College of American Pathologists
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  President’s Desk Column


cap today

A matter of interconnectivity

It is not in the manner of how you build the boat, but how you affect the wave. — Leland Kaiser, PhD

June 2003
Paul A. Raslavicus, MD

The Centers for Disease Control and Prevention recently convened a conference of laboratory professionals from academia, hospitals, the independent clinical laboratory sector, professional associations, and government in a thoughtful program titled Quality Institute Conference 2003: Making the Laboratory a Key Partner in Patient Safety. It was an intellectually satisfying session in which the contributions of pathologists and of the College to patient safety and improvement in care quality through cancer protocols and other programs were consistently favorably cited. Our clinical colleagues spoke repeatedly about how difficult it is for the front-line physician to keep up with progress in laboratory medicine. To avoid diagnostic errors, they know they need to tap the knowledge base that our specialty possesses. They urged us to work in close partnership with them by contributing our unique knowledge base of the medical laboratory.

Not that we have not known of this need for many a year! It was in 1981 that George Lundberg, MD, defined brain-to-brain turnaround time as the critical full cycle in patient care. “Brain-to-brain” views a laboratory test as an event that begins when the clinician starts to think about what tests to order and ends when he or she has taken action on the results. An error at any point within this critical path, which includes the cerebrum of the attending, can compromise patient welfare and must be avoided.

Pathologists and other professionals in the laboratory have been the leaders in designing the quality assurance systems required to root out error. We have worked hard for nearly 50 years to improve the testing process, and we have now come to the time when error in analysis is least likely to be the cause of an erroneous result. Most “laboratory error” occurs outside the laboratory analysis, in the preanalytic (procedural) and postanalytic (communication) phases of the brain-to-brain cycle. Procedural errors in patient and specimen preparation, identification, transportation, handling, and accession are not uncommon. Communication-related problems most often relate to report delivery, format, clarity, timeliness, and integration of information. Add to these the pitfalls inherent in a potentially inadequate knowledge base of the physician who is ordering and interpreting the tests and you have myriad failure possibilities.

Some 15 years ago Peter Howanitz, MD, and Paul Bachner, MD, used their bold imaginations to launch the Q-Probes program in which many of you participate. Later, Richard Zarbo, MD, introduced Q-Tracks, and over the years, dozens of pathologists designed and analyzed the 122 studies of both programs. Through your efforts in hundreds of laboratories we have identified the areas in the pre- and postanalytic phases of testing that are especially vulnerable to affecting the quality of care. We have demonstrated that we practice in a world of medicine in which everything is interconnected in an ever widening scope of systems within systems within systems. We were the first to take the giant step that identified and publicized the trigger points that have high potential to harm patients. We should be proud of the leadership position we have achieved.

But who has studied the neuronal synapses of the attending physician so critical in the brain-to-brain quality equation? Speakers at the CDC conference told of the failure of our clinical colleagues to understand the complexities of laboratory medicine and to turn laboratory data into correct information for decision-making. All of our efforts in the clinical lab will be for naught if tests are ordered and interpreted incorrectly or ineffectively. To prevent this failure in interconnectivity, we must educate and communicate.

Yes, these are generalizations, but consider the following:

  • How many medical schools present to their students pathology and laboratory medicine as disciplines in their own right, with their own body of knowledge, operating constraints, and intellectual challenges?
  • How many surgical residency programs require reasonable familiarity with the discipline of surgical pathology, leading to an understanding of its limitations and intellectual challenges?
  • How many internists are exposed in their training to the challenges of laboratory medicine, such as the variation inherent in methods and the influence of drugs on test results? How many truly comprehend the ravages of disease on the human body as seen at autopsy?
  • How many pathologists are sufficiently trained in the complexities of laboratory medicine to feel comfortable being consultants to their clinical colleagues who are often in the dark on what the findings mean, let alone how to integrate multiple laboratory data points into a diagnostic algorithm? How many of us understand the constraints operating in the direct patient care environment and are willing to help, or are capable of helping?

    The combined effect of these realities is that we as physicians frequently can hardly understand one another or how communication among us is so necessary for patients’ sake. The lack of understanding by our clinical colleagues of the body of knowledge that is laboratory medicine has stifled the appropriate use of the expertise of the well-trained and dedicated clinical pathologist. Similarly, the lack of reward systems for working in laboratory medicine has stifled the recruitment of physicians into clinical pathology. Given that laboratory-based information influences so much of medical decision-making, we have paid a terrible price.

    At this CDC conference, those leading the patient safety movement called for all of us to leave our laboratories and to help our clinical colleagues understand and more appropriately use the tools we provide for them. We can lead by providing educational conferences for our medical staffs, by participating in outcomes measures and patient safety activities in our hospitals, and by being involved in the clinic and on bed rounds. We must also encourage the use of our knowledge through consultations. Vanguard hospitals and foresighted pathologists are doing precisely that. Institutions such as the Massachusetts General Hospital know that greater use of clinical pathology consultation improves patient outcomes and reduces costs. Using his 24/7 laboratory SWAT team, Michael Laposata, MD, PhD, has proven the value of the clinical pathologist at the MGH in the expeditious, cost-effective, error-reducing, length-of-stay-improving consultations in coagulation, therapeutic drug monitoring, toxicology, and other specialized areas.

    The interconnectedness of our work to patient care and safety signifies a larger role for the clinical pathologist in years to come. But we cannot do what is needed without our technologist colleagues, our phlebotomists, our colleagues in independent laboratories, and nurses. Yes, even patients are part of the interconnectivity paradigm. They need to share information about themselves, from their clinical symptomatology to their social history. Shared responsibility for patient safety means more emphasis on communication—patient-to-physician, pathologist-to-clinician, technologist-to-pathologist, brain-to-brain. As speakers at the conference said, only then will we be able to do things right—and do the right things. In a systems world, interconnectivity rules.