How clinicians should use the diagnostic laboratory in a changing medical world
Section snippets
The big picture
In developed countries, we are living in the golden age of medicine [1]. This age is characterized by huge advances in science, abundant technology, excellent facilities to care for patients, enough physicians to take care of all of our people well, adequate finding to do the job if the money is used efficiently, and pluralism in most countries. We are living in an era of rapid communications and computers and are emphasizing constructive entrepreneurialism in many environments. We are focusing
Quality
Quality is very hard to define. Some people even say that it lies in the eye of the beholder. The American Society for Quality Control defines quality as the `totality of features and characteristics of a product or service that bears on its ability to satisfy given needs.' Quality of care can be assessed by approaches of structure (anatomy), process (physiology), and outcomes. Outcomes are currently given highest priority but all three do matter. Quality control is the operational techniques
The consumer, the physician, and the laboratory
Who is the consumer of diagnostic tests? Is it the physician, the nurse, the insurance company, the government, the employer, the union, the managed care company, or the family? I would argue that no matter who pays the bill, it is the patient who is the consumer of diagnostic tests and it is the patients interest that must come first. Why do physicians order laboratory tests and x-rays? One study of the question in a large teaching hospital showed that roughly one-third of the tests were
Guidelines and clinical interventions
Every use of a clinical laboratory test constitutes a form of clinical intervention. Lawrence has identified nine methods of assessing the effectiveness of clinical interventions [5]. They are shown in Table 2 in the order of decreasing likelihood of validity. It is from these nine methods that clinical practices result. Such practices may be independent, singular, group, coordinated, or enforced. One would hope that such practice in Western medicine would be scientific. Science is the
Disease management
Springing from the managed care competitive environment in the United States, has come the concept of `disease management'. This is based on the belief, buttressed by many recent studies, that people or organizations that perform the same kind of procedure or take care of the same kind of patients in large numbers with great frequency can do a better job in terms of efficiency and outcomes than those that see fewer patients with said problems. From this has evolved a substantial new book by
Competency characteristics of a clinical laboratory director
One might ask in this complicated world of diagnostic and therapeutic medicine who is the point person or the so-called linchpin? I posit that in laboratory medicine this is the clinical laboratory director. I do recognize, however, that the functions of a clinical laboratory director could be shared across multiple individuals but somebody still has to be in charge. Some years ago three pathologists in the United States (G. Stevenson, J. Barger, G. Lundberg) meeting in Las Vegas created these
The necessity of professionalism and the patient–physician covenant
The practice of medicine (including laboratory medicine) has always been both a business and a profession. Even Chaucer wrote about it. In a proper practice, a balance must be struck between the business and professionalism of medicine. In some of our modern environments, physicians come down much too heavily on the business side so he behooves all of us to remember the features of a learned professional [9]. Chris Cassel has determined these as shown in Table 4.
In modern societies where the
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