Agreeing to disagree.

Colleen Gannon's reply to Dr. Block Thank you for your comments regarding my recent publication, "Responsible reporting in microbiology," [see letters to the editor, February 2005, p.38]. I agree with your points about the two case histories and the important role of the clinician in determining clinical signs and symptoms of disease.

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Regarding your claim that the laboratory should not be in the business of medical decision making, I would point out to you that, by law, every laboratory must have a licensed, board-certified medical director. Medical decision making is part of the practice of pathology, and laboratories cannot disclaim this responsibility because "the patient is independently entitled to rely on the laboratory and its staff to implement appropriate safeguards for patient protection. This includes issuing only results in which the lab has reasonable confidence of accuracy" (see MLO September 2004, p. 43, Barbara Harty-Golder, MD, JD, "Legal dangers of testing unacceptable specimens").

Regarding your point about the Gram stain: Dr. Joan Barenfanger, chair of pathology, Memorial Medical Center, Springfield, IL, asked a physician to assess the Gram-stain report using the "busy" format (line-listing every organism detected) on a respiratory secretion. His response was just to ignore the Gram stain and treat presumptively. Alternatively, given the "more userfriendly" form, he said he would consider narrowing therapy to an appropriate antibiotic. Dr. Barenfanger conducted an informal survey of physicians who treat pneumonias, and the vast majority of them preferred the shorter report and thought that it promoted better patient care. Physicians do not generally understand our "morphologies," nor should we expect them to do so. We need to arm them with as much useful information as possible. One must keep in mind that any nonsterile specimen is at best only a rough guide to patient management. To report "everything" and "let the physician decide" does not result in improved patient care.

In response to your comments about urine-culture handling, see my statement about errors regularly committed in laboratories: "2. Too rigid an adherence to routine without taking note of individual circumstances." We look at several things when determining how best to work up a urine specimen for culture. We understand the exceptions and take note of the patient's age, location, previous culture results, urinalysis report, previous antimicrobial treatment, and attending physician (e.g., oncologist, urologist, etc.).