose wisely, and don’t compromise! If your hospital/laboratory/healthcare system is following PPE and international safety regulatory compliance, good for you and those around you. We are the most knowledgeable infectious control specialists on the planet, and we have the obligation to lead the way in international and personal safety.

And as I mentioned in my last blog, let’s roll up our lab coat sleeves—and put those gloves and masks on…we have a lot of work to do!

–Beverly Sumwalt, MA, DLM, CLS, MT(ASCP) is an ASCP Global Outreach Volunteer Consultant.

Dilutions: How Are You Doing Yours?

If you ask someone to dilute a sample in half, pretty much everyone will do it the same way – add an equal volume of sample to an equal volume of diluent, whether that’s 1 mL to 1 mL or 100 µL to 100 µL. But if you ask people to do a 1 to 2 dilution, you may be surprised to get different results. That’s because I’ve found that the convention for writing dilutions is taught differently at different Medical Laboratory Science (MLS) schools.

A 1 to 2 dilution should be written as ½. It means to dilute something in half. But many times it will be written as 1:2. These two forms are actually not equal, despite the fact that they are used interchangeably in the laboratory. One is a dilution and the other is a ratio. In the scientific literature, if you see “1:2”, it means to add 1part to 2 parts. That will be 1 mL added to 2 mL, for a total of 3 mL, or a 1/3 dilution.

Unfortunately, this problem is prevalent in the laboratory. I’ve seen 1 to 10 dilutions written both as 1/10 and 1:10. It’s very important to know how the technologists in the lab are performing that 1 to 10 dilution. Are they doing a true 1/10 (1 mL sample plus 9 mL diluent) or are they actually doing a 1 to 11 dilution (1 mL sample plus 10 mL diluent)? Your patient results may be different depending on who does the dilution!

Coming into this field from a scientific background rather than an MLS background, I prefer the convention of writing a dilution as 1 over something, ½, 1/10, rather than as a ratio, 1:2, 1:10. However, perhaps the majority of medical laboratory scientists are taught the ratio. Either convention works fine as long as it is clear to everyone in the lab what dilution they are actually performing and being asked to perform. You might want to just check your own MLS and see how they do their dilutions.

-Patti Jones PhD, DABCC, FACB, is the Clinical Director of the Chemistry and Metabolic Disease Laboratories at Children’s Medical Center in Dallas, TX and a Professor of Pathology at University of Texas Southwestern Medical Center in Dallas.

Management and Administration Housekeeping Items

A few items relevant to your interests have crossed the editor’s desk over the past few days.

1. As we mentioned several months ago, laboratories need to provide lab results to patients (or their representative) when requested to do so. The Privacy Rule amendments went into effect on October 6, 2014. Is your lab compliant? Read the regulations to be sure.

2. The Draft Guidance for the FDA regulation of LDTs has been published. You can read them here and here. The FDA will accept comments about the draft for the next 110 days.

The Beginning of the Fellowship Trail

Well, last week my fellowship applications became quasi-complete. All my letters were sent for molecular genetic pathology (MGP) programs although I did find out that several never received them. Most of the hematopathology programs I am applying to had received three out of four letters of recommendation. And some did offer interview invites before the third letter came in (but most programs want at least three letters to consider my application complete for review). Basically, I’ve been receiving one to two interview invitations by email each day.

I thought to myself that I should’ve started this whole process earlier. I thought that I had started early enough. I had asked for letters of recommendation (LoR) informally before I transferred from my previous program in June and then formally asked at the beginning of August. I had intended to submit my applications on September 1^st and hoped that the letters would be in by then or shortly thereafter. Throughout this process, I did find out that some programs began accepting applications as early as July 1^st and some had deadlines of September 1^st. I hadn’t been able to research as much as I would’ve liked before I left Chicago because I was on our busiest surgpath rotation (with over an hour drive twice a day and I only got the last day off) and I was also in the middle of moving cross-country.

I encourage you all to be early birds – to put everything together and ask early enough so that your application is complete (ie – letters are written and ready to be sent) by sometime in July, August by the latest. Remember that your letter writers are probably writing letters for other residents are well, especially if they are your program director since every program requires a PD letter.

After I sent my applications in early September, some programs responded with a thank you email but most did not respond at all and so I wasn’t sure if they had received my application materials. I would receive weekly emails from a couple of programs telling me that my letters were missing but that was the exception and not the norm. So I would suggest following up with programs to make sure about the status of your application. I had no idea that programs were missing some letters I believed had been sent until I received an email from one. So then I called or emailed all the others to find that other programs were just waiting for letters as well to send my application for review.

Some of this confusion could have been avoided. I think that some of this happened because I added on additional programs – I was overcompensating thinking that I might not have applied to enough programs – and my letter writers weren’t sure which programs they had already sent letters to. Avoid this scenario by researching your programs early. Then make ONE master list of places you are applying to for your letter writers to have to (e)mail their recs all at once (at their convenience).

In terms of personal statements, programs seem to like them short and sweet. Most had limits of 500 words or one page and a couple even had a limit of 250 words. I found it very helpful to have multiple attendings in my subspecialty of interest and fourth year resident friends (who had gone through this process last year) read my personal statement and give feedback. You can write the personal statement any which way you like but the advice I received that helped me most was to write it in 3-paragraph (not too many sentences) form: 1) why/how I decided to pursue the subspecialty, 2) what I bring to the table in terms of the programs I am applying to, and 3) what I am looking for in a program and my future as a practicing pathologist.

As for CV’s, there is no one accepted way (like there is in the business world) to write a pathology-oriented CV (or at least that I know of; enlighten me if you know better). I’ve been updating my CV since college so I already had the basic structure. I’ve had a lot of leadership positions so much of it had to be abridged or left out when I composed my CV for residency applications so I didn’t need to do much this time around either. Speaking with one MGP fellowship director, it was suggested that I include my lab based skills on my CV since I have significant research/wet lab experience and she would like to see where I would start from in terms of my knowledge base. I already had this information from one of my previous job resumes so I just added it on to the end of my CV. So, if you are applying for MGP and have some skills in the lab, then highlight them!

The tricky part I’m finding is scheduling interviews. It’s not as easy to get time off during residency especially with call/tumor board/conference schedules and other service duties as when we had residency interviews as a medical student. So plan ahead and ask for lighter months during the interview season when your chiefs/PD compose the schedules for the coming year. I’ve found that it helps to call programs that are near each other to ask about the review process timeline once I receive an invite in a city where I applied to multiple programs. Let them know the situation and ask politely when a decision will be made so that you can schedule interviews in the same city/area together (especially if they are on the opposite coast from where you live).

There hasn’t been any method to the madness when it comes to each program’s interview schedule. One program emailed last week and asked if I could interview during their first round this week but I’ll be leaving for ASCP Annual Meeting for the whole week in a couple of hours. Other programs gave me dates to choose from in either October or November. For those programs which adhere to the CAP suggested deadline of December 1^st (which I’m finding to be rare), those interviews occur in Jan/Feb but since I’m on rotations like surgpath where it’s difficult to get time off, I most likely won’t be able to make these. And with limited vacation days and finances to interview for 2 consecutive fellowships, I’ll most likely not be able to attend all the places I’ve received invites from for interviews.

I’ll let you know how it goes from time to time and hopefully someone will find my experiences on the interview trail useful.

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Thoughts from Pathology Job Market Conversations

So, as you know, I recently attended the 2014 CAP Annual Meeting in Chicago. In addition to meeting with residents, I also had many interesting conversations and meals with non-trainees. I met new-in-practice pathologists who had completed two or three fellowships who were unemployed and were at the meeting networking with potential job prospects. I met veteran pathologists who were working in part-time or locums tenens positions while searching for a more permanent position. And finally, I met pathologists who were currently working but who told me that over the years, the amount of work that they have had to do for the same or less pay had significantly increased.

These conversations left me wondering how we can address this issue. How do the reports that this country would see an impending shortage of pathologists in the near future fit in with these first-hand stories? Most, if not all, of the reports about a pathology workforce shortage were based, at least partially, on survey data. This can be influenced by selection bias, volunteer bias, or both depending on how the survey was conducted. Also the modeling applied, at best, can only make estimates about future occurrences based on the data available now. It cannot take into account unforeseeable game changers (eg – Affordable Care Act) that may significantly alter the practice of medicine compared to the practice today. I’m not saying that we should discount these reports, just that we should be aware of how to critically analyze the conclusions from them.

I do believe that there is a pathologist shortage in terms of misdistribution geographically and subspecialty-wise, but this is a trend that holds true for most medical specialties. We may not have enough pathologists per person (aka a shortage) in this country but we definitely have a surplus in many urban settings where it may be more popular to practice. Certain popular and well-paying subspecialties, like dermatopathology, could have a surplus but don’t because the number of fellowship positions are limited. But other popular subspecialties like hematopathology seem to be saturated in terms of positions near cities that are popular to live in from my anecdotal experience.

And even though an impending shortage is always the battle cry to increase the number of residency spots, our community is polarized on this issue. Some residents and pathologists I’ve spoken with feel that we should, like other specialties have done in the past, limit the number of residency positions we have. Without more data, I can’t really say which side of the argument I agree with but I do acknowledge that we are at a crossroads. The decisions we make now about how we train our residents and what roles pathologists should fill (eg – molecular diagnostics) will affect our future, patients’ futures, and our profession’s future.

But regardless, the problem does remain that the job market currently seems tight and that pathologists have had to perform more work than they have had to in the past. So, what is your take on the situation and your suggestions for a possible solution? And how can we incentivize to address misdistribution of pathologists to address a shortage in more underserved areas?

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Confirmed Case of Ebola Diagnosed in the United States

CNN is reporting that a patient in Dallas, Texas is the first person diagnosed with Ebola Virus in the United States.

According to the CDC, the patient traveled to the United States from Liberia on 9/19-9/20. The patient exhibited symptoms on 9/24, sought care on 9/26, and was admitted to the hospital on 9/28. Today, the CDC received and tested samples from the patient and confirmed the presence of the Ebola Virus by PCR methodologies.

The CDC and the Dallas County Health and Human Services will conduct contact interviews to determine if the patient may have had contact with anyone while infectious. If any contacts are identified, they will be quarantined and monitored for 21 days (the longest known incubation period for the virus).

CDC director Tom Frieden, MD, MPH says, “I have no doubt in my mind that we will stop it here.”

Be that as it may, it doesn’t hurt to be prepared. Lab professionals and pathologists should be familiar with the CDC’s Ebola information page.

Making Solutions

It often seems to me that the art (or science) of making solutions is becoming a lost one. In this current day and age when most of our solutions come in a pre-made form and only require mixing, or at most, thawing and mixing, I believe we’re losing the ability to make solutions ourselves.

This thought came to me when I overheard a comment in a hallway about a shortage of physiological saline. It was back-ordered and we’d be in dire straits soon if we didn’t get any in. And I wondered: if we have solid sodium chloride in the laboratory and we have water, how can we have a shortage of physiological saline? And physiological saline is incredibly easy because you don’t even need to know the molecular weight of sodium chloride. If you want 0.9% physiological saline, that 0.9 grams of NaCl in 100 ml of water.

The same is true for any other easily made-up solution. We’re so used to having them pre-made for us, that we’re forgetting everything we learned in school about how to make solutions. Of course, being able to make solutions from scratch does presuppose that the lab still has chemicals, a balance and a pure water source. My lab does, but that’s because we run a lot of laboratory developed tests (LDT). Most laboratories may no longer keep chemicals, and even if they do, using a home-made reagent turns your assay into a LDT. Plus so many pre-made reagents have proprietary formulas that making them up from scratch is not possible. But for simple reagents like physiological saline, that perhaps is being used to perform dilutions or wash cells, I find it kind of sad that we rely on “store bought” reagents so much that we never consider making them ourselves. In that respect, I guess I’m something of a lab dinosaur.

Don’t get me wrong. I’m totally in favor of making our lab lives as easy as possible and pre-made solutions are one of the wonderful things that do that for us. In addition, if you buy pre-made reagents, you remove one variable that can affect results – was the reagent made up correctly, using the correct chemicals. On the other hand, I believe it’s also a good idea to know how to make up a solution if you should need to do so.

It’s a little comforting to know that this loss of ability may not be confined to the lab. I heard a pharmacist talk about a shortage of total parenteral nutrition (TPN) solution, which I suspect at one time every pharmacist knew how to make up from scratch.

Resident Concerns, Part 3: Networking Opportunities

Just as an addendum to my previous post about fellowship applications, my suggestion would be to have everything ready to send by July 1^st or earlier, if possible. I’ve found that some programs started accepting applications on July 1^st. And this includes asking for letters of recommendation as early as possible so that they are ready by then as well or you may find yourself, like I have, in the bottleneck with programs emailing weekly that all they need are your letters because they have started reviewing and/or interviewing already and won’t look at your materials until its complete with letters of rec. I submitted most of my applications (minus letters of rec which still have to come) by September 9 and one of the programs had already filled for both hematopathology and molecular pathology. I would guess with an internal candidate or an early interview candidate because their website didn’t list yet that the position was filled. Some of the programs for molecular genetic pathology, in particular, have early deadlines of September 1^st, so make sure you know the deadlines and have your materials ready to go way in advance.

Now on to this week’s topic: networking. Throughout our journey to and during medical school, it was often hard work and studying that got us to where we needed to be. Yes, there were the “legacy” students who got into colleges and medical school based on who their parents or families were but those are not the students that I speak of. I speak of those like myself who form the majority and who didn’t have those types of connections. But in the workplace, if we take the group of “legacies” out, we still have to deal with the power of connections but at a more palpable and potent level than previously encountered. On multiple workplace surveys, the #1 manner through which people (and pathology trainees) obtained jobs is through “word of mouth” and referrals. Having someone make a call on your behalf can be a powerful factor in helping you to obtain that fellowship or job.

With respect to fellowships or jobs, the market is tighter. There are far fewer positions available. So how do you set yourself apart from the crowd of others with similar or even, slightly better, credentials than yourself? Connections can greatly help so start early. Local and national conferences are great places to meet other residents but more importantly, other pathologists in your intended field. Make yourself business cards and give them out like there’s no tomorrow. If you impress someone, they most likely will keep your business card and remember to get in contact with you when a position opens up that you’re a great fit for. At annual meetings, there often are networking receptions for residents to meet practicing pathologists. Also at these venues, job seekers get the word out that they are available and have access to job boards. This also holds true for attending your state society or other local subspecialty meetings.

Another way to meet and make connections is through getting involved with organized medicine and advocacy organizations. ASCP, CAP, USCAP, and subspecialty organizations (like AMP for molecular pathology) often have junior positions on their committees and councils for a resident. Find one in an area of pathology that you have an interest in and apply. Many also have travel awards to their annual meetings or grants for research also set aside for residents. I’ve found that many of the people who volunteer in national leadership positions in these organizations frequently overlap so once you start meeting people, you will see them at other meetings, and it makes it easier to meet more people. So if you are able to obtain a junior member/resident position, work hard. People recognize and value hard work and enthusiasm and it’s a way to make a great impression doing work that you are passionate about. And if you apply and are not chosen, then don’t give up. These positions have many more people applying for them than positions that are available. But persistence is a virtue and when TPTB (“the powers that be”) see your name on a subsequent application, they might be impressed that you applied again.

Some of these positions are advertised and others are through referrals. As a resident, I never found it that easy to find when many of these positions have an opening so I’ll try my best to advertise through this blog when those times arise. But you can get involved early and at a more junior level first by being a representative for your program to ASCP (contact angela.papaleo@ascp.org) or a delegate to the CAP Residents Forum (contact Jan Glas at jglas@cap.org). I know that at some programs, this is through election, but even if you are not elected, you can still attend the CAP Residents Forum (you just won’t be your program’s voting delegate) and still ask to get the ASCP e-newsletter (where they advertise when new resident volunteer positions are open).

If you can decide early what you want to do when you are a pathologist (subspecialty-wise, etc), then the easier it will be for you to get involved with your specific pathology community in leadership/volunteer positions early. You can even participate in other activities such as blogging, creating podcasts, and writing for these organizations. You’ll be surprised that you meet people through these venues as well. You can write about a pathology topic of interest for CAP NewsPath which is then converted into a podcast. I blog for ASCP’s Lab Medicine Lablogatory as you all know, but we are always looking for resident bloggers. If you can’t commit to writing weekly, then contact me (chungbm@rwjms.rutgers.edu) and I’ll happily have you do a guest blog here one week! For those of you attending the upcoming ASCP Annual Meeting in Tampa, I’ll be looking for bloggers to write on their experiences at the meeting so just shoot me an email or find me at the meeting (I’ll be one of the poster judges). Check out the websites of organizations you are interested in to see how you can get involved – it does take some effort on your part but you won’t be disappointed! For positions that work through referrals (where I didn’t have one), I was still able to apply because I identified the person in charge (internet searches are your friend), contacted them, and asked. So, it never hurts to be proactive.

And in my attempt to keep you all informed of opportunities, for those of you who want to do an external/away elective or international/global elective and need financial support, the application period is now open for round 2 of ASCP’s subspecialty grants. You can find more info at the ASCP website but you need to apply by Jan 16^th!

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

Steady the Ship

The relationships you have as a supervisor with the people you lead (notice I did not say “manage”) are important when it comes to day to day operations. They become especially important is when you have to guide them through change or conflict. I won’t even comment on the appropriateness of intimate relationships except to say if you engage in one then you are taking your career into your own hands and don’t plan on it lasting long. Beyond that, the lines are blurred and you may be engaging in an inappropriate relationship that won’t get you in trouble with management but will with the people you lead.

I am 31 years old and the majority of the people I lead are double my age so I have a unique (but becoming a bit more common) relationship with them. With many reaching retirement age in the near future the younger generation is taking the responsibility of leading and it creates unique issues. Do I sometimes feel awkward discussing a behavioral incident with someone who could be my grandmother? Absolutely, but my approach is what makes it a successful or unsuccessful discussion. I have learned that a “by the book” or “letter of the law” approach is not always successful. This is where emotional intelligence comes into play. As a leader you need to identify the needs of the people you lead, both as a group and individuals. It is very important to distinguish between the two because the needs of the group may be vastly different than as individuals. Once you do this it is easier to lead them because you know what they need to be successful and what you need to avoid, staving off failures. If you can successfully identify the needs of the group and individuals you can have relationships that grow and the people you lead will have confidence in you to lead them.

One issue that gets supervisor/managers into trouble is favoritism. It doesn’t even have to be true; perception in any workplace is often seen as fact. If one employee thinks that you favor another employee over them you will instantly lose their respect (not to mention a certain amount of work ethic). This can be especially difficult if you have worked with a group for an amount of time as coworkers and then you are promoted to supervisor. You will already have developed relationships and more than likely friendships with them so some of the perceptions may start with the start of your new role. If this is the case it may be a good idea to have a discussion with the group once the new role is assumed.

I have had the experience of taking over for someone that had their responsibilities taken away so I had some hard feelings to deal with when I took over. It was very difficult but I learned that if I took it day by day and worked with each individual they eventually came around and understood I was only there to help. There are all different kinds of situations that pop up as we lead our teams. We fight fires and make sure we don’t take on too much water that we cannot float. If you do not address these issues when they present themselves you may wait too long and not be able to steady the ship.

–Matthew Herasuta, MBA, MLS(ASCP)CM is a medical laboratory scientist who works as a generalist and serves as the Blood Bank and General Supervisor for the regional Euclid Hospital in Cleveland, OH.