Girls and Science

Almost 73 percent of laboratory professionals are women, so exposing young girls to science is important. The editors of Lab Medicine recently discovered this post on Scientific American that discusses gender bias in Lego’s minifigs. Series 11 features a woman scientist—complete with little Erlenmeyer flasks—which is definitely a step in the right direction.

Pre-July 1st Reflections

So, July 1st is fast approaching. It is that date each year when new residents officially start their employment. And for us senior residents, even though it may not be as momentous as our first, it still is the start of our next year of rotations and a great time for reflection. As I sit here amidst an apartment full of unpacked and half-packed boxes as I prepare to move cross-country to start my new residency, like many of the PGY-1’s, I’m reflecting on what I’ve learned, what I should’ve learned but haven’t yet, and the journey that is to come at my new residency.

First, I’d like to congratulate all the graduating seniors and fellows! You finally are on to the next phase, whether that means fellowship or employment. Most of you have put the dreaded beast of boards behind you and have reached a milestone that says you are assumed to be ready for practice with less supervision. Gone is the safety net of having your attending verify the cases but you are not completely on your own because you will still have more veteran physicians who can help you. I know that there is a lot of negativity, especially on the internet, about the current job market and decreasing reimbursement codes, but persevere. There are pathologists and advocacy organizations lobbying for our profession. It’s easy to become disillusioned but uncertainty about our future can also be looked at in a ‘glass half-full’ view – we can shape how that future evolves because nothing is set in stone as of yet. In my grassroots organizing experiences, I have seen the underdog aka ‘the little guy’ win but only when they believe that they can bring about change, mobilize and organize together with like-minded individuals, and fight for what they believe is right.

Next, I’d also like to congratulate the incoming PGY-1 again for surviving that beast we call med school. You should be very proud. I know you are probably moving cross-country now and excited about what is to come. There’s a lot to learn but it’s a great time for you. My guess is that most of you will start with an introductory surgical rotation, although I do have some friends who are starting with a CP rotation. Either way, you have probably started your orientation and/or ‘boot camp’ so you can get acquainted with your hospital’s medical record system, dictation system, and pathology basics. Although I know that some of you won’t get a boot camp and will start on rotation immediately after orientation. Don’t despair…every first year in your program with you is in the same boat. And even if some people start off ahead of others on the learning curve, what I’ve seen is that by the end of first year, most people are caught up and at the same place. The thing that may set others apart is more the effort that they put in once residency starts.

So, what is essential during residency, not just for newbies but for all of us? Here’s some surgpath advice that can also apply to other rotations:

  1. Comfortable footwear: I can’t stress this enough, especially on rotations where you may standing for all or most of the day. I personally like Merell’s but I know that Dansko clogs are also popular – these may be expensive and sometimes not the prettiest but oh so worth every penny when your feet are not killing you at the end of the day.
  2. Teamwork: Working long hours with high expectations where your work will impact a patient’s health can be daunting. This element really can make things easier or much harder for you. So, be observant of your peers when they are having a hard time, don’t just point out that they “are getting slammed,” offer to help (eg – gross, take pictures for a conference they need to give soon but are stuck grossing, etc) and hopefully, they will return the favor. Sharing resources with each other is also helpful. Think of the Golden Rule.
  3. Responsibility: Pathology is one of those specialties where our hours can be reasonable and we do not have overnight call or night float. It’s also one where residents can feel as if they can leave the hospital early (especially on CP rotations) and no one will notice. But your attending will notice, especially if you are on call (eg – autopsy) and you’re not there when a task does come up. Make sure that you really take ownership of your assigned tasks. People want to know that you are reliable and keep your word (implied and explicit). And be honest…people don’t like liars who say they completed a task when they haven’t.
  4. 100% commitment: There will always be a task/rotation that we are not thrilled about (eg – performing/writing up autopsies) but remember that for each task, there is a patient attached to it. Even with autopsy, there is the patient’s family. There is always someone waiting for your diagnosis so take that responsibility seriously even though we may not feel the same urgency as those in fields who take care of the patient in person. Don’t cut corners (we all know what this means and have seen residents who do this even while we were in med school). Do things right the first time and you won’t have to repeat and waste resources.
  5. Make a plan and set aside dedicated study time: It helps if you have a (mental) checklist (eg – read one chapter or half of one in Robbins/your book of choice, work on writing that publication, etc) of tasks and a consistent time that you devote to it each week (eg – every Sunday night), otherwise, it’s very easy to get distracted…and behind…and it will just get worse as more time passes until you re-commit to doing this. But if at first you don’t succeed, you can always try again until you perfect your discipline and time management. A few trusted sources that fit your learning style is better than having too many sources. The internet is great for this (but also make sure that the info you get is correct and from a trusted source).
  6. Never stop reading: In addition to studying, you need to keep up on what’s current, whether via hard copy or the internet. This will help you in your daily work and also help develop yourself as a lifelong learner.
  7. Find a good mentor and learn from them: Learn from their experience and knowledge but also develop rapport with them as these are the people who will ‘go to bat’ for you and give you recs when you apply for fellowship or a job. Be a role model and give them good things to say about you through the quality of your work and dedication. And also don’t be afraid to ask for advice or help but be humble.
  8. Get involved: Whether it’s research, the GME council, a pathology advocacy organization, or something else, participate. It will enrich your experience and also help prepare you for when you are in these types of leadership roles as an attending.
  9. Learn to tie in the clinical with the practice of pathology: Make sure you know the clinical history, radiology, and previous pathology on your patient and tie them together. Get the previous slides or lab results for your patient (eg – biopsies) and compare the diagnosis with what you are seeing now. It usually matches up but occasionally you may get a surprise. Understand what’s needed for staging and the implications (eg – surgery, radiation, amputation, etc) of our diagnoses for our patients.
  10. Double check your work and QA yourself: One of my attendings has this method and I find it useful for surgpath – “skim” your slides to get a “feel”, then look at them again more closely and fill out your diagnosis, and finally, QA yourself after you’ve written in the diagnosis to confirm and to check for anything you’ve missed.
  11. Fix well and cut good sections: I have attendings who for cancer specimens will have you prep the specimen but fix overnight (and others who say cut fresh). Believe me, the specimen cuts better if fixed well and if you cut with skill (and a fresh sharp scalpel blade) but not force, especially with friable lesions. If you cut good sections, then you get good slides.

Above all, put the patient first and stay positive!

 

Chung

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

Improving Transparency in Healthcare

In December 2013, Forbes reported a new study that found that “organization transparency” (candid and open communication by management) plays crucial role in maintaining an engaged, motivated work force. The study results were based on analysis of over 40,000 survey responses. Three key findings were:

  1. The top factor when determining employee happiness is transparency of management,
  2. Managers did a solid job outlining employee roles and responsibilities, and
  3. Management did not do a good job outlining the organization’s vision, mission and values to their employees.

The survey respondents also said that they would work harder at work if they could “believe and trust” their management.

Failure to communicate can lead to disastrous consequences in an organization, including disengaged employees, non-congruence of employee interests, and organizational goals that could negatively affect the organization. Carlos Ghosn (CEO of Nissan and Renault) is known as a “Transcultural Leadership” and “Turnaround Specialist.” He has helped turn around three different companies from losses. Under Ghosn leadership, Nissan went from an annual loss of $5.5 billion at early fiscal 2000 to a stunning $2.7 billion profit at the end of the year 2000. Ghosn emphasized transparency across the organization and consensus among management in decision making. He based job promotions on talent and expertise instead of experience and age. He stated that “Once you set the direction for the company, you have to start heading that way. Success is 5 percent strategy and 95 percent execution … motivation of the employees was the greatest tool that led to the Nissan turnaround.”

On the other hand, John Chambers ( CEO of Cisco in Silicon Valley, CA) is known for his “Collaborative Leadership” that states: “There are three characteristics that make a good leader: first is producing results, second is building a quality team, and third is the ability to communicate direction.” Chambers helped grow the company from $70 million when he joined Cisco in January 1991 to $1.2 billion when he assumed the role of CEO to record revenues of $48.6 billion in FY13. Cisco has encouraged all employees to participate in the organization’s product development through blogs, YouTube, and videos that promote upward communication, feedback, and shared values as well as tying the executive bonuses to cross-functional team accomplishments.

Could the healthcare industry adopt the organizational successes in other industries? The New England Journal of Medicine published healthcare organization transparency successes by the adoption of disclosure, apology, and offer (DA&O) programs among healthcare organizations. In taking a principled approach to addressing medical errors, organizations instituting these programs commit to fully investigating adverse events and implementing interventions to prevent their recurrence. The organizations also openly admit their errors to patients (and make offers of compensation, when appropriate), letting the chips fall where they may when it comes to reputation and liability. Contrary to many predictions that DA&O programs could result in the proliferation of legal claims and costs, data from two pioneering programs have revealed improved liability outcomes, including a 60 percent decrease in legal and compensation costs in one program. University of Utah has started posting its Press Ganey patient satisfaction results online. Their physicians’ ratings have been boosted almost 10 times in less than a few years.

A clear and consistent sense of purpose when handling employee issues, such as removing or correcting employee behavior inconsistent to organization goal and objectives, would help shape a collaborative environment. Increasing transparency at the workplace could help healthcare organizations nurture a collaborative work environment, shared values and mutual engagement, which are all important key concepts in obtaining high commitment and motivation among all employees.

Reference:
Kachalia, A. M.D., J.D (2013). Improving Patient Safety through Transparency, N Engl J Med 2013; 369:1677-1679, October 31.

 

Information on policies or practices are solely from my personal experience ONLY and have NO relation to my affiliation with any regulatory or government agency.

satyadi

-Caroline Satyadi, MT(ASCP), SM, DLM, SLS, MBA, MS, CQA (ASQ) has been a laboratory management professional for over 25 years. She has worked with several different medical industries for CLIA/CMS, FDA/ICH/ISO, TJC/CAP/COLA/HFAP accreditation survey readiness.

Improving Staff Morale in Healthcare Organizations

In 2009, Healthcare Finance News reported that twenty percent of more than 350 healthcare employers reported low morale among employees. Meanwhile, thirty-eight percent of healthcare workers cited lack of motivation and nearly twenty-five percent reported no loyalty to their employers! Nearly fifty percent of healthcare workers surveyed cite increased stress on the job, and fifty percent noted an increase in their workload in the last six months. Most would agree that these numbers will not go down in the next coming years but will go up.

Staff morale can make or break any organization. When employee morale is low, decreased productivity or little collaboration to support organization goals and objectives can result. Unfortunately, there is no magical formula in boosting employees’ morale. The challenge in improving employee morale is complex as it involves the organization’s culture and environment. Healthcare organizations should “prepare and support” their employees appropriately in this healthcare challenging time. As more new technology applications are introduced in healthcare , employees are faced with more complex accountability. It is crucial for healthcare organizations to reassess each employee’s “task alignment” whenever introducing new technology into the work environment.

Task alignment is an approach to employee behavioral change that starts with the identification of key issues in the work units within the organization and asks employees to realign their roles, responsibilities and relationship to perform necessary tasks. Training encourages dialogue and feedback among employees. This feedback should focus on what needs to be improved from both the employee and the management perspectives.

According to Harvard Business Review (April 2014) in its article “Stop Trying to Control Employees or Make Them Happy,” the traditional management “hard” approach started in the 80s; however, this approach is not effective in the 21st century when dealing with digital communications and managing the “X” and “Y” generations. Management should try the “soft” approach by understanding and clarifying what employees do through dialogue and feedback loops; reassessing task alignment; increasing employee power; improving organization transparency; increasing employee reciprocity; and improving the working environment. That would in turn increase employee accountability. Give frontline employees more autonomy to do their job—for instance, by empowering them to make critical judgments and encouraging them to cooperate with each other. When there are dialogues and shared purposes among employees, challenging situations become less complex and employees can work collaborate together to create mutual engagement.

Scheduling regular “social events”, such as monthly /quarterly birthdays, ice-cream social or holiday potlucks can boost morale. Through social events, employees can strengthen their working relationship. Congruence between organizational values and individual values should be nurtured to create an organizational culture comprised of employees who have the desired traits in supporting the success of the organization. Increasing feelings of ownership among employees will boost employee morale and productivity.

Some healthcare organizations have focused on employee perks to increase morale and productivity. One company in Phoenix, Arizona built shower rooms to encourage its employees to bike to work and exercise; large healthcare organizations in California implement walking meetings across the organization and built walking tracks inside the building. Many managers find that walking meetings have strengthened relationships with their team members. However, not all meetings should have this type of structure. It is not the time for employee discipline or other formal business operations requiring lots of documents for the meeting.

At this time, Google, Inc. is probably at the top of all organizations to provide perks for its employees to boost their morale, productivity, loyalty and creativity; these include free meals, onsite day-care, fitness room, game room, free shuttle to and from work, etc. Not many organizations can compete with Google, Inc. for the employee perks and morale boosters; however, investing in flexible work schedules, organized work environment, day care program, comfortable break rooms, game room, family fun nights, discount programs, social clubs, and other amenities would be worthy investments for boosting employee morale.

 

Information on policies or practices are solely from my personal experience ONLY and have NO relation to my affiliation with any regulatory or government agency.

satyadi

-Caroline Satyadi, MT(ASCP), SM, DLM, SLS, MBA, MS, CQA (ASQ) has been a laboratory management professional for over 25 years. She has worked with several different medical industries for CLIA/CMS, FDA/ICH/ISO, TJC/CAP/COLA/HFAP accreditation survey readiness.

Root Cause Analysis

Root Cause Analysis (RCA) is a problem-solving tool that is most frequently used to determine the basic underlying factor(s) responsible for an event (ie, its root cause). This analysis is then used to determine the best method of preventing that event from occurring again.

A multitude of different RCA methods are available, but most of them have some basic principles in common. An RCA involves a systematic, data-driven, well-documented investigation into an event. It is a reactive method used to identify the steps in a system or process that are prone to failure, to determine the one or ones that failed and caused the event under investigation, and to determine how to prevent the failure from recurring. The RCA will also determine how many other factors were affected by the event under investigation.

The first step in an RCA is to clearly and factually describe the event or problem. Often the initial description of the problem will involve a timeline description of the proper process, the way the system SHOULD work, and then define the point or points at which the event under investigation differed from the proper course of events. Thus most RCA include a timeline, qualitative and quantitative data depicting the proper process and the failure steps, and thorough documentation of each step. Data is collected wherever necessary in order to be making decisions from data rather than from assumptions of how the system works. Once the root cause or causes of a problem have been clearly determined, an RCA again uses data to identify corrective actions to remedy anything that is wrong due to problem, as well as corrective actions to prevent the same problem from occurring in the future

Let’s pretend that patient test results were reported with the incorrect reference interval. In order to determine why this happened, we start by making a timeline depicting each step in the normal process. In our example, this means reviewing all the procedures in place for setting, maintaining, and changing reference intervals. Then, step by step, it can be determined where the process failed in this specific case, as well as other steps that might be prone to failure. Corrective actions to amend any incorrect patient results and notify caregivers would begin immediately, with thorough documentation. Once the root cause of the process failure is clearly identified and the step or steps that failed have been determined, additional corrective actions would be taken to remedy the necessary steps in the process so that this error cannot recur. Occasionally an RCA will lead to instituting an entirely new process in order to prevent problem recurrence. It’s important to note that everything associated with the RCA is fully documented.

Identifying and implementing solutions is probably the most important part of an RCA, yet it cannot occur effectively if the actual bottom-line cause of the problem has not been correctly identified in the first part of the process. If the root cause has not been correctly identified, the solutions become only a temporary patch on the problem, and the problem it will occur again. RCA generally involve time and work to do properly, and yet can be incredibly useful in preventing a recurrence. In a hospital or laboratory environment where potential patient harm can occur when a mistake it made, the RCA is often an important part of operating a healthcare system.

 

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-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.

Advice for the Incoming PGY-1 Residents

As I am repeating the motions of yesteryear when I was moving from NJ to Chicago to start my residency, except this time in reverse to return to NJ to complete the final two years of my residency, I’m reminded that it’s always good to ask for advice from those who have blazed the trail before me. And so I’d like to start with a hearty CONGRATULATIONS to the incoming pathology PGY-1 residents! This is truly a time of excitement and maybe a little apprehension of the new and unknown for you. So, I thought that I’d devote this week’s blog to pearls of wisdom I’ve picked up along the way. Fellow residents, please pipe in if you also have some advice for our incoming residents.

  1. Enjoy your time before residency (and in some of cases, June orientation a la boot camp style) starts. Take that vacation backpacking through Europe that you always dreamed of…or volunteer overseas if you’re so inclined. Whatever you do, take some “me time” now. I know it’s easy to think that you might need to read up on your pathology but there’s time for that later. Once you start working (residency, fellowship, job), even if you are promised 4 weeks, it might be difficult to schedule that time off due to grossing schedules, your colleagues’ vacation requests, and so on. So decompress from the past 4 years of medical school and enjoy what’s left of your summer.
  2. Hopefully, you already have done this but look for your housing way in advance, especially if you are out-of-state from where you will be a resident. Apartment websites and Craigslist are good but be careful of scams especially if they ask you send in a deposit ahead of time without seeing the place. If something sounds too good to be true, it probably is. I strongly suggest going in-person or having a trusted friend or family member check out places for you if you can’t. A great piece of advice that was given to me was to use a realtor (or more than one) who can line up places and show you around. They are usually a good source of information about where is best to live and what are reasonable prices…and you can ask them to only show you places where the landlord pays the commission. It saves time to have someone organize the appointments according to your specifications (pets, within X distance to the hospital, safety, covered utilities, parking, amenities, etc) so that you only need to show up and view the places you like and decrease the number of apartment hunting trips/calls you make. You can even search for places you like off the realtors’ website just like you’d do on Craigslist, Trulia, or Zillow especially if you want to rent or buy a condo unit. Sometimes you may need a letter of employment stating your salary and a credit report (by federal law, you can get this free q12mo from all 3 credit reporting companies through www.annualcreditreport.com but you will need to pay a small fee, about $10, to get the credit score – you can get the score free via Credit Karma but a lot of realtors will not accept it from this company so be forewarned)
  3. Think about selling any large items you may have (such as furniture) to save on moving costs. If you really must move a lot of large items, look into moving options early because June/July is a busy moving cycle and you don’t want to be left with the less reputable companies that may be cheap but do not do a good job or very high prices or even worse, no options. You can either hire a moving company or use portable containers such as PODS, U-Haul’s U-box, or ABF U-Pack where you pack the container yourself and they drive the container to your new home and often have options to store it until you are ready to access it. Check to see if your program has an Employee Assistance Program (EAP) that can help you with relocation services and/or discounts but either way budget yourself 1-2 grand.
  4. Get all your paperwork done ASAP. You will receive mountains of forms that need to be filled out to obtain your (temporary) medical license and allow you access to the various hospitals you will rotate at. Make it a habit now to not procrastinate because once residency starts, you will find yourself often too busy and too tired. You also do not want any delay in starting your job due to incomplete paperwork. Better to find out now if you are missing an item (eg – vaccination, physicals) and take care of it before you arrive to start.
  5. Get to know your colleagues. Introduce yourself to everyone over email and offer to help out if they need (such as unloading their moving stuff). It’s a great way to break the ice and meet your fellow residents and start off on a friendly foot. You can even suggest some chillaxing activities to do together at the start of residency to explore your new city to get to know each other and your new home. Bonding starts from day one and it is difficult to do once the hustle and bustle of work starts and if you are in a program where you are separated to different hospitals. Also, you’ll find that your senior residents will have a lot of good advice to give and you might even find a new friend or mentor.
  6. Join pathology advocacy organizations like the American Society of Clinical Pathology (ASCP), the College of American Pathologists (CAP), and your state/city pathology societies because they often have resident resources and this is the last time you can get free membership. Once you graduate, then you have to pay membership dues. CAP has a Residents Forum with 2 meetings per year that I found a great place to meet other residents. Both ASCP and CAP have a Resident Council and Residents Forum Executive Committee, respectively. Get involved and run for a position on either of these or on ASCP or CAP committees where you will serve with attendings. Other international organizations such as USCAP or subspecialty organizations may have dues but these are often greatly discounted for trainee members and you get discounted registration if you need to attend their conference (eg – to present a poster) so it still makes sense to join – find out if your program will pay for the dues.

Once you start residency, I won’t lie, it will be stressful. There will be times you wonder what you’ve gotten yourself into and when you may doubt if you can do all that is expected of you. But persevere and this, too, shall pass. Find yourself some good mentors – other residents, attendings, and/or ancillary staff. You may feel that you are behind and that there is so much to learn but I promise if you make sure you have a solid foundation at each step, one day you will be that senior resident who seems to know so much more than you did on day one. But for now, enjoy yourself! The studying can wait–at least until July 1st!

 

Chung

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