Lablogatory

What are Important Must-Haves in a Pathology Residency?

So, we’re about 1 month into our interview season for resident candidates for our 2014 PGY-1 cohort. Each year, answering prospective candidates’ questions over lunch forces me to re-evaluate what I was looking for when I was in their shoes and what opinions have changed since then. I’m always surprised at myself that some things that I thought were initially important are not so much now and vice versa. So I always tell the “prospies” (a word we used when I was in college) to try and figure out what is most important “must-haves” for them and at least make sure that the programs they are looking at have those characteristics and resources.

But as I’ve learned, as time passes, some of those things will change…while some will not. For me, coming from a research and public health background, it was important to me that I could do basic science, translational, and molecular epidemiology research during residency….and that I would have these types of opportunities and that my program and faculty would support me in these endeavors. I wasn’t as interested in the “brown stains” or case series type of research as much that I see coming out of virtually every program that also includes my own. Not because there is anything wrong with that type of research either but just that my exposure and interests weren’t along those lines.

One of the interviewees today said something interesting to me. He said that he read on the websites of the programs he is interviewing at how they supported resident research. But that when he specifically asked about it was discouraged and told that residents don’t really have time for research in between their service duties. To me that seemed contradictory to the branding that these programs’ website at least made an attempt to endorse which was interesting but not entirely surprising.

For me, “fit” was a lot more important than a prestigious name and I interviewed at some high-powered programs, too. But I wanted a program that worked with an underserved minority or immigrant population (most of my advocacy work has been with these groups), made changes based on resident feedback to improve their program (I don’t like or thrive in “top down” situations), and supported each resident’s unique needs and goals. I wanted a program that would support and didn’t limit conference attendance and participation in leadership roles, both within the program and within the profession…a program and faculty that would work with me to do those things that would benefit my professional goals and allow me these freedoms even if I was on a surgpath rotation and not try to fit residents into a “one size fits all” mentality. Don’t get me wrong, like all programs, mine has some very real kinks as well. But I think that I’ve found some great and supportive mentors, PD, and chair who allow me to create the non-traditional experience I seek.

So what did or do you are think are “must-haves” for a residency and did those ideas change over time? Leave me a comment if you like.

-Betty Chung

Reference Ranges

According to Wikipedia, reference ranges in health-related fields are generally defined as “the prediction interval between which 95% of values of a reference group fall into, in such a way that 2.5% of the time a sample value will be less than the lower limits of this interval, and 2.5% of the time it will be larger than the upper limit of this interval, whatever the distribution of these values.”

In other words, reference ranges are important! They provide the necessary context for medical analysis and diagnosis. Without a reference range (also sometimes referred to as reference value or reference interval) medical professionals have no comparison group for which to make diagnosis and advise treatment.

In all instances where reference ranges are used, context is key. In sub-Saharan Africa many labs use European established reference ranges which represent a primarily Caucasian population. This is because reference ranges specific to populations in sub-Saharan Africa do not universally exist. This presents a problem as many factors can contribute to what is considered “normal” in different populations. Genetics, dietary patterns, pregnancy, gender, age, ethnic origin, and prior exposure to pathogens all can influence reference range values.

Establishing accurate reference ranges for a given population takes time and an enormous amount of resources. It is often recommended that laboratories establish their own reference ranges based upon the population that they serve. This is cost and resource prohibitive for many laboratories in the developing world. In absence of region specific reference ranges, it is recommended that each lab validate existing ranges using their own population. However, even this can be prohibitive in resource (both physical and human) limited settings.

This can lead to egregious errors in disease diagnosis and treatment. Clement Zeh, Collins Odihiambo and Lisa Mills write that reference range research thus far reveals that African populations differ from their European/Caucasian counterparts with lower hemoglobin, red blood cell counts, hematocrit, mean corpuscular volume, platelet counts, and neutrophil counts and higher monocyte and eosinophil counts (see http://www.intechopen.com/books/blood-cell-an-overview-of-studies-in-hematology/laboratory-reference-intervals-in-africa for their chapter on Laboratory Reference Intervals in Africa).

In addition to diagnosis and treatment of individuals, reference ranges are crucial components in drug and vaccine studies. Historically, clinical trials of drugs and vaccines have relied upon ranges developed in the Western world. This can have significant impact upon the research data resulting in health risks to study participants, poor data, and huge amounts of resources wasted.

Thus, while it is costly and time consuming, reference ranges specific to populations in countries in the developing world need to be established. This would help both the treatment of individuals, and the testing, study and development of important vaccines and drugs.

-Marie Levy

The Post-Antibiotic Era, Part 2

Linking to a few articles by Maryn McKenna because you need to read them.

In this blog post, Ms. McKenna writes about a man from New Zealand who died from a bacteria completely resistant to all antibiotics.

In this article, she imagines the post-antibiotic world. In a nutshell: it’s a scary place.

-Kelly Swails

Rising Cost of Send Out Tests

More and more in this day and age, the laboratory is encouraged to reduce costs and streamline operations by using available resources in the most effective and efficient manner possible. One of the areas of the lab that is increasingly becoming a problem when it comes to cost reduction is the send out area. Since most labs can now perform the vast majority of their testing on automated chemistry and hematology analyzers, tests that must be performed at reference laboratories are increasingly esoteric, manual, and/or molecular diagnostic tests. And those tests are expensive.

As an example, my own lab sent out about 10 chromosomal microarray (CMA) tests in 2008; that number increased to 400 CMA tests in 2011 and is on track to be 865 in 2013. At $1400.00 each, the cost to the lab increased from $14,000 to $1.2 million over that time period. And that’s just one relatively inexpensive molecular diagnostic test. Some of the gene sequencing tests can run between $5000, and $10,000 per test.

Labs are trying a multitude of different schemes in order to try to curb these send out test costs. One method that is fairly effective is to have a “gatekeeper” – a person or persons who review and must approve every test that leaves the lab that costs over a pre-set amount. This particular method is probably one of the best for controlling send out costs, but it requires time and commitment on the part of the gatekeeper, and a willingness to interact with physicians who have ordered the tests that may be less than happy than someone is questioning their order.

Another method used for send out cost control is to include some indication of the cost of the test in the computer system. When the test is ordered, the ordering provider is aware of the exact cost of the test. Some institutions are using a dollar sign system to implement this. For example “$” may mean that a test costs under $50 and “$$$$$” may indicate a test costing over $5000, with other levels in between these two.

A third method is to have a lab “formulary.” Any test found in the formulary can be ordered with no problems. Tests that are not included in the formulary must be approved by the lab before being ordered and sent out.

Whatever method a laboratory uses, it is clear that some means of regulating the rising send out costs is going to be necessary for all labs. Until molecular diagnostic tests become automated and routine, they will continue to be expensive.

-Patti Jones

Succession Planning

You have found yourself as a supervisor/manager ready to take the next step in your career. A position has become open for which you have been waiting and preparing. You get to the interview and then the question you weren’t prepared for comes: “With you stepping into this new role, who amongst your staff will be ready to step into your current role?” Is this possible? With all of your hard work you forgot one of the most important details about you moving on: succession planning. We have all heard it before but it can and will be a limiting factor to your success in your career. Executive management looks for people that can mentor the next in line for when it is your time to claim another rung on the career ladder. A CEO once told me in an interview, “Your moving up in any company is limited by how successful you are in finding and mentoring the people that will follow behind you.”

As a laboratory supervisor I have found one of the toughest issues I face is finding people with the correct credentials that could fill my spot. Bachelors programs in Medical Technology or Clinical Laboratory Science (My degree) are few and far between. I had four students in my graduating class and the university closed the program two years after I graduated. While there is nothing subpar about the associate degree programs, we are bound by regulations that state supervisors and managers have a bachelor’s degree. There are options for people to go back and get the bachelor’s degree and then take the MT test but that adds another level of difficulty (finding people with the desire to take that next step). Identifying the person qualified first, then capable second is the challenge that all supervisor/managers face.

We have to start somewhere so let us start with qualified. This starts with the hiring process. It may be easy to hire candidates with the minimum qualifications to fill that spot you desperately need filled but you must resist that temptation. Look ahead and try to envision where this candidate fits six months or a year down the road. You should always be looking for your next supervisor. If you find yourself hired into a new laboratory you must identify quickly who will be able to take on more responsibility. I would take tasks that you perform and rate them on difficulty and level of problem solving. If an employee shows interest in taking on additional responsibility you give them low level tasks first, then you progress. This allows you to mentor them and let them grow into more responsibility. It also allows you to delegate tasks which can free up more time for you to take on higher level responsibility yourself.

This progressive thinking and working should be happening on a consistent basis. It should be fluid and really start from the top of your organization. If it doesn’t then try to get it started yourself and build up the people beneath you. When it comes time for you to take that next step the person that fills your shoes will be set up for success.

-Matthew Herasuta

It can be hard to find “fun” pathology sites–you know, the ones that talk about pathology in a way that makes it fun to learn. Pathology Student is one. It’s written by Dr. Kristine Krafts, Assistant Professor with the Department of Pathology at the University of Minnesota School of Medicine. She features short case studies and answers to the questions that some pathology students might find confusing. Clinical laboratory scientists will find the content interesting even though this blog isn’t tailored strictly for them.

If you check it out and like it, let her know Lablogatory sent you!

-Kelly Swails

Fellowship Choices…Choices…Choices…

So, I’m almost halfway through my PGY-2 and starting to think more seriously about what fellowship to apply for next year. According to the ASCP 2012 Fellowship and Job Market Survey, 69% of residents surveyed decided on their choice of fellowship during their PGY-3 year while only 18% decided during PGY-2. Coming from a heavy research background, I always knew I would do at least a fellowship in molecular pathology and genetics – and I totally enjoyed and rocked my molecular pathology rotation. So that told me that at least I was thinking in the right direction.

But even though I often thought about pursuing CP only, I could never commit to it for fear of not getting a job once I was done training. It was even suggested to me to change my application to CP only by an interviewer at one of the top CP programs when I interviewed for residency and even then could not fully commit. My PGY-1 RISE scores also would support that I am more CP oriented since I either scored near or greater than the PGY-4 average in most CP subjects.

But now, I’m glad I decided to go AP/CP and to wait on that decision until the end of my PGY-1. It was then and at the start of my PGY-2 that I was assigned 3 consecutive months of hematopathology. And for 2.5 of the 4 weeks of my time at the VA, my attending was on vacation so I got more autonomy and had to meet those expectations or I’d be in serious trouble. Sink or swim time. But it was a good experience and made me think about combining a hematopathology fellowship with the intended molecular pathology. Hematopathology was only peripherally on my radar coming into residency even though I enjoyed the hematopathology I did during my hematology rotation at the NIH during medical school. I actually had entered residency thinking I’d do a second fellowship in clinical microbiology and a portion of my MPH concentrated on infectious disease diagnostics, surveillance, and epidemiology in addition to molecular epidemiology.

But I was fortunate during my hematopathology rotations. Sometimes, it takes the perfect storm of unexpected experiences and mentors to really change your perspective, to see something that was always there but not so obvious…at least, not until you’re ready to see it. I didn’t realize before, even though I had done a month of hematopathology previously, that it paired so well with my interests in molecular pathology. Currently, I’m still mulling over the idea in my mind but only in terms of how some personal aspects of my life will affect my abilities to perform in certain settings. And unfortunately, these things may end up dictating my choices more than I’d like. But for now, I’ve put off the final decision to early 2014 and feel a little more breathing room because my journey has become a little bit clearer.

So, did you have a “light bulb” moment or a special person who helped you decide on a choice of fellowship? Let me know in the comments section.

-Betty Chung

Internationally Thankful

Settling into November, fall is “in the air” and in the United States we all start to think about most everyone’s favorite holiday, Thanksgiving. I’ve been fortunate to have traveled to many places both for work, for volunteering, and for pleasure—and I always come home “thankful” for the people I’ve met.

Relationships with people are what matter most to a consultant. And over many years I’ve enjoyed reinforcing my belief that people are the same everywhere—our differences are so small compared to our similarities. We all laugh, we cry, we share with friends, we want the best for our families, we celebrate life and mourn death, we strive to do meaningful and challenging work that makes a difference, we seek to understand life and have moments of personal reflection when we look in the mirror. The fact that we do it in a myriad of languages, wearing different clothing, eating different foods and honoring different holidays and beliefs, coping with different weather and available resources are all just part of the platform.

A feast in any country, any language, any culture is a celebration, a way to say “welcome—come and share—you are friend and family”. Celebrating our holiday of Thanksgiving, it is very easy for me to say “thanks for what international work gives” to all of us! I’d be happy to share some “feast favorites” with you, just send me an email at bsumwalt@pacbell.net . But the real treat is the smiles!

Celebrating with the Batwa

My good friend Matthew in Namibia

Cheers,
Beverly Sumwalt

Red Tape

I like debates so I’m going to start one and I hope people will comment below and get a dialogue going. How many pieces of paper do you have framed on your wall in the lab from regulatory bodies? If you are a reference lab that serves nationwide customers you may be putting up regulatory wallpaper! I have heard of more and more inspections in regards to laboratories.. My laboratory is inspected by CLIA, CAP, and AABB. With budgetary constraints the importance of the AABB certification has been discussed numerous times. I even feel myself that AABB is becoming more of a consulting company that publishes medically relevant treatment recommendations than an inspection body. I would like to see consolidation between CAP and AABB where the somewhat higher standards of AABB are adopted by CAP and laboratories would not have to pay separate fees for each.

Let’s take it a step further. If CLIA inspections are increasing are there rising tensions between them and CAP? What is making CLIA step up? Do they not trust the job that CAP is doing performing inspections of the laboratories? If CLIA inspections are becoming that difficult what do you as a manager/supervisor put your efforts toward to ensure you will be compliant no matter who inspects you? How does a laboratory go through 3 or more inspections a year and still stay on top of everything else? All these questions must be answered and quickly if you expect to have time to do what is required of you as a manager/supervisor. I don’t think too many laboratorians would care who inspects them, but I do think we would care about having one universal checklist that we can abide by and really dig in to what is important to keep the lab accurate and safe.

How are we expected to grow our business and serve our patients when we are constantly guessing on what checklist to abide by or who is coming to inspect us? We are consolidating in every other sector of healthcare to improve efficiency except in regulatory bodies. Is this just another consequence of big government or do we actually need them all? We should start the discussion and make our voices heard on what we feel we need from regulatory bodies to ensure we are doing our jobs as laboratorians. Are you as frustrated as I am? Or have I inadvertently started my career as a lobbyist for the laboratory field? Comment below.

-Matthew Herasuta

On the Lab Medicine Website

We’ve posted some great features over the last few weeks. A sampling:

-How do NASA scientists test analyzers to see if they’re capable of accurate analysis aboard the International Space Station? This article discusses the process, as does this podcast by the lead author.

-If you’re curious about the effects of brown recluse spider bites, this paper and this video will tell you everything you need to know, including laboratory considerations.

-Middle East Respiratory Syndrome hasn’t reared its ugly head in the States yet, but with international travel it’s just a matter of time before it does. Check out our resource page so you can be prepared.