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.
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 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 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.
Lab Med. 2014;45(1):4-5. © 2014 American Society for Clinical Pathology
