clinical pathology – Lablogatory

A Pathology Emergency

Hi everybody! Welcome back. Thanks for following along last month’s update on Zika epidemiology and clinical lab crossovers. This time I’ve got a story to tell…

This is my last month of medical school! And, as such, I decided to go out with a bang and finish up with my last rotation in Emergency Medicine at The Brooklyn Hospital Center. It was a fantastic month! One would think that EM and Path are two very distant specialties, but they are more alike than you might realize. That could be a whole separate article but consider this: managing critical situations, ensuring fast-paced accurate response times, engaging in high-stakes algorithms, and making sure mistakes are caught early. Sounds to me like there’s lots of overlap…remember my discussion on high reliability organizations or the critical role interdisciplinary medicine plays in creating good patient outcomes? All things aside, all clinicians have a critical role to play, but what happens when you put an (almost) pathologist in an emergency room?

Basically, you get me having a fun four weeks—I used to be an EMT and help teach EMS courses, so I do like this stuff. But something else happened this month that really made this experience special…

Image 1. Typically, med students have minor roles to play in real-life critical codes, but some of our duties include managing monitor attachments for vital signs, securing peripheral IV access, obtaining emergency labs, and other supportive measures while the rest of the code team manages…well, the resuscitation efforts. Source: Life in the Fast Lane.

Saturday, July 27^th. I got to sleep in because I was on the night shift for four days. No big deal. When I finally got to the hospital, there was pandemonium. Extra ambulances in the loading bay, a couple squad cars outside, a stab wound victim in the trauma bay, lots of noise and folks everywhere—what was routine hospital stuff somehow seemed like I was in the middle of filming an actual episode of ER. (I’m obviously partial to particular shows…okay, maybe Chicago Med?) When I report to my team, I learn that the computers have been down. All day. No electronic health records, no charting, no histories, no internet to look up guidelines/recommendations on UpToDate—and most tragically: no lab results.

Ok. This is it. I’m on the other (read: clinical) side of an awful downtime shift. I’ve experienced plenty of downtime in the lab, but this night I took a deep breath, reminded myself its going to be okay, and did my best to label things right. But a problem appears that’s more serious than labeling type and screens the right way without a computer: results are backlogged for hours! I’m talking no blood gases, no lactic acids, no pregnancy confirmations! I overheard senior residents and my attending that night talk about how the lab is struggling and they didn’t have enough people to figure out this downtime debacle.

This was a moment. It’s not often med students get to be literally useful in any clinical situation but after high-speed thinking about it, I interjected and made my elevator pitch:

“Dr. X, Dr. Y – I’ve got several years of hospital lab experience and lots of background in managing crises and downtime situations, if you want I’ll head over to the lab and see if I can help this situation at all, at least for the ER…”

There was a short pause. Then an enthusiastic wave of approval with hands waving me to go help out our laboratorian colleagues. Please note: the instances where tidbits of knowledge as a medical laboratory scientist prove useful as a medical student on rounds are far and few between for their ability to really captivate a group of doctors who identify themselves far from any lab medicine; so, this was a win. Explaining the importance of order of draw, or why sensitivity goes down when you don’t adequately fill blood cultures, or why peripheral smears should come with some interdisciplinary caveats aren’t quite as sexy as an emergency room, on metaphorical fire, with no one but you knowing anything about how labs work.

So, I ran on over to the laboratory, fully intending to do what I could to help in my unofficial just-a-friendly-neighborhood-med student capacity. That’s when I met Jalissa Hall!

I walked into the main lab area and asked if I could talk to the supervisor, thinking I would just explain my experience and offer what I could to their staff who I’m sure were buried in downtime SOPs and make sure I got critical results back to my team in the ER—a win-win! When I asked who was in charge, a very busy Ms. Hall walked out from behind the chemistry section and said, “you can talk to me. What’s going on?” I’m sure she thought I was there to complain, seemingly like many other clinicians were, but I stopped and gave her the same elevator speech I delivered moments ago with the postscript: “what can I do for you?” I remember she stopped, thought about if for roughly 10 seconds, and presented me with her situation briefing:

Computers have been down since roughly 05:00 am
There’s a computer virus that had all servers shut down indefinitely
There’s no communication between the hospitals EHR and the labs LIS
Moreover, no patient information is coming across to the analyzers (MRNs, specimen IDs, etc.)
There are 4-5 critical units (ER, OR, ICU, OB, NICU) that require STAT results
Clinicians have been coming to the lab all day looking for informal results reporting
The limited lab staff has had to manually print results on paper and work to match them with barcodes, specimens, and manual requisitions before releasing results

Image 2. Jalissa Hall, MLS(ASCP) (left) and a very tired me (right) after a great night of solving lab-related communication problems! Anyone else need an emergency room pathologist? Sounds like a new clinical specialty/fellowship to me…

Deal. I know I can’t jump on the analyzers because New York is one of the states that requires clinical laboratory licensure (which I do not hold). In my informal survey I noted three medical lab scientists (including Ms. Hall), someone in specimen processing, and someone in blood bank. Basically, in order to make sure the lab could operate at peak performance with what they had, I helped alleviate the “paper problem” for them at least for the ER specimens. I matched requisitions with instrument raw data, made copies for downtime recording, delivered copied results to the ER, rinsed, lathered, and repeated—for eight hours! I obviously had to toe the line for the ER results, but there were other nurses and doctors who came in for the other areas’ results. No one worked more than the folks in that lab that night, and no one more so than Jalissa. After things cooled down a bit, I got the chance to connect with her and talk about her career and asked if she had anything to share with all of you—she definitely did.

Lablogatory family: please meet Jalissa Hall, MLS (ASCP)!
(Responses paraphrased because, honestly it was late, and downtime was busy, and we were tired, ok?)

Jalissa has been working for about five years as a generalist, with two jobs—like most of us have done. She works at The Brooklyn Hospital Center as a generalist and at NYU Hospital Lab in their hematology section. She is a graduate from the excellent MLS program at Stony Brook University in NY. She’s got ambitious career goals that are aimed at climbing as high as she can in laboratory medicine, and she’s got the enthusiasm and work ethic to match! I got the chance to ask her some real questions, during a real down-time crisis. This is what she had to say:

What made you go into laboratory medicine?

JH: I really want to help people. I love the behind-the-scenes aspect of being a medical laboratory scientist, but I think sometimes it can be too behind the scenes…

What did you think of tonight’s downtime issues?

JH: …it could have gone better. There seems to have been some panic, people kept walking in and shuffling the papers around. I tried my best to organize by floor, have two copies of each result (one for us and one to send upstairs), and requisitions match orders, but it was difficult. We have a downtime protocol, but we just couldn’t keep up with the volume and extent of how long it’s been down for. There’s really been no help outside the lab to work with us during this time so it’s a challenge.

What could have happened better?

JH: No outside help meant no room to breathe. On the inside, supervisors off duty tonight called staff in but none were available to come in. We don’t have an on-call person. We’re understaffed or short-staffed like so many labs out there; it’s problematic.

How is this going to look tomorrow?

JH: It’s not looking good, haha! Morning draw is definitely going to have a hard time. Catching up with these backlogs is one thing, but if orders can’t come across the LIS we’ll have to address that problem for sure. We’ve got a great staff though, so I’m sure it’s going to be fine.

What would be your “top tips” for all our fellow laboratorians reading this?

JH: First and foremost, being driven matters. If you want to get ahead, if you want to excel and climb high within an organization or in our profession, you have to work hard and keep working toward your goals.

Pro-tip #1: One of the biggest issues is “vertical cooperation.” Basically, some call it administration-buy-in, but it means administration working with employees in the lab to make the best decisions for our patients. If employees are burned out or if there aren’t enough resources to effectively perform our responsibilities it creates risks! It all comes down to patients, and making sure we’re in the best position to deliver diagnostic data for them means considering all aspects of lab management.

Pro-tip#2: If we want to fix the workforce shortages our labs regularly experience, we have to increase our efforts in advocacy within our profession. Having programs increase awareness of this job as a profession increases the pull and interest of potential new partners to work with. My school did it, other schools do this; increasing the number of programs that expose students to career opportunities in lab medicine would address our short-staffing problems everywhere!

Pro-tip #3: TELL OTHERS ABOUT OUR PROFESSION! I talked about our role being too behind the scenes…well the way to fix that is professional PRIDE! Own our accomplishments, share our role, advocate for our recognition, celebrate our peers!

Pro-tip #4: The future is not scary. Lots of folks shy away from tech advancement, fearing that automation and other developments mean losing jobs—it doesn’t. Why can’t today’s lab scientists become tomorrows experts on automation, LIS software, and other aspects of our cutting-edge field?

It was a pleasure to meet Jalissa and even better to work alongside her and learn about her passions and goals within the field we both care about! It was particularly special for me to be able to use my knowledge and experience to really contribute to my clinical team and bring laboratory medicine to the forefront where it doesn’t often shine!

Image 3. In a fantastic book I read recently, the authors of You’re It: Crisis, Change, and How to Lead When it Matters Most talk about leadership as a moment—a moment where you step up to a situation because you have skills and experiences which make you uniquely qualified to serve in a role which aims at a positive outcome. I had a small version of that in front of my attending (important for evaluations in medical school of course), but that downtime night was Jalissa’s “you’re it” moment for sure! (Source: Google)

Signing off from any new clinical rotations because this guy’s done with his medical school clerkships! Now I’ve gotta knock out some board exams and go on some residency interviews…wish me luck! I’ll check in with you next month after the 2019 ASCP Annual Meeting in Phoenix, Arizona—hope to see some of you there!

See you all next time and thanks for reading!

–Constantine E. Kanakis MSc, MLS (ASCP)CM graduated from Loyola University Chicago with a BS in Molecular Biology and Bioethics and then Rush University with an MS in Medical Laboratory Science. He is currently a medical student actively involved in public health and laboratory medicine, conducting clinicals at Bronx-Care Hospital Center in New York City.

Moving Forward One (Baby) Step at a Time

As this summer passes quickly by, I find myself, once again, anticipating the fall Annual Meeting of ASCP. Deadlines are fast approaching as I pull together my own power point presentation, review the schedule for sessions to moderate as well as those I wish to attend on my own time.

Many of you are involved in the planning process for the Annual Meeting and understand the deliberation and organization that this entails. The plethora of educational proposals is vast, submitted by numerous respected individuals and teams. Given the back-drop of this immense undertaking, I must say that I was thrilled this year to be a part of the discussion for the newly -created Hot Topics in Clinical Pathology. This has been a long-awaited moment for me and many of my cronies who have felt for quite a long time that the focus on Surgical Pathology at the Annual Meeting has essentially pushed aside the importance of Clinical Pathology and Laboratory Medicine as a vital part of everyday pathology practice.

With the creation of the “Hot Topics” track, we at least begin to see a small, but significant move forward. Clinical Laboratory Scientists clearly identify their work and the laboratory as primary contributors to patient care. Pathologists should begin to embrace this concept more fervently. The fields of Microbiology, Coagulation, Hematology, Transfusion Medicine, Serology, Chemistry (and a multitude of other areas) are expanding rapidly and are the KEY to understanding, diagnosing, monitoring and treatment of disease. Our clinical laboratories support and enhance our Surgical Pathology practices as well and the sooner pathologists regain the interest and care for these areas within our expertise, the better off our patients will be (and yes…they are OUR patients too!)

Hats off to the Annual Meeting Planning Committee for taking this bold step (although a “baby” one) toward bringing Clinical Pathology back into the fold. I hope to see this agenda pushed forward and expanded, not just at the Annual Meeting, but also in our other educational offerings. We are, by the way, the American Society for Clinical Pathology!

Our clinical laboratories and clinical pathologists are not the departments or doctors of the lesser god! Hope to see you in Tampa, in attendance at the Hot Topics sessions!

-Dr. Burns was a private practice pathologist, and Medical Director for the Jewish Hospital Healthcare System in Louisville, KY. for 20 years. She has practiced both surgical and clinical pathology and has been an Assistant Clinical Professor at the University of Louisville. She is currently available for consulting in Patient Blood Management and Transfusion Medicine. You can reach her at cburnspbm@gmail.com.

Flexibility within Structure: Towards Competency-Based Clinical Pathology Training

Since I previously blogged about introductory surgical pathology training, I thought that I’d switch gears and focus this week’s post on introductory CP training. Based on my limited experiences during medical school rotations and at two different residency programs, I can say that developing a targeted CP curriculum (both introductory and more advanced) to train pathology residents can be difficult. Often many of the CP services can function without a resident so clinical laboratory scientists (CLSs) may be in a quandary as to what to do with residents when we are present.

I found that I’ve had the best and most educational experiences when I spent time at a CP lab bench with a CLS who likes to teach and does it well. Lab directors should either identify techs who excel at or train their CLSs how to teach. It’s not as easy as it sounds. The technologist has to not only complete their usual daily workload but at the same time break down the important and most clinically relevant parts of what they do to residents as well as to deliver all this information in an engaging manner.

Having a written syllabus with a logical flow of requirements that builds on previously learned concepts helps to provide structure for those who need it. The syllabus should include rotation objectives, important contact information, and topics and tests necessary to cover by rotation-end. But within CP, I see more of an opportunity for us to train in a competency-based manner at our own pace and toward our individual interests. For someone like me with extensive, hands-on lab and research experience, I need less (sometimes none) of my time spent learning how tests are set up (I basically told my attendings that it wouldn’t be useful for me to watch the CLSs pipetting; by reading up quickly on an unfamiliar permutation of a test based on a concept I already know, I usually can understand it as well). Also, since I learn more by doing, letting me act as a first consult for referring physician calls about test issues really accelerated my learning because if I didn’t know about the test/issue, you can bet I did by the time I called the physician back with a response. And I also learned that a good clinical work-up is key to good care but that applies in any area of pathology that we work in.

But I understand that not everyone has experience or comfort in the lab setting. At my current program, they do two months of an introductory ‘wet lab’ rotation during their first and second years. They have competency/credentialing checklists of tasks they must perform during these rotations. The first month is spent in chemistry, special chemistry, microbiology, hematology, and blood bank becoming acquainted with the staff as well as understanding the theory and performing hands-on applications and analysis of the repertoire of tests available in each section. This is not because we will be expected to do things like a Gram stain in the future but so we have some context to understand what we will be explaining often to referring physicians when they call about a particular test. I think it also helps us to understand the time frame of task completion to help explain when we do serve as the intermediary with referring physicians. And most importantly, you get friendly with technologists who honestly really will help you a lot. Being competency-based, I was allowed the flexibility to decide my competency level (ie – I skipped the ‘perform a Gram stain’ portion of my checklist because I already had done many of these in the past). The second month is spent in more specialized areas such as molecular diagnostics, cytogenetics, advanced microbiology, and special coagulation.

Telling residents to just ‘go sit at a bench with a tech’ is not all that useful, especially if the tech is busy or not interested in or good at teaching. That’s why it is so pivotal that medical directors identify technologists who can serve in this role or do in-service trainings so they understand how to participate in resident teaching. Also, telling residents to just ‘go read up on X’ is also not the most helpful because we learn more by actively doing than just passively reading. For residents in specialties with more patient contact, they have no choice but to participate in direct patient care. At times, it seems more difficult to remember to train pathology residents to feel that same urgency they would if they had the patient in front of them and also to train them in a manner that more actively engages them, but it’s possible. It just requires more effort and thought during the curriculum design phase.

Another thing that I like here at my current program is how during July they have separate orientations to each service regardless of the fact that the first years are on intro to SP and I’m on a hybrid intro to wet lab/comprehensive CP (chemistry and microbiology) rotation with some grossing time to learn the nuances of how grossing is done at this institution. We all have to attend these AP and CP orientation sessions that are geared toward preparing us for situations we will see on call – grossing late Friday prostates for the Saturday call person, how to accession and handle a frozen, transfusion reaction calls, and so on. First years also participate in supervised CP day call with an attending to learn how to handle specific situations so that they are pros by the time they have night/weekend/holiday call as a senior resident. Here, we cover both AP/CP call at the same time as senior residents.

So, how do they teach intro to CP at your institution? How do you think is the best way to train residents during introductory CP rotations? I would love to hear your opinions.

-Betty Chung, DO, MPH, MA is a third year resident physician at Rutgers – Robert Wood Johnson University Hospital in New Brunswick, NJ.

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.