Lablogatory

Hacking Pathology Residency Training

As we celebrate the Christmas season and gear up for 2014, I’ve been thinking about resolutions and things in my life that warrant change. And since I was able to go home this year for Christmas break, I’ve had some time to do something that I enjoy but haven’t been able to do in a while – watch TED videos. I recently watched this one given by a 13-year old about hackschooling at TedxUniversity of Nevada. Makes me wish I had done some when I was younger (my first aspiration was to be an artist) but of course, I was raised in a traditional Asian household that revered education and practicality (“you can do drawing as a hobby but you should be a doctor”). Don’t get me wrong, I do not blame my parents and now at this point in my life, it is my choices that will determine my future and happiness.

And so I’ve been thinking about my education, both personally and professionally. In terms of nurturing my creative side, I realize that I need to set aside some “me time” where I engage in my previous interests (though probably not during PGY-2). And for my social justice/service side, I know that I will eventually return to my community activities when I can consistently have time to give, although I still watch from the sidelines and contribute when I can. But in terms of my chosen profession, I often wonder if there is a way to “hack” our residency training to make it both more creative and effective and to be proactive rather than reactive?

Tying together some themes I have previously blogged about (competency evaluation and transforming our profession), I’d like to address some issues I see. Pathologists need to be more engaged, both within the system and within society or be left behind. With healthcare reform, gone will be the days when a physician can continue to practice the way s/he was trained – there will be a constant drive for life-long learning, both in terms of knowledge and utilization of new technologies, especially disruptive or exponential ones, than is present currently. I’m not going to argue for or against the finer points of the ACA or the recent cuts in pathology codes in the new physician fee schedule except to say that the landscape we residents will inherit will be vastly different than the one our attendings, or even we, now currently train.

But competency needs to be more than a checklist. We need to learn how to navigate and show our worth within the value-based systems where we will most likely work. First, of course, we need to learn our material well. We cannot interpret data, educate non-pathologists, or advocate for specific decisions if this foundation is lacking. But how do we residents take ownership and accomplish this in addition to the training we may or may not receive in our residencies? And how do we learn to be a patient advocate rather than just a reporter of results?

I will leave you these questions to ponder until my next blog where I will elaborate on some of my observations and ideas on this topic. For those of you who attended Eric Topol’s keynote at CAP ’13, I will leave you with similar talk by Dr. Daniel Kraft given at TedxMaastrict about 2.5 years earlier – http://www.ted.com/playlists/23/the_future_of_medicine.html– and hopefully, it’ll spark some ideas.

I hope everyone has a prosperous year in 2014!

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

Happy New Year—Making 2014 a Year to Remember

If you are one who likes to make a resolution for the New Year, let’s have a look at the word “resolve”:

re·solve:

verb: settle or find a solution to (a problem, dispute, or conflict); to sort out, solve, deal with, rectify; to decide firmly on a course of action; determine, decide, make up one’s mind, make a decision
noun: resolve, resolution; determination to do something, strength or decisive commitment

Or, another way to define it might be, “re – solve”. Laboratory professionals are trained and skilled at solving problems, particularly analytical ones; why not “resolve” to “re – solve” something? Perhaps this is your year to make a commitment to giving back to your profession, your faith, your future. Consider volunteering, either at your laboratory, your hospital or clinic, your community, or perhaps even globally. There is no end to the list of opportunities for service, using skills and training to add value to improving health. If you want some ideas, just contact me at bsumwalt@pacbell.net and I’d be very happy to explore the idea with you!

This is one of my favorite quotes—let’s make 2014 a Year to Remember!

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” ~Anne Frank

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

Dangerous Beauty

Potentially deadly pathogens have never looked so good. A false-color electron-microscope slideshow on Discover depicts organisms such as Campylobacter and Streptococcus pyogenes in a whole new light. Apparently actresses and models aren’t the only ones who benefit from Photoshop.

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

Season’s Greetings—International Style

In this season of extending kindnesses and gifts and sharing the blessings of family and friends, I am reminded of something I have heard many times; World peace isn’t achieved in government board rooms or international caucuses…it is achieved quietly in each other’s homes, around the table, one-one-one, face to face. I believe that is true; and some of the most lasting impressions I have of the world and the world’s people have been gifted to me in conversation, at the table, exchanging ideas, thoughts and building relationships and forging ways ahead to make health and care better globally. This is the essence of change and the heart and soul of peace and prosperity. May this season bring peace and joy, no matter where you live or what faith you follow, and may we all strive to sing the melody and the harmony together whenever we can.

Happy Holidays!

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

Harmonization

What does “harmony” mean to you? And how does it apply to lab testing?

One of the biggest problems that arise where lab testing is concerned is that tests run in two different labs will give you two different results unless the labs happen to be using the same equipment (and sometimes even then the results won’t match!) This is a huge problem for doctors of patients who use different laboratories for their testing or patients who move across the country and need to continue following lab test results. A prime example of this dilemma is the current state of T4 testing. The same CAP sample when analyzed using different assay methods for thyroid stimulating hormone (TSH) can yield results which range anywhere from 2.66 to 8.84 mIU/L. Although CAP samples are not always commutable with patient samples, thyroid testing on patients shows this same lack of harmony.

This example underscores the need for harmonization. In our increasingly small world, where nearly everyone will soon be using the electronic medical record, and all lab results on a patient will be in one place whether they were all performed at the same place or not, it will be paramount that the lab results for any given test can be compared. Efforts to date have successfully harmonized several important analytes, including creatinine (IDMS-creatinine), cholesterol and hemoglobin A1c. Efforts are on-going to harmonize vitamin D assays against the NIST standards. These harmonization efforts took a massive amount of coordination and work between the in vitro diagnostic industry, regulatory agencies and laboratory and clinical societies.

Laboratory professionals have long recognized this problem, and sought to inform non-laboratorians of the realities at every opportunity. Lack of comparable test results can lead to patient safety issues, including misdiagnoses and/or inappropriate treatment. Recently an international consortium has recognized the need for harmonization of all lab results and begun to work on the problem. Although this effort is just beginning and the road ahead is long until general test harmonization can occur, it is a road worth traveling.

-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.

Happy Holidays from Lab Medicine

It’s going to be a little quiet here over the next few weeks while our team of mad scientist writers enjoy time with their families. We’ll be back in action after the New Year with lots of great information for you. In the meantime, the editors of Lab Medicine would like to wish you and yours a happy and safe holiday season.

Preanalytical Errors

The Center for Phlebotomy Education recently produced a video depicting the medical nightmares that can result from improperly trained or managed phlebotomy staff. You can watch the video here.

Pathologist and Pathologist-in-Training Engagement as Patient Advocates

I’m used to being surrounded by people who are passionate about transforming systems. I’ve spent many years involved in organizing grassroots movements, health advocacy, and health equity campaigns in the minority and immigrant communities. And the year before I started residency, I studied for a masters degree in public health where I focused on these same issues, along with more scientific training in molecular and infectious disease epidemiology. But as a resident, I have had to make some tough choices.

Even though I am back in Chicago where I attended college and first got involved working with minority and immigrant health issues, my community organizing, for now, will take a back seat to my education and service duties. And even though I sometimes reminisce about and miss the electrifying momentum involved in pushing toward such social change, I know that once I’m finished my training that I can return to contributing to these movements again on a more personal level. So I’m fine with the decisions I’ve had to make. We all have to make choices about what is most important at that specific time in our lives.

And so as a resident, I’ve focused my thoughts and efforts on how to create a movement within pathology to question our role on the clinical patient care team and to engage those in our profession to respond to this question – reasons why I got more involved with ASCP and CAP. With the gradual implementation of portions of the ACA since 2008 that is now moving into a more palpable phase, pathologists, tech staff, and residents have an opportunity to show our worth to the health care team. We have the opportunity to show that we are the experts in data interpretation and that in terms of more complicated testing such as flow cytometry, cytogenetics, or molecular tests, that the pathologist would be the best person to order the most appropriate tests.

No one knows better that we do what are the costs, indications, and limits of specific tests and despite what non-pathologists may think, we were trained just as they were in how to work up a patient and differential diagnosis. So who better to choose the right test for the right patient at the right time? I know that pathologists have the reputation of being not the most vocal or interactive doctors so how do we engage not just our leaders but also pathologists in general to take more ownership of patient care decisions and to speak up? How do we train our next generation to also see this as the big picture?

In grassroots organizing, strategy requires an understanding of the power dynamics and forces involved in decision making within the system one wants to change. So what drives pathologists and pathologists-in-training and how do we light a fire within our profession not to waste this opportunity that has been provided by health care reform to redefine our role within the patient care team? How do we nurture true patient advocates? I’ve been a little frustrated with these thoughts lately so please leave a comment with suggestions on how you think that we can accomplish these goals.

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

Passport Nostalgia—Looking Back

One of my life mottos is, “Never let your passport expire.”I just renewed mine and when they sent back the old one, punched full of holes, it was interesting see all the passport stamps and colorful visa stickers, and reflect on places I’ve been in the past ten years. I enjoyed revisiting a variety of unexpected journeys and the opportunity to relive some very special travel memories.

The pages are home to circles, squares, and odd shaped stamps in a variety of inks. I find hurried and smeared signatures, kanji graphicsand Aramaic scripts, and a variety of illegible initials; there is a whole page devoted to the amount of US dollars and Ugandan currency I was required to pay for an “on foot” border entry; there are colorful images and seals; the back has a host of barely legible security stickers in a rainbow of colors; there is even a page announcing an “amendment” to add more page. Ten years of travel history bound in a single, 3.5 x 5 inch dark blue booklet, and it speaks about the world in a subtle stillness from the corner of my desk.

As I flip through the pages, I’m reminded that this little booklet has been with me for all my laboratory consulting journeys, and occasionally has had a mind of its own. The Johannesburg airport incident for one; and next time I’ll tell you about passports and horses. I don’t have a stamp in there for this little side trip in the mountains outside Bishkek, Kyrgystan, but I’m thinking I should have—you can be the judge.Take a moment and thumb through your passport. I promise it will jog travel memories, and perhaps invite you to take another international journey soon. The world is indeed a small place, and I intend to fill as many pages as possible in the next ten years!

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

Inborn Errors of Metabolism in Adults

In general when people think of a genetic defect or an inborn error of metabolism (IEM), they think in terms of disorders that are diagnosed and treated in infancy or early childhood. Interestingly, the more we learn about IEM, the more we see that IEM can be diagnosed at nearly any age. Milder forms of the disorders may present in later years, anywhere from adolescence through adulthood.

Classical presentations of IEM are generally due to total or near total enzyme deficiencies that result in life-threatening medical crises, or major developmental delay and mental retardation. Adults or near adults who present with a range of milder symptoms may be misdiagnosed or nor diagnosed at all.

A few examples of IEM that may have later and milder presentations include:

1) Ornithine transcarbamylase (OTC ) deficiency, the most common urea cycle defect which is often fatal in newborn male infants, can and does present in the teenage years as altered mental status, when a protein load cannot be handled and ammonia levels rise and impact brain function.

2) Carnitine palmitoyltransferase 2 (CPT2) deficiency, a disorder of fatty acid metabolism, presents with cardiomyopathy and liver failure in the newborn period. It can also present with muscle weakness, myopathy and rhabdomyolysis in the teenage or young adult years when the teenager tries out for a sports team and the muscle cannot metabolize adequate fats.

3) 3-methylcrotonyl-CoA carboxylase (3MCC) deficiency, a disorder of leucine metabolism, may present in infants or toddlers as feeding difficulties, neurological symptoms including seizures, and can cause death. 3MCC can also present in a completely asymptomatic mother whose infant is picked up on newborn screening because of the Mom’s abnormal metabolites in the infant’s blood.

In most of these cases the deficiency is mild enough that the individual is self-regulating, avoiding foods or activities that make them feel bad. In addition, the IEM may not manifest unless some other confounding factor precipitates it, such as stress, illness, or fasting. The important thing to remember though, is that altered mental status in a teenager does not always represent alcohol, drug or other mood altering substances. IEM can be diagnosed at any age and should always be considered as part of the differential diagnosis.