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Guest Editorial Putting the Patient First – Using the Expertise of Laboratory Professionals to Produce Rapid and Accurate Diagnoses Michael Laposata, MD, PhD DOI: 10.1309/LM31UQ3NJCQXJUCC
The test menu in the clinical laboratory continues to increase dramatically in size, complexity, and cost. There is a growing recognition that errors in test selection and results interpretation can have significant adverse clinical consequences to patients and painful financial consequences to healthcare institutions. Michael Laposata, MD, PhD
Since 2008, the Centers for Disease Control (CDC) has sponsored the work of the Clinical Laboratory Improvement in Healthcare Collaborative (CLIHC) to address the patient safety issues associated with incorrect test selection and misinterpretation of test results. A survey by the committee is now in progress of all U.S. medical schools to understand how our newly graduating physicians are learning the appropriate use of the clinical laboratory. Preliminary results from nearly three-quarters of American medical schools indicate some startling facts (personal communication, Brian Smith, MD, PhD). Keep in mind that in practice, physicians are required to order the correct laboratory tests, with thousands of tests from which to choose, largely from what they have learned. On the other hand, however, there are experts in anatomic pathology who systematically interpret every case, and test selection is not an issue because all tests involve the same thing— gross and/or microscopic examination of tissue collected from the patient. Despite this, virtually every medical school teaches more than 100 hours of anatomic pathology, while only 9% have a separate and distinct course in laboratory medicine. Even more startling is that the mean number of hours spent teaching medical students about the appropriate selection of laboratory tests and the correct interpretation of the test
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Lab Medicine Winter 2014 | Volume 45, Number 1
results, over the entire 4-year curriculum, is about 10 hours, and in many institutions less than 5 hours. Instruction in transfusion medicine, a major segment of laboratory medicine, over the complete medical school curriculum was found to be 2 hours! It is widely known that errors in the administration of blood products can have lethal outcomes, and our medical graduates are compelled to make transfusion decisions millions of times per year with virtually no training in the area. For a problem that could be solved promptly by curriculum revision, medical students in the United States today are still taught anatomic pathology which they do not have to perform after graduation, and taught virtually no laboratory medicine, which they need to know essentially every day that they encounter a patient. Importantly, patients have little awareness of this shortcoming in medical education, and how it adversely affects their clinical outcomes. A recent survey from the CLIHC group, led by family physician Dr. John Hickner (J Am Brd Fam Med, in press) found that primary care physicians are uncertain about the appropriate test to order in 14.7% of diagnostic encounters and uncertain about correct interpretation of the test results in 8.3% of cases. With more than 500 million primary care patient visits per year, these data indicate that approximately 23 million times a year primary care physicians are not certain about the best use of diagnostic tests. So what about laboratory leaders who have knowledge about appropriate test selection and result interpretation? When the physicians in the CLIHC survey were asked about the helpfulness and the frequency of certain tactics to overcome their uncertainty in ordering diagnostic laboratory tests, they noted that a request to a lab professional for advice would be extremely helpful, but that laboratory experts are simply not available to practicing physicians. In the practice of medicine in America today, only 35% of
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Guest Editorial
responding physicians in the survey said it would be useful to ask a lab professional to help them with their uncertainty in interpreting test results, and only 6% responded that they were actually able to ask a laboratory leader for advice. Prior to 1980, radiologists “managed” radiology suites that produced simple imaging studies, which most physicians could interpret without a radiologist. When the CAT scan and other more complex imaging modalities appeared in the early 1980s, the radiologists rapidly shifted the focus of their daily activities to interpreting the complex images. “Managing” the radiology suite largely became the responsibility of an appropriately trained operational or technical director. The same has not happened for leaders of clinical laboratories who continue to focus the vast majority of their activities on the daily “management” of the lab, handling consultations only when asked. At this moment, there is an enormous opportunity for clinical laboratory leaders to refocus their efforts 1) on the generation of interpretations of complex clinical laboratory evaluations, without being requested to do so, and 2) to implement in their institutions, in conjunction with their treating physicians, test selection algorithms which obviate the need for physicians to pick from thousands of available tests. When that happens, the correct tests, and only the correct tests, are ordered, and expert-driven, patient-specific narrative interpretations are provided to the requesting physician. Despite the clear request from physicians across the country for the expertise of laboratory leaders, too many of us are afraid to open the door to this opportunity because it represents a complete change in what we do every day. If the patient comes first (how could it be otherwise?) with a great sense of urgency, laboratory leaders must adopt the three A’s of every successful medical consult service—Accuracy, Availability, and Affability. We have the knowledge and skills to help millions of patients every year, and it is time for us to step forward with our medical knowledge to increase their likelihood for a rapid and accurate diagnosis.
About the Author Dr. Michael Laposata is Edward and Nancy Fody Professor of Pathology and Professor of Medicine at Vanderbilt University School of Medicine. He is the executive vice chairman for the Department of Pathology, pathologist-in-chief at Vanderbilt University Hospital and director of clinical laboratories. He received his MD and PhD from Johns Hopkins University School of Medicine
and completed a postdoctoral research fellowship and residency in Laboratory Medicine (Clinical Pathology) at Washington University School of Medicine in St. Louis. He took his first faculty position at the University of Pennsylvania School of Medicine in Philadelphia in 1985, where he was an Assistant Professor and director of the hospital’s coagulation laboratory. In 1989, he became Director of Clinical Laboratories at the Massachusetts General Hospital and was appointed to faculty in pathology at Harvard Medical School, where he became a tenured full Professor of Pathology. His research program, with more than 160 peer reviewed publications, has focused on fatty acids and their metabolites. His research group is currently focused on the study of fatty acid alterations in cystic fibrosis. Dr. Laposata’s clinical expertise is in the field of blood coagulation, with a special expertise in the diagnosis of hypercoagulable states. Dr. Laposata implemented a system whereby the clinical laboratory data in coagulation and other areas of laboratory medicine are systematically interpreted with the generation of a patient specific narrative paragraph by a physician with expertise in the area. This service is essentially identical to the service provided by physicians in radiology and anatomic pathology, except that it involves clinical laboratory test results. In 2005, Dr. Laposata was recognized by the Institute of Quality in Laboratory Medicine of the Centers for Disease Control and Prevention for this innovation. Dr. Laposata is the recipient of 14 major teaching prizes at Harvard, the Massachusetts General Hospital, and the University of Pennsylvania School of Medicine. His recognitions include the 1989 Lindback award, a teaching prize with competition across the entire University of Pennsylvania system; the 1998 A. Clifford Barger mentorship award from Harvard Medical School; election to the Harvard Academy of Scholars in 2002, and to the Vanderbilt University School of Medicine Academy for Excellence in Teaching in 2009; and the highest award - by vote of the graduating class - for teaching in years 1 and 2 at Harvard Medical School in 1999, 2000, and 2005. LM
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