Controversies in Laboratory Medicine: A Series From the Institute for Quality in Laboratory Medicine

John R. Butterly, MD; Richard E. Horowitz, MD

In This Article

Dr. Butterly's Response

I will do my best to address Dr. Horowitz's points, but I will have to say up front that I can understand why these issues are irritating from the laboratory's perspective. Both Dr. Horowitz and I were immediately struck by the relative congruence of our lists, and I think that it is especially gratifying that our colleagues believe as we do that, all in all, the relationship between the clinical physicians and clinical pathologists is not broken.

We can probably all agree that it is the responsibility of the ordering physician, or his/her coverage, to accept the report of a critical value lab result and take the proper steps to see to it that the involved patient gets the needed attention. In my example, the physician is wrongly identified, and therefore both the physician and the laboratory should work together to identify a solution. As stated by Dr. Horowitz, this problem is clearly owned by the clinician, who needs to be sure that a responsible individual is accessible if she/he is not. Although there are many ways that this may be solved, one thought that comes to mind is to standardize the inclusion of patient contact information on all laboratory requisitions. That at least would fix the problem faced by the responsible physician who gets a critical value reported when she/he is not in the facility and may have no way of knowing how to contact the patient.

I am sure that this is frustrating, and communicating this with your clinician colleagues would hopefully go a long way to changing people's attitudes toward ordering STAT labs merely for convenience. The one point that I would make here is to ask the clinical pathologist to understand that sometimes, although it may not be apparent to the lab, the clinician is feeling worried or insecure about a patient's well-being, and may order a STAT lab that is not necessarily needed stat as a response to that anxiety. In my experience, this occurs more frequently with house staff and others in training, and is part of the learning process. If, in fact, the saying "good judgment comes from experience; experience comes from bad judgment" is true, we must allow for some degree of bad judgment on the part of the people who we are training (as long as patient safety is not compromised).

Fair enough. Not only is it important for there to be adequate information in the requisition so that the pathologist can give an informed opinion; it is frequently important for billing purposes. We will be subjected more and more to external regulations requiring us to do things that we should have been doing all along. As far as Dr. Horowitz's lament that requests for consultation hardly ever come with relevant history, welcome to the club, my friend. We are all working on that one.

Ah, this is a good one, and Dr. Horowitz has already explained what the problem is. As he has pointed out, the increasing complexity and rapid evolution of medical science are a challenge for all of us. None of us know what we don't know. Medical and surgical grand rounds would be a great forum for yearly presentations from the clinical pathologists on advances in clinical laboratory science.

Illegibility, inexact orders, and inappropriate or dangerous abbreviations are not only quality concerns; they are also patient safety issues best dealt with by organizational policy and information technology. Information technology offers the added benefit of automatic decision support to solve the problem of inappropriately prepared patients or specimens, eg, a flag that reminds the clinician that a certain test has to be fasting when it is ordered on the clinical information system.

Improper labeling is a serious problem that can, as Dr. Horowitz points out, lead to tragedy. However, this is not a physician problem, but a systems problem, and one that should be approached with that in mind.

I agree that many clinicians do not have a clear understanding of sensitivity, specificity, and predictive value -- that is why I have suggested that clinical laboratories provide that information along with the normal range of values.

With apologies to Rodney Dangerfield, there is never any excuse for rudeness. I have nothing more to say about that.

In summary, the partnership between the clinical laboratory and the physician is, in the vast majority of instances, an extremely functional, valuable, and rewarding relationship remarkable in its lack of problems and "irritating issues." The vast majority of the few problems that do exist can be solved by collegial communication and collaboration on functional policies and systems, which will be most easily developed if the primary focus is always the patients' best interests. The development and universal use of medical information systems will obviate many of these problems, although they will undoubtedly cause new ones about which we can write.


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