"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.
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
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
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
Arrowhead Regional Medical Center
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.