One doc's complaint about pathologists...

[docbiohazard]

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Ok, so I recently completed a dermatology elective in a private practice office. At one point, the doctor told me they had a "beef" with pathologists over the way they "took over" in-office labs back in the 1980's.

The way she describes it, some "greedy pathologists" started using techs to read Pap Smears, resulting in some misreads that resulted in quite a bit of hubub. In response, she said, they formed CLIA to federally regulate every in-office lab. This, the doctor purports, resulted in doctors having to jump through hoops to do simple things like gram stains, KOH fungal preps, fungal cultures, etc. They also assert that most physicians don't want to deal with the hassle, wind up sending out such simple tests and getting crap results back due to sample degredation, etc. This results, in this doc's opinion, in physicians just guessing at fungal illnesses and such, empirically treating, and in general makes doctors "more stupid."

I was kind of at a loss, as I don't know the history of CLIA and so forth, so I just had to listen attentively and nod. Is CLIA really that onerous for a private practice doc? Also, I thought certified techs still reviewed a lot of Pap smears... so what gives? Just trying to get some more info so if this ever comes up again (not with an attending), I could have some counter-points.

BH

 

[PathJet]

It seems likesort of an outdated complaint. Medical laboratory science has moved on quite a bit from KOH and gram stains for microbiology. Has this doctor been in the lab in the past 5 years?

It is sort of short sighted to blame one specialty/CLIA for "making doctors stupid"? I think we have enough problems in the healthcare than to continue this cycle unecessary paranoid blaming of other phyiscians . this sort of of disgruntled shortsightedness keeps physcians from communicating , sharing ideas, and forming a solid network. She should blame herself and her generation for this sperateness-this dichotomous (sp?usage?) thinking is what allows the large conglomerated healthcare organization/helathcare providers to keep chipping slowly away at physcians' ability to make decisions. soi would say not being able to read a fungal stain is the least of all of our problems at this moment. blaming pathologists for this situation is sort of misdirected. dont you think?

What about dermatologists reading pathology slides of skin? Is this greedy to her?

but anyway if you are doing a rotation or something you really cant do much about what other people say you just have to roll your eyes and say to yourself...i hope i am not this disconnected in 10 years...

 

[Daddydoc]

I don't think that doctor really understands what he's talking about. CLIA '88 really just required labs performing moderate to high complexity testing (which is anything that is not a waived test) to run controls and do proficiency testing. If he thinks doing that is too many hoops to jump through, then he probably shouldn't be doing any kind of lab work. The QC and PT for the things specifically mentioned really are quite simple and relatively inexpensive. Some people get really upset over any change, even if the change is a good thing.

 

[Neddy]

From: Sharon S. Ehrmeyer and Ronald H. Laessiga. Has compliance with CLIA requirements really improved quality in US clinical laboratories? Clinica chimica acta [0009-8981] Ehrmeyer yr:2004 vol:346 iss:1 pg:37 -43

"The regulation of US laboratories has a brief history. From 1967 to 1988, 12,000 large clinical and reference laboratories were required to follow the quality standards embodied in two federal regulations, the Clinical Laboratory Improvement Act of 1967 (CLIA'67) and Medicare 1968 [5 and 6]. The purpose of these regulations was to improve the quality of laboratory tests in federally funded programs and to ensure that federal healthcare dollars were spent on high quality laboratory tests. In the mid-1980s, a series of newspaper articles highlighted laboratory errors associated with Pap smear testing. The U.S. congress generalized these errors and enacted the CLIA'88 amendments designed to ensure quality in all laboratories including physicians' offices. For the first time, all clinical laboratory-testing sites were required to meet uniform standards.

CLIA'88 as implemented by the February 28, 1992 and subsequent regulations recognize three major categories of testing: waived, moderate complexity and high complexity. Only laboratories registering as moderate and high complexity are required to participate in PT and to undergo bi-annual inspections for the mandated, good laboratory practices. Waived tests were originally limited to a total of nine analytes using methodologies described as “so simple to perform” that there is essentially no possibility of a wrong test result or, if erroneous, pose no risk to the patient. Most of these were already available, over-the-counter, without prescription to the general public."

 

[docbiohazard]

Thanks Neddy. It looks like KOH and other wet preps aren't CLIA waived, but fall under the Provider Performed Microscopy permit. I can't find specific info on fungal cultures, but I'm guessing they're moderate complexity...

In anycase, the regs didn't seem that terrible to me.

BH

 

[Gene_]

If he thinks the quality of care to his patients is suffering because he can't do a fungal smear, etc. he is doing a disservice to his patients by complaining instead of jumping through a few hoops to get his certificate and comply with federal standards.

 

[docbiohazard]

If he thinks the quality of care to his patients is suffering because he can't do a fungal smear, etc. he is doing a disservice to his patients by complaining instead of jumping through a few hoops to get his certificate and comply with federal standards.

The physician in question had the necessary CLIA permit and so forth to perform in office KOH, fungal cx, and also perform in office frozen sections associated with some surgeries (utilizing a qualified histotech)... so hoops were being jumped through, he was just complaining about it. Oddly enough tho, I don't think they performed any in-office CLIA waived tests except for UPTs. They sent out their UAs. *shrug*

BH

 

[LADoc00]

Ok, so I recently completed a dermatology elective in a private practice office. At one point, the doctor told me they had a "beef" with pathologists over the way they "took over" in-office labs back in the 1980's.

The way she describes it, some "greedy pathologists" started using techs to read Pap Smears, resulting in some misreads that resulted in quite a bit of hubub. In response, she said, they formed CLIA to federally regulate every in-office lab. This, the doctor purports, resulted in doctors having to jump through hoops to do simple things like gram stains, KOH fungal preps, fungal cultures, etc. They also assert that most physicians don't want to deal with the hassle, wind up sending out such simple tests and getting crap results back due to sample degredation, etc. This results, in this doc's opinion, in physicians just guessing at fungal illnesses and such, empirically treating, and in general makes doctors "more stupid."


I was kind of at a loss, as I don't know the history of CLIA and so forth, so I just had to listen attentively and nod. Is CLIA really that onerous for a private practice doc? Also, I thought certified techs still reviewed a lot of Pap smears... so what gives? Just trying to get some more info so if this ever comes up again (not with an attending), I could have some counter-points.

BH

CLIA is a Federal quality standard. Yes it is onerous just like everything else that is spewed forth from the government.

But a dermie calling pathologists greedy? Kettle...black.

Anyone read the recent Wall Street Journal article on self-referral? They are likely going to eliminate all Medicare self-referral payments which would include dermatologists who see their own slides or send them to pathologists they employee. The same would be true for GI and GU groups.

 

[djmd]

CLIA is a Federal quality standard. Yes it is onerous just like everything else that is spewed forth from the government.

But a dermie calling pathologists greedy? Kettle...black.

Anyone read the recent Wall Street Journal article on self-referral? They are likely going to eliminate all Medicare self-referral payments which would include dermatologists who see their own slides or send them to pathologists they employee. The same would be true for GI and GU groups.

I guess that means the that Dermatologist will blame us again, even if it was the GI and GU guys who caused this...

 

[PathJet]

wiki-pot calling the kettle black


The phrase "Pot calling the kettle black" is an idiom, used to accuse another speaker of hypocrisy, in that the speaker disparages the subject in a way that could equally be applied to him or her. In former times cast iron pots and kettles were quickly blackened from the soot of the fire. If personified into animate objects, the pot would then be hypocritical to insult the kettle's colour.

The phrase "It takes one to know one" has a similar meaning.

Chinese philosopher Mencius relates a similar story about a soldier laughing at another soldier retreating 100 steps, while retreating 50 steps himself.[1]

There is a similar idiom in Turkish; "Tencere dibin kara, seninki benden kara" (literally; "pot, your bottom's black; no yours is blacker than mine")

 

[Neddy]

CLIA is a Federal quality standard. Yes it is onerous just like everything else that is spewed forth from the government.

But a dermie calling pathologists greedy? Kettle...black.

Anyone read the recent Wall Street Journal article on self-referral? They are likely going to eliminate all Medicare self-referral payments which would include dermatologists who see their own slides or send them to pathologists they employee. The same would be true for GI and GU groups.

Wow, that would be huge. How confident are you about that, and what's your source (other than WSJ)?

 

[ZZPath]

Change is afoot on both the regulatory (Medicare) and legislative fronts (Pete Stark, D-Calif, chairman of the House Ways and Means Subcommittee on Health). The hospital trade groups are lobbying intensely, but have more pull with Republicans. W. has threatened to veto recently proposed legislation that expands the State Children’s Health Insurance Program, in which Stark's new anti-kickback proposals are piggybacked. Clinton, if elected, would probably help pave way for these changes on the legislative side. Only one thing is certain - the rules are going to get more complicated for physician-businessmen. The ever expanding IRS regulations are a quintessential model of how this kind of debate is settled.