Going for Gold in a Different Competition

I have never been a super fan of the Olympics, but like many of you I have been thrilled by the grace, strength and joyfulness of the US Women’s Gymnastic Team. The incredible aura they project, and their spirit of camaraderie and affection for their coaches has made watching them a pleasure. So in honor of the US team and the Five Olympic Rings, I thought I would explore the five part team that provides the results that leave our laboratory every day. Though I will describe them separately, just as the Olympic Rings are linked, so is each part of our team, all interdependent on each other.

In our first ring, we have our lab assistant team. While lab assistants vary in duties and titles at various labs, in our enterprise they are the like the springboard that gets the Olympians onto the balance beam. They get us going! Arriving to the lab early in the morning, they are the first to get a look at the days specimens, matching containers, labels, test orders. As I have mentioned before, keeping patient identities correct on specimens is Job One. Our assistants are also responsible for the Gross Description of our biopsy specimens, counting the pieces of tissue in each jar, measuring the dimensions of each piece and preparing them for processing.

Our second ring, keeping the fast pace, goes to our histology and cytology staffs. The histology team takes our biopsies and through multiple steps converts human tissue to ultrathin stained slices on glass slides. Patience, concentration and a deft hand are key, especially when operating the rotary microtome, the lab equivalent of the delicatessen salami slicer. Our cytology staff is responsible for preparing urine specimens (yuck-but we ARE a urology practice) for bladder cancer evaluation. We use basic tests that are almost one hundred years old, as well as much more sophisticated tests that examine individual chromosomes as we help our clinicians battle this common malignancy.

The middle ring, the tent pole, is for our technologists in the areas known as “clinical” pathology. In a hospital or large commercial lab, this may constitute thousands of tests on blood and other body “fluids.” In our more specialized lab, we focus on a a handful of relevant blood tests, including PSA and testosterone, and bacterial cultures of urinary tract specimens looking for the microbes that causes pesky urinary tract infections. We also perform a special test to cut down on the risk of infection in men who will be undergoing prostate biopsies.

Pathologists get our next ring, heading for the home stretch. Trained physicians with extensive experience in laboratory medicine, it is our job to interpret the various findings in the lab, make diagnosis on the biopsy specimens, and generally guide the lab in the direction that best serves our clinical colleagues and their patients, while maintaining the lab accreditation by guaranteeing we meet all applicable laws and regulations. It means wearing a few different hats and keeping a cool head.

The final ring, the one that gets us across the finish line, belongs to our administrative department. Fielding questions from the clinicians offices, resolving discrepancies, managing the endless stream of consultation requests, they make sure the right result goes to the right physician for the right patient. As we know, the job is never done until all the paperwork (or electronic report) is completed.

Five rings, five squads working together. Our team may lack a stirring theme song, and we don’t have the time to stand up on a podium, but in our behind the scenes way we earn gold medals every day.
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Standard Operating Procedures.

If the rule your followed brought you to this…

…what use was the rule?

No Country for Old Men — 2007

Standard operating procedures (SOPs) are the life blood of the laboratory. They tell us what we are doing and how to do it. The best ones even tell us why we are doing it. I would never suggest changing an SOP without validating any new process, verifying that any changes produce results at least as accurate, timely and cost effective of what came before. But rigid procedures can lead to monotony and lack of attention. And lack of attention can lead to errors. Sometimes just a tiny tweak, not in the procedure itself, but how you go about following it, can freshen up an otherwise mundane task.

In my work as a urologic anatomic pathologist, I spend several hours each day examining prostate biopsies. Now, I cannot vary that I have to look at each slide carefully, need to make decisions about presence or absence of malignancy, grade the tumors I observe, and record my findings. Those steps are immutable. And after 11 years, they could easily be cemented in stone. But I have discovered that making small changes in the way I go about each step gives me elasticity and prevents mind freeze.

What kind of changes am I talking about? First, I have to admit that there was one big one. For years I had been using the same microscope, actually one I brought with me from my old hospital position, an older ‘scope the hospital sold to me for a song. Last year my colleagues convinced me that an ergonomic microscope with a tilting head and eyepieces would go a long way toward preventing back and eye strain. And that’s important as I enter my fourth decade of peering down the ‘scope — something both my Lab Safety Officer and more importantly my Occupational Therapist wife, agree with.

So that was a pretty big variation, but most of the others have been small, simple and inexpensive. I changed the location of my microscope, putting it just a quarter rotation of my chair away from my desktop computer. As we have become integrated with an electronic medical record, I find myself more and more frequently logging into the computer to get some patient information from the EMR, so the proximity is a real time saver. And the change in “locale” made the work seem fresh again.

My latest initiative changes the way I dictate my cases. I have traditionally used dictation equipment using a foot pedal so that I can dictate in real time as I look through the ‘scope. We progressed from tape to digital a few years ago, but that didn’t change my style. However, I recently decided to record my findings in writing and then dictate at the end of each case. I developed a worksheet that makes it simple to record Gleason Score and extent of tumor in my prostate cancer cases. It’s a snap to read my findings off the worksheet after each case. Now I have a written record in case the dictation gets disrupted. And no complaints from the transcribers so far.

Even outside the lab, “SOPs”, can be useful, but find a way to keep things fresh! It may be adding nutmeg to a recipe (easy), finding a new route to the job (moderately challenging), or building a new house (insane). It will keep you rocking.

(Note: To my colleagues on the various lab listserves, feel free to distribute)

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Can Newman and Redford Paint Our Lab or Fund Our House?

Remember-one man’s ceiling…

…is another man’s floor.

Paul Simon–1973

How many of you remember the two great Paul Newman/Robert Redford buddy films from the late 60’s-early 70’s? Most people of our certain age can probably recall “Butch Cassidy and the Sundance Kid,” but my favorite was “The Sting.” The two played a pair of con men trying to work the ultimate grift on gangster Doyle Lonnegan, played by the appropriately fierce Robert Shaw. In one scene, the con men and their team, posing as house painters, fake a Western Union agent out of his office and paint a wall or two before vacating, leaving the unhappy agent to return to a half painted office and a big mess. And that’s what we have here at the lab. No con, just the big mess!

The lab has been operating for more than 10 years, and the walls, floors and ceilings are showing their age, not to mention wear and tear from exposure to formalin, paraffin, and other assorted chemicals and solvents. So working with building management, we agreed on new paint, carpeting and ceiling tiles, as well as refreshing our vinyl flooring which was deemed too difficult to replace. The problem was how to coordinate all that work with a lab that has some sections open seven days a week, and others that work on a pretty tight schedule to get our cases out on a daily basis. No way can we shut down for a week, or even a day or two. And oh yes, we have an unannounced accreditation inspection coming up. We have to look all in order for that, whatever day it may fall on.

After multiple walk-throughs with the building agent and several different contractors, we arrived at a work schedule. We were provided with a floor plan of the lab, highlighted with seven different colors, each representing a different work phase, each to be done on a different weekend. Doing our best to not interfere with the daily work flow except for those pesky Chemistry and Microbiology sections with their weekend hours. Now that was really tough to work around!

So the painters and ceiling guys are hitting those sections on the run, painting Chemistry on a quiet Monday, and Micro between plate reads from Friday night to Saturday morning. We have pleaded with the painting crew not to unplug any incubators, refrigerators, our temperamental tissue processors, and so far they have been gentle. On the downside, the non-toxic paint is giving everyone a headache and making us all cranky. Our Safety Officer is popping the respirator masks out. And the paint just keeps on rolling.

So with the ragtime theme music from “The Sting” (Marvin Hamlisch playing Scott Joplin’s “The Entertainer”) playing in the background, I ask how all of you have dealt with maintenance in the workplace. Any secrets to your success?

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On the home front, construction is moving along, though not as quickly as everyone had hoped. First floor walls are up, and with good weather we should make some progress this week. Barb and I (well, mostly Barb) are struggling through all the essential decorating decisions. So many choices. So many permutations and combinations. So much money! But I have the ultimate trust in Barb to get it right, and still leave a few dollars in the rainy day fund. And if we go broke, we can always try pulling a con. It worked for Newman and Redford!

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5 Things Your Pathologist Never Told You

Doctor, doctor…

…give me the news.

Robert Palmer-1979

We have been called “The Doctor’s Doctor.” Pathologists stood in the background for decades, running laboratories, interpreting biopsies, staging tumors and making diagnoses. We rarely exposed ourselves directly to patients. There is even a law in New York State that explicitly prevents such contact. But now we live in a much more connected world. At the dawn of the digital age I created Pathwise, a company that “translated” biopsy reports from medical jargon to easy to understand English for patients with a desire to know. Now pathologists communicate via the Web, via Facebook, via Twitter. But even with all this improved interaction, there are still things you may not know about what really happens to your blood or your kidney or breast once it exits your doctor’s office, your hospital bed, the O.R. And even less that you might know about the pathologist who coordinates all the activity.

Most likely, the laboratory that analyzes your specimens has a pathologist as a Medical Director. To have an accredited laboratory, there is a long list of obligations and requirements that the Medical Director must ensure are occurring. This does NOT include running every blood test or making every slide personally. It DOES include verifying that qualified, well trained personnel are on hand to perform those tasks. And the scrutiny we are under to guarantee that keeps on growing.
Pathologists deal with our own version of Moore’s Law. In computing, Moore’s Law predicts that over time, denser and more powerful integrated circuits will be developed. In pathology, we are faced with the proposition that tissue samples are getting smaller and smaller, but the amount of information we need to derive from them is getting greater and greater. In the last decade, tests looking at cancer cells for the various changes in their genes–how these cells differ from normal cells–are becoming essential in determining the precise type of tumor in a biopsy, as well as in deciding what chemo- or immunotherapy treatments will work best for a particular patient. And by the way, those tests are not cheap.
The concept that there is a sharp line that separates “benign” from “malignant” can be a false one. Yes, in the vast majority of cases I can unequivocally call a biopsy benign or malignant. But that border line can be fuzzy; there can be a gray zone. Sometimes we just cannot accurately predict how a tumor will behave. And it is not just us local diagnosticians who are in this quandry. National experts don’t always agree on the nature of what they see under their microscope. And it can be a moving target. As new techniques are developed, and as our knowledge of the molecular underpinnings of illness grow, our interpretations and naming of disease processes change as well.
You may be surprised to see a bill from a lab halfway across the country. Not all of your blood tests or tissue tests are performed locally. Some large national laboratories operate central hubs which may handle all specimens from a wide geographic area. Some more esoteric tests, particularly molecular and genetic studies on tumors, may only be performed at one laboratory in the country. Laws relating to patenting of genetic testing have changed, but laboratories can still create test combinations that are difficult to duplicate elsewhere.
Pathologists are frequently leaders in a Medical Center. With offices and laboratories in the hospital, the pathologist often spends more time in the building than their clinical colleagues. This, combined with a general sense of trustworthiness, lead to many roles both within the administration of the hospital and the concerns of the physicians that make up the medical staff.

One more thing. Most pathologists love their job!

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