College of American Pathologists
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September 2005
Feature Story

Cytology exam

I must compliment Cris Anderson, MD, for his articulate and excellent letter regarding the MIME testing (July 2005). We received two test sets when we took the exam. The test sets that we used contained five straightforward slides, two equivocal unsatisfactory samplings, two borderline low-/high-grade lesions, and one very difficult case that everyone called negative but according to the graders had a few small high-grade cells.

Eighty percent of us failed because of one very difficult slide and nine correct responses. Dr. Anderson is correct in that this untested and unproven exercise has no relation to the real world. Where is the "ASC-US, cannot rule out high-grade lesion," which is an accepted diagnosis? Where is the collegial collaboration on difficult cases that is mandatory for the best patient care?

I’ve never been prone to paranoia, but is there a hidden agenda? Could it be that now as the profit has returned to Pap tests and $60 charges are common, there is a government-corporate agenda to drive the independent labs out of the Pap testing business?

As a practicing pathologist in central Indiana, I know that the laboratory associated with MIME misses its share of dysplasias and invasive cancers. It is an excellent laboratory, but the complexity of reading Pap smears as yet defies infallibility. This testing program needs to be eliminated.

Gregory H. Ellis, MD
Director of Laboratories
St. Johns Health System
Anderson, Ind.

Technologist licensure

As a pathologist and director of one of the few remaining medical technology schools, I believe we are ignoring at our own peril the problems related to medical technology careers. As pathologists, we are endangering ourselves because medical technologists, as we all know, are of great strategic significance in the laboratory.

Medical technologists have bench-level experience that helps the laboratory director evaluate potential technology alternatives. They can and do extend the breadth of control of one pathologist to very large operations. They’re a lot like physician assistants, but unlike PAs, medical technologists are tightly linked to quality control. Thus, I would posit that the future of the clinical laboratory under pathologist control is inexorably linked to the future of medical technology as a career.

Despite this link, I see little evidence that pathologists are supporting measures to increase medical technologist salaries or improve the recognition of the medical technologist as something more like the physician assistant.

If you accept the premise that we will need medical technologists in the future, and realize that the cadre of current technologists is nearing retirement, then you must support licensure requirements for the technologist. Such requirements will increase professional recognition for technologists, and they could help address salary issues and in the long term the supply of MTs. In some states, a nurse with no experience can earn more than a well-trained technologist with 10 years’ experience.

It sounds odd, I know, to support anything that could lead to higher salaries in today’s medical environment. But if we ignore the problem and let the MT career vanish, Wall Street will change the field radically or technologists will unionize. Neither option serves the interest of patients or pathologists.

Jeffrey Tarrand, MD
Chief, Microbiology and Virology Laboratories
M.D. Anderson Cancer Center

Communication with clinicians

Karen Titus’ excellent article, "For digoxin, simple fix to stubborn problem" (July 2005), brings to light a chronic and disturbing issue: The communication between pathologists and clinicians continues to be dysfunctional. In the article, Peter Howanitz, MD, recalls many years ago finding (with his laboratory colleagues) digoxin-timing errors at the hospital where he was working. Physicians were notified, and many became hostile. "They told us we were telling them how to practice medicine," he said.

Why do clinicians, who should consider us medical colleagues and peers, so disdain clinical pathologists? What have we done to engender such feelings? Why do they perceive our assistance as their loss of autonomy in treating their patients? We have no conflict of interest and no notion of competing for their patient. We simply support them by providing prompt and appropriate laboratory services, and accurate results, for the benefit of their patients.

Anesthesiologists recently scored a glowing report in the Wall Street Journal for the actions they have taken in the past several years to improve care and lower their malpractice insurance costs. We have not heard that surgeons were up in arms over their colleagues’ actions. Why should improvements in laboratory medicine be isolated to never-ending incremental steps to improve already impeccable analytical testing? We are constantly held responsible for pre- and postanalytical errors beyond our control. Obvious solutions are often rejected.

P. Ridgway Gilmer Jr., MD
Retired pathologist