Earning our Spot on the Patient-Centered Care Team

By Jennifer Dawson, MHA, FACHE, CPHQ, LSSBB, DLM(ASCP)SLS, QIHC, QLC  bio

There is a lot of talk these days about integrating the laboratory into patient-centered care teams¹ and about forming diagnostic management teams². Throughout the industry, the need for education and decision support for ordering providers around test selection, test utilization (both overuse and underuse) and interpretation given a specific clinical context is widely recognized^3,4,5.

At all levels, from pathologists to medical laboratory scientists to phlebotomists, we are passionate about the value that laboratory medicine brings to patient care and management. We are outspoken and insistent that we should have a seat at the table and that patients deserve and our organizations need our guidance.

Urgent care to lab

I was recently quite ill for about a week, so I reluctantly went in to urgent care. After waiting for what seemed like forever, I was called in. The Nurse Practitioner (NP) reviewed my symptoms with me, ordered some lab tests and told me to take an over-the-counter (OTC) medication. If symptoms didn’t improve with the OTC remedy, I was to take a prescription medication. I thanked her and went on my way to check in for the lab and grab my medications from the pharmacy. When I was finally called in for my labs, the phlebotomist first wanted to just give me collection supplies and send me away to bring samples back later. I had to explain that the NP had specified that I was to give samples now as there was some urgency to understanding the cause of my illness. She finally obliged and said, “But you can’t do the three day today”. “Okay”, I thought, “That makes complete sense. It is a three day test”. The phlebotomist then said, “And you can’t take any of the following medications for two days before or during the three days”. I responded, “But the physician just told me to go straight to the pharmacy and pick up the OTC version of one of those medications and take it now”. She responded, “Well, doctors and nurses never understand the tests that they order and what’s involved”. I didn’t tip her off that I work in a lab. That day I was a patient in need of help. I responded, “I understand that they may not understand the tests, but what you are telling me directly contradicts the instructions I was given by the urgent care provider that I just saw”. The phlebotomist looked at me and actually said, “Do what you want”. I was desperate and frustrated. I responded, “I don’t want to do what I want, I want to do what I’m told so that I can get better”. I left, knowing that I wouldn’t be able to complete one of three tests that the NP had thought important to understand what was ailing me.

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Pick up the phone

I encourage all laboratory professionals to think about this situation. How different would my experience as a patient have been if the phlebotomist had just taken the time to pick up the phone and call the ordering NP, who was just upstairs in the very same building? How often are laboratory professionals so caught up in thinking that they are the black sheep of the care team banished to the basement that we don’t recognize opportunities right in front of us to make a difference for our patients? Are we so concerned that doctors and nurses think the lab is a black box, that they don’t understand what we do or how we do it, that we miss real opportunities to educate and collaborate with providers for the benefit of our patients?

I recognize that this is only one fairly minor instance involving one individual but I think it represents a prevalent attitude amongst clinical laboratory professionals. When a laboratory repeatedly receives improperly labeled or collected specimens, is that feedback given to the ordering provider in the interest of continuous improvement? Or do we just roll our eyes and scoff at how they don’t know what they are doing? When a laboratory receives an order for an obsolete test or a test that doesn’t fit the clinical picture described on the requisition, does someone pick up the phone to have a discussion with the physician? Kudos to those of you that do take the time and initiative. You are champions of patient safety and progressive thinkers! However, in my experience this crucial communication and interaction does not happen as often as it should.

I challenge each laboratory professional at every level to overcome the emotions and frustration, allowing us to see clearly and seize opportunities to communicate with providers. Actions speak louder than words. Only when we begin to truly act in the interest of the patient will we earn our spot on the patient-centered care team.

References

1) Patient Engagement with Patient-Centered Care Teams Task Force, Defining the Patient Centered Care Team: Doing More with More, https://www.himss.org/defining-patient-centered-care-team-doing-more-more, Accessed June 25, 2019

2) Laposata, M. Curing Our Diagnostic Disorder. 2017 Sept. https://thepathologist.com/outside-the-lab/curing-our-diagnostic-disorder. Accessed June 25, 2019

3) Freedman D. Towards Better Test Utilization – Strategies to Improve Physician Ordering and Their Impact on Patient Outcomes. The Journal of the International Federation of Clinical Chemistry and Laboratory Medicine. 2015 Jan; 26(1): 15–30.

4) Laposata M. Errors in clinical laboratory test selection and result interpretation: commonly unrecognized mistakes as a cause of poor patient outcome. Official Journal of the Society to Improve Diagnosis in Medicine (SIDM).2014 Aug; Volume 1, Issue 1.

5) Plebani M. Towards a new paradigm in laboratory medicine: the five rights. Clin Chem Lab Med. 2016 Dec. 54(12):1881-1891