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!

Blog 10 Celebrating with the Batwa
Celebrating with the Batwa

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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