Week Two at Thomas Memorial Hospital

Grossing at Thomas Memorial has continued to go smoothly. I have become much more accustomed to the voice-recording style of dictation than using the voice-recognition software CoPath. It seems that on some computer systems, CoPath just makes so many mistakes that I spend a considerable amount of time correcting the spelling and grammar mistakes instead of doing what's really important, that is, grossing and gaining more experience.

Especially, when it comes to dictating biopsies, I have found that speaking into the voice recorder saves me about half the normal time. As with all surgical pathology laboratories, biopsies make up a significant portion of the specimens that are processed. That doesn't make doing them any less important, however their simplicity often means that speed, rather than detail, becomes the focus point of the gross. (Hey, laboratories need to make money to run, too.) Of course, as with all specimens, completeness of the gross is absolutely necessary and I make sure to pick up every little piece of tissue found in the containers. I also make sure that my instruments are clean between each specimen. Now that I have gotten used to processing large volumes of biopsies, I am challenging myself to increase my speed even faster. I would never take a short cut to improperly decrease my time, such as not inking a resection margin on a polyp, but I look for other ways that I can take. Questions such as the following help to challenge me in improving my dexterity and decrease my processing time while still retaining my accuracy.
-"How fast can I say the sentences while still allowing the transcriptionists to understand me?"
-"How can I arrange my table so that I have to make the least amount of hand movements?"
-"Which materials should I use (plastic bag vs. empty container) to most quickly and efficiently gather endometrial curettage tissue?"
-"Should I ink a specimen using the applicator stick blot-by-blot or use a sponge?"
Now that I think about it, the grossing bench has a very feng shui feel to it. Every tool, every material, every container has it's proper and individual place. When one is out of place, the whole grossing process becomes sluggish and delayed. When the grosser is looking for a misplaced pen or reaches with their left hand to instinctively grab a forcep on the right side of the bench, the bench is out of harmony. I am sure that Confucius would be proud of me.

I am always trying to find ways to improve my grossing abilities and I'm really glad that this program at WVU gives us that opportunity at so many different clinical sites.

First Week at Thomas Memorial Hospital

Other than what I've already written about my first day here, I can't say that I have much to add. Which is a good thing. My progress at work is going smoothly and I enjoy being able to work with all of the nice people together with my knowledgeable and entertaining classmate.

This is a test week and I have been brushing up on my anatomy. It has seemed like ages since I have learned the brachial plexus and the forearm and hand muscles. It's really going to be a mind-boggle for the final certification exam. I am a fairly self-motivated person so I am sure that my studies little by little will sufficiently prepare me for the exam, but it's still not going to be easy.

I wish I had more to say, but everything is going along just fine! 

Last Week at UPMC Chilren's Hospital and First Day at Thomas Memorial Hospital

It has been a busy weekend what with the move that my classmate and I have made from Pittsburgh to Charleston, but it has come as a welcome change. I highly value my time spent at Children's Hospital and got to do a lot of good specimens that I had never done before. There are a lot of things that I would like to talk about while at Children's, but for the sake of privacy I will have to show restraint.

In addition to the interesting specimens that I was able to do at Children's I learned to think more carefully about what I write down in my dictations. There are small nuances that were pointed out to me and I was very grateful for it. For example, in my dictations I would often say, "The serosa is..." and go on to describe the external surface of the specimen. However, the reality is that the serosa is a thin, transparent membrane and usually has no color of its own. So I have changed my dictations to "The serosal surface..." instead. Other small things include giving internal and external diameters to tubular tissues. If I say that, "The diameter measures 0.6 cm" then the reader still won't know whether I am talking about the outer tubular diameter or inner lumen diameter. Also, people interpret words differently, so it's best to be careful with words such as "multi-cystic" or "multiple" because for one person it may mean four while for others it may means hundreds. Grossing is as much a science as it is an English lesson.

The move to Charleston, although initially rainy, turned out to be smooth in the end. On Sunday, I had the opportunity to explore the town a little bit and I already like the atmosphere better than Pittsburgh. I was never much of a city person in the first place because of the cramped roads, the pollution, the noise, the high cost of living and the lack of privacy. Despite Charleston being smaller than Pittsburgh, I was pleasantly surprised while driving around Charleston to see the four lane freeways that are so desperately needed in Pittsburgh. I am already certain that I will thoroughly enjoy my seven-week stay here.

On top of that, the pathologists here have been extremely kind to lend us a whole house of our own while we are here for free. The house is very comfortable to live in and has already come with all of the amenities needed for daily living. Even dishes, silverware and washcloths are provided. I only wish that we had the same housing boon while living in Morgantown and Pittsburgh.

The first day at Thomas Memorial has gone well enough. It stayed busy throughout the whole day, but that may be partially due to being unaccustomed to the dictation system. Similar to Allegheny General Hospital in Pittsburgh, grossers use a voice recorder and transcriptionists physically type out the gross pathology report. My most common blunder was forgetting to say "period" or "comma" or "new paragraph" and I lost some time going back and correcting myself. I'm sure that the transcriptionists will be kind enough to forgive our small mistakes this first week at least.

Week Three at UPMC Children's Hospital

Things are busy as usual and I can't believe that it's almost time for me to move again. Just when you think you've gotten something down it's already time to move on. In preparation for the move to Charleston, Prashant and I have switched off our internet at home. I don't usually make blog posts from wifi spots, but Einstein Bros will have to do this time. I can't complain about their bagels.

I've once again learned a lot while at Children's Hospital. To me, the most fascinating protocol that I've seen and participated in over there is 'tumor mapping'. It's actually much simpler than it sounds. I think that it makes a pathologist's job much more easy.

For larger cases at Children's Hospital, they take their normal photographs of the specimens, but then they add to the picture using photoshop. "What do they add?" you might ask. The PAs add lines and squares to indicate exactly where they took each section. The pathologist no longer has to struggle in their mind where each section came from. All they have to do is look at the picture and it will tell them, "Alright, slide 3F came from this part of the tumor. Ah, I see." Tumor mapping certainly takes more time to do, but if a pathologist's assistant has the time to spare, then it could really make the pathologist's life easier. That's what were here for!

Unfortunately, I will have to cut my post short this week. Take care everyone and keep on working hard.

How Obamacare Could Affect Laboratories and PAs

This past Thursday the Supreme Court made a landmark decision to uphold the individual mandate of Obamacare or more formally known "The Patient Protection and Affordable Care Act." Although I have my own opinions about the moral implications of this ruling, I will try to leave aside the politics and analyze how the Affordable Care Act could affect the future of the field of pathologist's assistants as well as its affect on clinical laboratories.

Of course, this is all contingent on President Obama becoming reelected in November. Mitt Romney has vowed to repeal Obamacare if elected, so all of these musings by myself could be for naught.

The following predictions are my own personal hypotheses and if I have used incorrect information, then please correct me.

Predictions:

-Pathology Laboratories will receive more specimens.
The individual mandate of course means that there will be many more people required to have health insurance. It has been estimated that as many as 34 million new people will now gain health insurance through Obamacare. The rule of subsidies follows the slogan, "If you subsidize it, you will get more of it." With more people becoming covered, I expect that these people will want to have more tests done. Whereas before a person might have ignored that strangely growing brown spot on their arm, now they will be more inclined to get it checked and have a biopsy done. This will be a great step forward in preventative care. More people will be getting their diseases checked out early before they become bigger problems later on.
Effect on PAs: Slightly Positive. More specimens means that laboratories will be busier and there will be a greater demand for PAs. Laboratories may have to hire more PAs so the job market should be favorable.

-Pathology Laboratories will receive slightly more biopsies. The number of complex specimens should stay relatively constant. The type of complex specimens may change slightly.
Because more people will be able to get their ailments checked out early, I would expect the number of biopsy specimens to increase. If these biopsies lead to the early detection of disease then the disease can be managed before having to visit the surgeon. As more people become covered by health insurance, the cost of health care is shifted to the insurance companies who will in turn raise premiums. When individuals are not responsible for their own expenses, then they will utilize the service more. However, we have a positive feedback loop here. Because higher utilization will increase the costs to insurance companies and lead to higher premiums, people will be impelled to use the service even more to "get their money's worth."
Earlier detection of diseases will lead to fewer complex specimens, but it should be countered by the increased number of prophylactic complex specimens. Tumors and so forth that would have gone undiagnosed (but would most likely have stayed benign) will now be caught. (For example, think of all of the prostatectomies that are occurring due to prostate cancer as a preventative measure. Most people with small foci of prostate cancer will die due to other causes, but nonetheless many still undergo the prostatectomy procedure. Another example would be mastectomies and hysterectomies.)
Effect on PAs: Neutral. The beneficial role of having a PA work in a laboratory is that PAs are certified by law to perform high complexity testing. I expect that complex specimens due to patients ignoring their health to decrease (lung cancers, large skin cancers, etc...), but I expect the number of prophylactic and non-life threatening complex specimens to increase (prophylactic mastectomies, prophylactic prostatectomies, hysterectomies, etc...).  I expect biopsies to increase, so I would expect that the demand for laboratory technicians, who are cheaper to hire than PAs, will increase.

-Small Pathology Laboratories will struggle to stay in business. Hospital Laboratories and Large Pathology Laboratories will be able to weather the increased costs.
When I write 'increased costs' what I really am talking about is the decreased reimbursement that laboratories will receive under Obamacare. It seems that laboratories always bear the brunt of cuts. They are an easy, out-of-sight target and patients don't ever visit clinical laboratories. A letter written by the American Clinical Laboratory Association (ACLA) states that the combined effects of the Middle Class Tax Relief and Job Creation Act of 2012, Obamacare, and anticipated future sequestration cuts calls for a total 23% slash in Medicare reimbursements to clinical laboratories over the next 10 years. (Imagine what it will be after you account for inflation!) Clinical laboratories only make up 1.6% of Medicare spending but will bear 15% of the Medicare cuts.
In addition, most smaller laboratories aren't reimbursed the same as some large hospitals and laboratories due to Section 508 of the Medicare Prescription Drug, Improvement, and Modernization Act. It has been around for a while; it passed in 2003. But, it puts further strain on smaller laboratories that are not a part of the 'in-group'. You may have thought that reimbursement rates for Medicare specimens was the same throughout the country, but that is a fallacy. Larger hospitals and laboratories located in areas with high costs of living are reimbursed a greater percentage than smaller laboratories. Reimbursement rates are basically tied to a cost of living index. The already smaller reimbursement rates will cause small laboratories to buckle even more.
Effect on PAs: Negative or slightly positive. The effect will be largely dependent on whether you work at a small community laboratory versus a hospital laboratory/large laboratory. Lower reimbursement rates could cause many smaller laboratories to go out of business or refuse to accept Medicare patient specimens. If the smaller laboratory can weather the loss of reimbursements, then it will put a strain on laboratory personnel salaries. If the smaller laboratory can't weather the loss of reimbursements and chooses to refuse Medicare patients, a large percentage of their specimen volume will be gone, leading to lower demand for PAs. 
Of course, hospitals will be more than happy to take on the Medicare specimens that smaller laboratories don't take. Classically, tests done at hospitals cost more money and hospitals/larger laboratories are reimbursed more for Medicare specimens. If nearby smaller laboratories close, hospitals and larger laboratories could see an increase in specimen volume. 
It should be noted that the other people who will be hurt are unsurprisingly Medicare patients. Some nursing homes may no longer have access to their local, low-cost, small clinical laboratory and will have to rely on the more expensive hospitals which are farther away.

I am sure that I have missed other important details regarding the effect that Obamacare will have on PAs. If there is anything else that you can think of or would like to add, please leave a comment!

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Update July, 4th 2012

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I have an additional prediction that I have thought up of.

-Laboratories will receive slightly more complex specimens. This goes in contrast to what I wrote above, that "the number of complex specimens should stay relatively constant". We know that with up to 34 million new people receiving healthcare and not a new doctor being trained to take on this increased load, waiting lines and appointments will take longer. How much longer it will take to see a doctor and how much longer it will take to see a specialist remains to be seen. However, the increased waiting times (whether it be weeks or months) could give certain cancers just enough time to become more invasive, metastatic or complex. It is a sad development for patient care, but a very real possible outcome of increasing patient load without increasing the number of doctors. A minority of Americans may be able to afford traveling abroad for instant healthcare (medical tourism), but the vast majority of Americans will have to compete with each other to be seen by the same number of doctors, or just give up altogether due to the increased waiting time.

Effect on PAs: Slightly positive. I would never want someone to develop a disease for the sake of providing a living, just like I would never want someone to pass away so that I could do an autopsy. A slightly increased load of complex specimens means that PAs will be in slightly higher demand.