Lablogatory

Tighten the Belt

It seems like healthcare is in a never ending cycle to cut cost and “see what you can do without…for now.” That “for now” statement usually turns into forever and it begs the question as a supervisor/manager, “Should I really tell them what I can do without for fear of losing it forever?” What seems to always happen is goals become increased and the resources needed to attain those goals become decreased.

Here is where my MBA kicks in and says, “Wait, tightening the belt is and always will be a band aid. Shouldn’t we be concentrating on GROWING?” In business, which healthcare most certainly is, we survive only if we keep growing, and I have witnessed how not growing dooms an entity. So why do very smart people concentrate so much on items that make little impact when the real solution is going out and getting new business?

A lot of people are afraid of new, or have a low tolerance for risk. Going out and getting new business is always risky and staying within your walls is safe. It’s easy to tell someone that they can do without something because it’s familiar. It is much more difficult to say “what could we do here that we aren’t already doing?” Growing takes ideas manifested from nothing, cutting just takes a look what is already in front of you.

Another challenge is getting support to fill positions that you have been doing without for long periods of time. On paper it may look like your department is doing a lot with very little. What the paper doesn’t tell you is that your employees are stretched to the extreme because without overtime and part time people working full time hours, you wouldn’t be able to survive.

Looking forward we will be forced to find new technologists that will be able to take our places. This is becoming more difficult as well with more and more technicians graduating and a lack of technologists. I have mentioned this before but the program I graduated from no longer exists and this isn’t rare. It will become vital to partner up with schools to keep pipelines open for future employees and leaders.

Looking forward it is going to take brave leaders to not only take on all of the challenges above but to resist pressures from above to keep cutting. It will be up to you to come up with ideas of new business to keep growing. Go outside your four walls and you will be surprised how much is out there ripe for the taking. Ask any Fortune 500 company or any company that has had an IPO in the last 5 years. Growth is the only way you survive. Summer is on its way and everyone wants to look good. We try to lose weight so we can tighten the belt, but if you ask me, muscle looks better than being skinny.

–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.

Listeria monocytogenes

The FDA is currently reporting an outbreak of Listeria monocytogenes in some Hispanic-style cheeses. While Listeria isn’t listed in the top five pathogens that cause food poisoning, it’s number four on the list of foodborne pathogens that cause death. It also causes meningitis, encephalitis, and septicemia; in pregnant women, it can cross the placenta and cause abortion, stillbirth, or premature birth. Perhaps now would be a good time for a refresher course in this bacterium.

Listeria grows on blood agar; this growth can be enhanced by cold enrichment. Selective enrichment–inhibiting other organisms while bolstering the growth of Listeria–is recommended if the specimen is food or environmental in nature. Other characteristics include:

Short gram-positive rods
motile
Beta-hemolytic
Smooth, light gray, 1-2 mm colonies after 24-48 hours of incubation at 37 degrees C
Will grow at 4 degrees C
facilitative anaerobe
catalase positive
oxidase negative

Listeria can be hard to identify, not because it’s fastidious, but because it can be confused with organisms such as Group B Streptococcus, Erysipelothrix, and corynebacterium. Don’t let that happen to you!

Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.

Viral DNA Testing, Cervical Cancer, and Cytology

An FDA panel recently recommended use of Roche’s Cobas HPV DNA test as the initial screening tool for cervical cancer instead of the ubiquitous Pap smear. The panel found that “A negative HPV result predicted a lower 3-year risk of ≥CIN3 than did a negative cytology result, suggesting that using HPV as the primary test is superior to cytology for cervical cancer screening.The low 3-year CIR for a negative HPV result also confirmed the safety of a 3-year interval for HPV primary screening and officer clinicians more confiedence in a negative HPV result than a negative cytology result.”

While this isn’t a final FDA guideline, it’s conceivable that clinicians could alter their practice based on these findings. Of course, this will affect the cytology and molecular diagnostics departments, as well. What do you think? Is HPV viral testing the way to go? Or should we stick with the test that’s been around for decades?

The Utility of the RISE…Or Not…

So, that time of year is now again upon us…the Resident In-Service Exam, aka the RISE. Even though this test is meant to assess our knowledge of what we’ve learned thus far, the competitive natures that have brought to this point in our careers push us to do well on it. We feel an impulse, regardless of whether we act on it or not, to cram some knowledge into our brains at the last minute for a test that we are told we are not supposed to study for. This is quite a paradoxical conundrum.

But just how much does it really test? We are graded on percentiles in comparison to others in our year taking the RISE. But there are those rumors we all have heard, of programs that have remembrance databases or have year-long RISE specific lectures or students taking the test at home unproctored…so how much of our scores are true measures versus our peers if we don’t have access to these things?

Additionally, there is the other question: just how relevant is the RISE? Rinder et al. published the article “Senior RISE Scores Correlate with Outcomes of the American Board of Pathology Certifying Exams” in 2011, but how much of their findings truly are tied to our RISE scores and how much to our inherent study habits and test taking skills? These questions may be even more apropos at this time when there is a stronger recognition that we need to develop curricula to teach true competency and not just the ability to pass standardized tests. So yet again we are confronted with this question of just what does true competency mean and how do obtain it?

For me, the competency that I want to gain means possessing the ability and confidence to practice with very little supervision the day after I finish my studies and get a job. For some, this may be directly after residency and for the majority of us, after fellowship(s). So do you believe that the RISE helps us to pinpoint our weaknesses or really doesn’t help us much on our journey to competency? Does it help predict whether we will pass the AP and/or CP boards or is just a meter of our test taking ability? As a second year resident at a program where we do not, to my knowledge, have any of those aforementioned aids, I’m not so sure that I can answer these questions. All I know is that I’m still not done taking day-long standardized tests.

So, do you feel that the RISE is useful? Why or why not?

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Mobile Technology and Health Care

I just stumbled upon this BBC article about a TED talk from about a year ago that discusses an app called Ucheck that can be used to test urine samples for a variety of elements, including glucose, proteins and nitrites. Instead of having to go to a lab to get these urine tests, an individual can use this app—the purchase of which includes the dipsticks and supplies needed to utilize the app—to run initial urinalysis screening tests.

I imagine the Ucheck folks have thought about and researched the pros and cons and possible issues with a system like this. Process issues, user error, contamination (although supposedly one of the elements in the test helps to gauge contamination), among others come to my mind immediately. My biggest question, however, is what does the Ucheck app-user do next after they receive their results? How does the patient proceed if they do need additional medical attention?

The internet can make mini doctors of all of us—there is enough information to make many self-diagnoses, but not necessarily accurate ones. My doctor recently told me they have stopped giving patients full reports from various tests because they found the patients would go home and Google everything on the report and come back to them scared and with inaccurate information. She said this Google-ing gives everyone access to enough information to be dangerous. Would this app give people just enough information to be dangerous?

The TED talk mentions that the app is being put to the test in a laboratory in India—if effective that certainly could be very useful in terms of providing mobile health care, particularly in remote regions of the world. Use of the app in a controlled medical setting where there are trained laboratory and medical personnel available to interpret results is a different story than an individual using it at home.

The TED talk and related articles I found were from 2013 so I did some sleuthing to see if I could find more recent information. I found an article noting that the FDA sent the Ucheck developers a note that the app needs to meet FDA guidelines in order to be in use. I didn’t find follow-up information on what happened after the FDA note, but I haven’t been able to find the app through my iPhone’s app store. Perhaps it’s been put on hold?

Regardless of whether this particular app moves forward, however, medical advances using mobile technology such as these are certainly on the horizon. Which makes for an interesting conversation. Mobile technology could be revolutionary in some parts of the developing world where access to medical resources is scarce. But do they provide what is needed? Are they being used in a setting where if a diagnosis is made there are resources to treat that diagnosis?

What do you think? Are these positive developments? Could they be helpful and harmful? How will regulation work?

-Marie Levy spent over five years working at American Society for Clinical Pathology in the Global Outreach department.

Live from Kyrgyzstan

Greetings from Bishkek, Kyrgyzstan! And Happy St. Patrick’s Day to those of you with Irish heritage and those who just think they’re a bit’o’Irish on this day! I have been in Bishkek, Kyrgyzstan the past week, joining colleagues to work with the Kyrgyzstan laboratories on preanalytical processes and phlebotomy techniques that are so important in patient safety and specimen integrity. Over the two weeks we are here, we are working with more than sixty people and have a very full agenda. I’m scrambling to refresh my Russian/Kyrgyz greetings and phrases, but oddly enough it’s coming back. I doubt I’ll ever master the Cyrillic alphabet, but the accents are growing more familiar.

We began last week with full-on challenges: agenda changes, delayed supplies and the ‘usual’ need to be flexible and unflappable. Our shipped supplies and materials were delayed in customs for two days, so we were “working without a net.” Our team works well together and we have been well received by our Kyrgyz colleagues so that diminishes difficulties. They are a lively and vocal group, giving us lots of opportunity for dialogue which is always a pleasure. We are finding that their knowledge is strong but their experience and skills with the standard equipment used to collect blood is lacking. Some of them have never seen or used devices we take for granted—evacuated disposable tubes and safe, sterile needles are often not available in rural parts of the country—and some of the statistics shared with us by their national infection control director are staggering. Some of the examples shared: uncapped, reused glass tubes for transport of serum to reference lab testing sites; rubber-stoppered pipettes reused after rinsing in water or alcohol; requisitions rolled up and used as “tube stuffers” that served as caps to specimen bottles; confusion on the difference between serum and plasma; single digit numbers written in wax pencil as the second (an in some cases, first) patient identifier. All are challenges they are facing in rural collection sites for lack of resources and training. Fortunately the groups we are working with are in position to change that, and it is energizing to see how much they really want safety and progress for their healthcare workers and patients. As always, I learn much more than I teach…and this week has been no exception. In between training weeks, we spent Saturday with a high level group facilitating and mentoring a country-wide process improvement project, and helping to identify and outline next steps. Working side by side with our CDC partners was an opportunity to learn and hopefully to contribute to the discussions and strategies ahead. This is where change will happen, and it’s exciting to see it up close and personal.

Next time I hope to share some customer service experiences with you, as we gather stories and experiences from our Kyrgyzstani colleagues about how they address and resolve issues at the point of service to patients. If you’d like me to ask our colleagues any questions while I’m here, email me at bsumwalt@pacbell.net . It’s a different world, but in so many ways it’s the same issues we face in our laboratories back home.

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

Direct To Consumer Testing: Wave of the Future?

Direct to consumer (DTC) testing is one of the fastest growing industries on the internet, and if laboratories are not careful, we’re going to be blind-sided by it. I wanted to know how this works because in general the websites for this testing have nothing whatsoever on them about the lab. I searched for lab information – accreditation, etc – and found nothing. What I found was that most of these sites are essentially online middlemen between the consumer and the labs – allowing access to lab testing and bypassing the doctor. I decided to do an experiment and see just how easy it was.

I went online and found a DTC company and ordered tests. I skipped their specials, “test of the month” was a complete thyroid panel, and settled for their most popular, most ordered test. It is actually a group of tests which includes a CBC with differential and a chemistry panel for a total of 27 tests plus six calculated values (eGFR, HDL/total cholesterol ratio, etc). The complete test cost me $97.00 plus tax. I can tell you that those tests run at my institution would cost well over $2500.00, and even at a big reference lab, the best price I could get was about $425.00.

It was when I placed my order that any mention of a lab came into the process. Before I could place the order, I had to make sure there was a LabCorp near me. I then went back to the website and printed the company’s requisition for the test and took it with me to a LabCorp draw station. They took the requisition, checked it against a photo ID, collected the appropriate blood samples and sent me on my way. Three days later I received an email from the online company that my results were available. I logged on, and it was just that easy. There were all my test results with appropriate reference intervals and flags. If I want my physician to have a copy, I can have them sent or print them and take them with me.

Amazingly, this is incredibly easy to do, although I suppose you would have to know enough to know what tests to order, or be told what to order by your physician. But I now have the ability to order my own tests, and at significantly less cost than the average hospital or reference lab. If doctors begin telling their patients just what tests to get run and then to bring them the results, this DTC testing will put hospital labs out of business, at least out of the outpatient lab business. There’s no way for a hospital lab to compete with this cost structure. Now all you need is a LabCorp interface to your hospital system and the test results go right back into the chart where the doctor ordered them and the hospital lab is totally outside the loop.

Of course, you will also have people just running tests on themselves after doing some online research, but they will still have to hook up with a doctor somewhere to explain abnormal lab results. I’ve already seen some of that – calls or emails from people off the street looking for explanations of results of metabolic testing. DTC is going to open many, many cans of worms, but it’s coming, nonetheless. I suppose there might be a role for the laboratory professional here, to help the consumer understand their lab results when they do them directly. And hospital labs will always be necessary for STAT and critical tests for inpatients. But the world is changing. We need to be ready for it.

-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.

On the Lab Medicine Website

In case you’ve missed it, here is the table of contents for the current issue of Lab Medicine. New articles are uploaded regularly, so be sure to check back often.

Theoretical knowledge helps troubleshoot wonky results, but unfortunately that knowledge is easy to forget if it’s not used every day. If you’ve worked the chemistry bench long enough to have forgotten some of theory behind the analytes, check out this series of articles to refresh your memory.

In the latest edition of our podcast series, Dr. Alex Thurman walks listeners through diagnosing a new acute leukemia in the middle of the night.

USCAP Fueled Thoughts about AP and CP

I recently returned from sunny San Diego where I attended the CAP Residents Forum and USCAP. While at USCAP, I met more than my fair share of pathologists from Canada. After all, the “C” in USCAP stands for Canadian. I was surprised to learn that pathology residency there is 5 years–they still have a clinical “intern-like” year–and their residencies are either AP only or CP (referred to as “general pathology”) only programs.

In the US, most pathology subspecialties belong to one group or the other. The one exception is hematopathology which bridges AP and CP;in some programs is considered as AP and in others as CP. So I asked how they consider hematopathology in Canada. Most of those whom I met were AP trained and told me that in terms of hemepath, they only look at bone marrows (“tissue”). The peripherals and aspirates (“liquids”) are read by hem/onc and not likely to be relinquished to pathology as it is a good source of revenue for them.

When I told them that I was trained to read peripheral blood smears, aspirates, clots, and bone marrows, they told me that was because I was “CP trained” in terms of hemepath. They also told me that when they study hemepath in Canada, (I’m not sure if I misunderstood this part) that they aren’t really trained to diagnose lymphomas well. So they prefer to go to the US to train in hemepath fellowships to get the exposure and tend to hire US-trained hematopathologists. But I was also told that Canadian residencies are transforming and now beginning to incorporate more training in lymphoma diagnosis.

So, this brings me to some thoughts on AP and CP training. I was re-reading my most recent posts and realized that some recent frustrations I’ve experienced on my surgpath rotations accentuated my natural proclivities and bias. So, first, I’d like to say that I do not dislike surgpath. But I do think that the culture and some personalities in surgpath don’t really mesh well with a research-trained physician-scientist me. I often get the comment that I am “too academic” or I’m “more like a scientist than a pathologist” (which I didn’t think was a bad thing for a CP-oriented resident).We all have our biases and there is nothing wrong with that. But I often notice that the needs of the AP portions of our programs sometimes dominate over CP.

At multiple programs I rotated through during medical school and in my current program, if there is no autopsy resident that month, residents on CP rotations are assigned autopsy duty during the week while the surgpath residents cover the weekends and holidays. AP inclined residents and attendings often try to convince me that I never know if I’ll end up practicing surgpath. Even though residents often take vacations during CP rotations or spend most of their time studying for boards and not 100% actively engaging in their CP rotations, most of the time, CP attendings just expect this sort of attitude towards CP.

And so this tension between the two pathologies sometimes befuddles me. A co-resident even asked me if I’d consider doing a little surgpath with hemepath like the general pathologists at our community hospitals do(my answer is “probably not”)or I’ve gotten the “what are you going to do with molecular training?” question as well. This is not because there is anything wrong with surgpath (I know I might rant when I’m frustrated but I think knowing surgpath can only help me with my future career choices). But I wonder why when a first year resident comes in saying they want to do dermpath, they get hooked up to do derm/dermpath research (it’s important to match for dermpath fellowships) and I have people trying to convince me that I should want to do surgpath. Why does it seem harder to accept when a resident says that they want to do a CP subspecialty (maybe with the exception of hemepath)? Have you had experiences where a tension between the AP and CP sides of pathology reared its ugly head?Why do you think this may be so?

–Betty Chung, DO, MPH, MA is a second year resident physician at the University of Illinois Hospital and Health Sciences System in Chicago, IL.

Gut Flora and Chron’s Disease

I’m fascinated by the connection between gut flora and overall health. I just stumbled onto this article that discusses the connection between gut flora and Chron’s Disease. It’s based on this paper published in Cell. Recent articles about antibiotic’s role in obesity and papers on gut flora’s influence on the immune system keep raising the issue: how much do common organisms like E. coli, Clostridium perfringes, and Bacteroides fragilis affect us? How can we use them to diagnose, prevent, or cure disease? I’ll be keeping my eye on future research.

–Kelly Swails, MT(ASCP), is a laboratory professional, recovering microbiologist, and web editor for Lab Medicine.