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A medical technologist in a physicians' office laboratory.

A medical technologist in a physicians' office laboratory

Physicians' office laboratories benefit patients by supplying test results quickly, but speed isn't enough. It must be accompanied by something medical technologists and medical laboratory technicians are trained to provide: quality.

At the same time, these professionals stand to benefit from working in office labs. They can enjoy more interaction with patients, a greater variety of duties, and more control and responsibility than hospital labs generally offer. That has been my experience as a registered MT working in a pediatric group practice for the last two and a half years.

Since graduating from medical technology school in 1971, I have held a variety of positions in large and small hospitals, including staff microbiologist and serologist, staff blood banker, education coordinator, and blood bank supervisor. When my third child was born in 1983, I decided to take a break from working, but soon I was ready to go back again.

My children's pediatricians, who wanted to upgrade their laboratory service, had a position available. They knew I was am MT and had asked me to work for them in the past. This time I accepted the job.

The three physicians operate a busy practice. In addition to routine pediatric care, they, treat children with attention and learning problems, Down syndrome, and other multiple handicaps. They believe in doing as much in-office laboratory work as is necessary to treat patients efficiently.

My predecessor in the job was not a medical technologist. She had performed several simple procedures, including CBC with differential, urinalysis with microscopic examination, rapid strep testing, simple cultures, and neonatal bilirubins. There was no evidence to indicate that procedures were improperly performed, but there was also no evidence of quality control. Moreover, expensive procedures had been chosen, probably for their convenience and simplicity.

Familiarizing myself with the necessary procedures became the first priority. The laboratory's procedure manual, while somewhat useful, was on the whole inadequate. Fortunately, the nurses who had assisted in the lab helped me find my way around.

Once I had reviewed the procedures, I gave myself a quick refresher in pediatric sampling. With continued practice, I perfected my technique for threading a vein with a butterfly IV and taking blood specimens from babies and children. Since most sampling with children is not done on a venipuncture, I had to practice finger, heel, and toe sticks.

Then I proceeded to reorganize the laboratory, using my years of management and organizational experience. In Georgia, state regulations for laboratory licensure do not apply to physicians' office labs, but I kept them in mind as I made changes.

After revising and updating the procedure manual, I turned to the matter of supplies. I contacted sales representatives for competitive price quotes and purchased less expensive kits and materials in bulk. A bulk system for hematology, in which we filled our own vials with reagent, reduced the cost per test to one third that of premeasured packets of reagents.

Many distributors were anxious for our business, although some did not carry the range of supplies we needed. Others could not meet delivery promises. They frequently back-ordered priority items and occasionally delivered extremely short-dated items, which had to be returned. I wanted most supplies delivered in a day or two, but one vendor took six weeks to deliver chemistry controls.

In three or four months, through discussions with sales representatives and trial and error, I found a distributor who could fill most of our needs. Once I had settled on this company, I asked for and received an across-the-board discount on all purchases.

I also instituted a quality control system. It would have been prohibitively expensive to use a comprehensive outside proficiency survey for our limited test menu. For example, our laboratory would only need the CAP survey for AST, bilirubin, hematocrit, and hemoglobin.

With our new savings on supplies, we could afford other quality control measures. As a result, the lab now has an outside hematology control program. To check on routine chemistry prodedures, I periodically submit duplicate samples to a referral laboratory.

It was a real challenge to add adequate quality control without increasing costs. The effort paid off, and the doctors have become relaxed and confident about laboratory results.

At the end of the first year, I realized we needed a more advanced spectrophotometer. There were many on the market to choose from, but most performed procedures we seldom needed. Based on needs, cost, and possible future use, I chose an instrument with greater capacity and higher quality. It has an internal microprocessor and temperature readout but is still a small, one-test-at-a-time instrument.

Since then, we have added a rotator to further speed up the rapid test for strep, and we are considering automated reading of urine strips. Because new equipment can be expensive, we change methods more than instruments.

As we performed more procedures in-office and the patient load increased, the laboratory became very busy. During their own busy periods, nurses could not assist me, and when I was absent, work had to be sent out. We finally decided to seek part-time help.

The doctors knew of another MT whose children were among our patients, and she was looking for part-time work. In short order, our office laboratory had a second medical technologist on staff.

I work from about 8:30 a.m. to 5 p.m. four days a week. My partner works a full day on the other weekday, and backs up the nurses and me at other times. Each of us also works one Saturday morning a month.

Today, in addition to the tests previously mentioned, we perform thyroid panels, theophylline levels, glucose and glucose tolerance tests, mononucleosis card tests, pregnancy tests, KOH preparations for fungal infections, vaginal wet mounts, reticulocyte counts, eosinophil counts, antibiotic susceptibility tests, and Gram stains.

We also do aerobic and anaerobic cultures, including cultures of wounds, throats, urines, ears, and eyes. Other test orders require us to collect specimens in the office for submission to a reference laboratory.

What is it like working in an office practice? It can be very hectic, especially in pediatrics. Everything is an emergency to the parents of an ill child. I have to deal with both patients and anxious parents. Therefore an important part of my job is maintaining a sense of calm.

I generally let parents be present to show their concern by holding a child's hand during phlebotomy. At times, they must help control the child, but usually they are just coaching. Sometimes, especially when parents are upset because their child is very ill, I send them out.

I may play a game to make it easier for a well child who comes in for a checkup hemoglobin, giving him or her a sticker as a prize for surviving a difficult episode. Sometimes I am remembered with a picture drawn just for me.

You also become involved in the entire case, not just the testing. If an ill child comes for blood work, I can quickly scan the chart to review the symptoms that prompted the testing. Then I have some idea of what results to expect and what additional tests might be ordered.

Patients are no longer just numbers --every specimen has a face to go with it. I get to know the children personally and track their progress. In a hospital, you don't see the patient unless you draw blood at bedside, which most supervisors don't do.

Because the doctors may base their diagnosis on laboratory results, we do as much lab work as possible while the patient waits. Simple chemistries and hematology tests can be available in 15 minutes.

We hold turnaround time for other tests to a few hours. If a cannot squeeze one more test into a busy morning, I will do it during lunch or in the afternoon. That way, the doctor gets same-day results. These time frames improve management of patient illnesses.

For example, if a child arrives with a history resembling bacterial meningitis, a blood count can be available in 15 minutes. Then, if needed, a blood culture and spinal tap can be done in another few minutes. The patient is placed on the proper medical regime without hours of in-hospital waiting. Simpler cases like infectious mononucleosis, strep throat, and possible teenage pregnancies have the same time advantages.

I have encountered diseases I had never heard of before. In one case, I found several abnormalities when performing a blood count. When I brought this to the doctor's attention, he sent the child to a specialist in hematology who diagnosed her illness as hemolytic uremic syndrome.

Kawasaki syndrome, a disease usually limited to children, has also cropped up. Its symptoms include abnormal redness of the mucous membrane lining the inner eyelids and upper respiratory tract, and enlarged lymph nodes in the neck. I perform a number of platelet counts on children with this illness.

The doctors know me and my co-worker well enough to rely on us for information about send-out tests they are unfamiliar with. They have learned to count on us for quality answers, timely results, and good rapport with patients and parents.

In an office setting, there can also be work beyond the confines of the laboratory. I have learned to staff the back office, taking patient histories, assisting with medical procedures, and holding wiggling heads. I have also performed tasks in the front office: pulling charts, taking phone calls and messages, accepting payments for bills, and bookkeeping.

There are some questions that laboratory-trained personnel should ask as patients and parents of patients: How much laboratory testing do the doctors perform in their offices? Who is performing the procedures, and what training do they have? Do they know the difference between alpha and beta hemolysis on throat cultures? Do they realize when a result is erroneous, or when the rapid strep test is giving a false positive? Do they realize a problem exists when a hematocrit and hemoglobin do not correlate? If training came from a salesperson, what was his or her background? Is there any quality control?

Questions such as these never occurred to me before I began working in a physicians' office. I took whatever happened there on good faith. But with so much office laboratory testing going on, we need to be concerned about quality. One way to promote test quality is to support regulation of these labs.

In-office laboratory medicine is not for everyone. A technologist or technician fresh out of school may find the hectic pace upsetting or lack the background for cost containment and organization. And much of the work is manual or at best semi-automated.

Right now, the pay scale is perhaps 10 to 15 per cent less than in larger laboratories, but state regulation may raise the scale. There are also hidden benefits to consider. Part-time laboratory positions, daytime only, can be difficult to find. In a group practice, however, two can easily share a position and provide backup coverage for each other during illnesses or vacations.

Many office practices have no weekend work. There's generally no holiday or evening duty, or call to take.

Some practices close for more than one hour at midday, which leaves time for shopping, jogging, or working out. Our office even has shower stalls for those who like to exercise during the lunch break.

Other benefits include health insurance, a profit-sharing plan, paid holidays and vacation time, paid time to attend local workshops, and paid registration for professional meetings. Although we don't get cost-of-living increases, we sometimes receive quarterly bonuses.

Since I have three children, one of the biggest benefits is free medical care for them. In addition, getting care elsewhere is easier with referrals from the doctors.

If you are an experienced laboratorian who enjoys dealing with people, consider switching to the physicians' office environment. You may find it to be one of the most rewarding moves you ever made. I certainly did!
COPYRIGHT 1987 Nelson Publishing
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 1987 Gale, Cengage Learning. All rights reserved.

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Author:Rinker, Judith Harris
Publication:Medical Laboratory Observer
Date:Sep 1, 1987
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