College of American Pathologists
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August 2005
Feature Story

"Your CPT Questions" (June 2005) featured a question about coding for the interpretation of a partial thromboplastin time, or PTT, mixing study. I am concerned about the interpretation, not the coding. The patient’s prolonged PTT corrected fully when mixed with normal plasma. The pathologist interpreted this as "... a factor shortage or deficiency rather than an inhibitor." That interpretation is incorrect. Some inhibitors of Factor VIII require more than a few minutes to exert their effects. A repeat mixing study with PTT measured after a one-hour incubation period at 37°C is recommended to detect such inhibitors. (Horne MK. Hemostatic testing and laboratory interpretation. In: Kitchens CS, Alving BM, Kessler CM, eds. Consultative Hemostasis and Thrombosis. Philadelphia: W.B. Saunders; 2002: 17-18).

Gregory Tetrault, MD
Director, Clinical Pathology
Department of Veterans Affairs Medical Center Memphis, Tenn.

Quality measures

I read with interest the article "A Dozen First Steps to National Quality Measures for Labs" (June 2005), and as a former CLIA inspector and having had management oversight for the CLIA program in Mississippi, I felt the sort of uneasiness that comes with another wave of governmental oversight about to descend on the laboratory. I have a few questions. First, what exactly are these new indicators to accomplish that the current regulations do not? Are not the preanalytic, analytic, and postanalytic requirements already embedded in the heart of our laboratory regulations? Also, I see few, if any, connections between quality indicators and the volume of lab testing. Is this not the reason for diagnostic coding for payment? I can see the requirement on the CLIA inspector checklist now: What unnecessary testing has the lab identified and what have they done to stop it?

If so much unnecessary testing is being performed, where is the medical staff intervention? Why is this burden being considered a lab responsibility? If the most consumptive one-fifth of Medicare regions performed twice the lab testing as the least consumptive, why aren’t the initiatives directed at this most consumptive area? Perhaps socioeconomic reasons make this region more consumptive. Perhaps more lawyers live there.

The pay-for-performance initiatives, I suspect, will have little effect on lowering health care costs by improving patient outcomes. It sounds and feels good, but the distance between arming medical technologist inspectors with punitive weapons (which they don’t want in the first place) and getting cost savings through better patient outcomes is just too wide to be plausible. Besides, how do these initiatives work in a physician office laboratory or a large commercial laboratory where the medical director in the office lab is also ordering the tests and the commercial lab has no connection to ordering practices?

Robert L. Nicholas, MT(ASCP)
Tri-Lakes Medical Center
Batesville, Miss.

The oversupply

I fully agree with the comments of Ming Cao, MD, and William Warren, MD, in the June 2005 issue (Letters). The duration of the oversupply problem is noteworthy. In 1982, when I finished my fellowship, you couldn’t buy a job in pathology in southern California. If by some fluke you landed one, it would last only until you were eligible for a raise. Several colleagues despaired and entered medicine or family practice residencies. Every pathology position for which I applied from 1983 through 1986 had more than 100 applicants each, and location did not matter—Akron, Buffalo, Cincinnati, North Carolina, Keewenau Peninsula in Michigan, and Los Angeles were all alike. Finally, I was hired in 1986 by a pessimistic director who was convinced that no sane person would want to work in what he considered the armpit of southern California.

Our professional societies have long been eager to see more graduating medical students choose pathology, and the decision of the American Board of Pathology to reduce the years of training from five to four years seems aimed at this goal. I think it is beyond cruel to combine two cohorts of residency graduates and allow them to compete in an already vicious marketplace. Better to increase the residency program to seven years and include a year or two of ER medicine, so that any graduating pathology resident can find some means of supporting a family.

Mark Seifert, MD
General Pathologist
Arrowhead Regional Medical Center
Colton, Calif.

Finding a job

My compliments to Michael S. Brown, MD, and Karen Titus on the excellent advice to pathologists for whom it is time to find a job. Secure lifetime positions don’t exist anymore. You and your department may be the best and most loved in town, but hospitals get bought, departments are closed, and your job may be outsourced.

I would have counseled on the process leading up to the job interview. Since your curriculum vitae is a self-portrait, make sure it’s a good one. Its chief purpose is to get you that interview. By starting to write it early and maintaining it regularly, you have a better chance of not leaving anything out, the benefit of showing it to those whose opinion you value, and an opportunity to revise and reorganize it.

If yours is a large residency program or medical center, you might ask the personnel or human resources department to help with CVs, if not give a series of seminars on this and other job-related topics.

Build a network of associates, colleagues, and friends. The Harvard Business Review estimated that 90 percent of the best jobs are found through or because of "the network." Become a CAP laboratory inspector, join your local pathology society, present papers at national meetings, and join the state medical association.

Additional good advice about finding a job and staffing the department can be found in "Innovations in Pathology: The Best of 30 Years," which you can download on the CAP Web site.

Seth L. Haber, MD
Emeritus Founding Chief
Department of Pathology
Kaiser Permanente Medical Center
Santa Clara, Calif.