[Histonet] RE: Qualifications for grossing

Horn, Hazel V HornHV <@t> archildrens.org
Wed Apr 25 14:18:53 CDT 2012

Well said.

Hazel Horn
Supervisor of Histology/Autopsy/Transcription
Anatomic Pathology
Arkansas Children's Hospital
1 Children's Way | Slot 820| Little Rock, AR 72202
501.364.4240 direct | 501.364.1302 office | 501.364.1241 fax
hornhv <@t> archildrens.org


-----Original Message-----
From: histonet-bounces <@t> lists.utsouthwestern.edu [mailto:histonet-bounces <@t> lists.utsouthwestern.edu] On Behalf Of Davide Costanzo
Sent: Wednesday, April 25, 2012 11:34 AM
To: Joanne Clark
Cc: histonet <@t> lists.utsouthwestern.edu
Subject: Re: [Histonet] RE: Qualifications for grossing


I wanted to take an opportunity to explain my, and most of my colleagues, feelings about CLIA '88 with respect to grossing standards. But I want to start by stating that this goes both ways, I also do not feel it is appropriate for an ASCP certified PA to be performing Immunohistochemistry, or other stains in the lab. Both histotechnicians (ologists) and PA's have a very clear role in the pathology laboratory. Both have very different training programs. Both HT's and PA's should be protected by law, and rules/regulations for each should be clear. One is not better than the other, and I certainly hope you do not think I have an opinion different from that. Both are highly qualified individuals in their area of expertise.

In many states, and I will use Florida as an example because that is what I am familiar with, there are clear definitions in the law as to whom can perform what tasks. In the State of Florida, a PA (regardless of training
level) is not to perform frozen sections. That State only allows Pathologists and HT's to cut a frozen. This is the result of much effort put in to changing those rules by the HT's in Florida. Clearly they saw PA's as a threat to their job, and took action. Not a problem, I am happy to let them do the frozen sections.

What was it about cutting a frozen section that the HT's thought a PA could not handle? I do not know, but nonetheless they reacted. Certainly PA's are heavily trained in how to cut a frozen section, and it is generally considered our responsibility in most places in the US that I have seen, and I have seen many. Rarely, outside the State of Florida, do I see PA's that do not cut frozens.

Now, on to the issue of grossing techs. There are myriad reasons why I, and most of my peers, think it is not appropriate to utilize "grossing techs".
For starters, and to be clear, the use of such techs serves one principal purpose to the pathologist's and institutions that employ them - to save money and increase their profits. They are not employed because they represent the clear choice for the utmost in patient care, and to suggest that is not just misleading, but completely false.

Grossing small specimens is never just about transferring tissue from a container to a block. Many tend to try and downplay the importance of that task, and overlook things that could be problematic without certain training/skills. And, there are many grossing techs that do larger cases, from gallbladders all the way up to mastectomies and beyond - all with no didactic education, no proficiency testing and no rotations through various types of insitutions.

I have never seen a study, but perhaps someone on here has, that points out the sharp increase in error rates found when a tech is used to gross, versus a trained pathologists' assistant. There is a drastic difference. It is distinct, and a study is really not needed to see that difference. Now, to be clear again, that is not to say that every tech that grosses does a bad job. No "vitriol" here. It is just a fact, and a troubling one at that.

Imagine the difference in quality you would see if you had me doing all your stains! I am not trained as an HT. You could argue that I could be trained, but do you really want to open that can of worms? Do you want medicine to allow for that, and risk the HT profession? Probably not, and we do not either.  Do you think I would be as good as you are, given all the real education you received when getting your HT training? I don't think I would be as good as you are at doing your job.

As an example to illustrate, anyone that grosses should know how to answer these very basic questions. These might help shed some light on the issue:

   1. What is the most common neoplasm of the gallbladder, what does it
   look like, and where is it found? Would you know it if you saw it? Is it
   benign, or malignant?
   2. What is the reason that all appendices should have the margin
   submitted in the initial submission?
   3. Would you know the difference between an esophageal bx and a bx from
   any other part of the GI tract simply by gross appearance? What would you
   do if you had 2 specimens, one esophagus and one duodenal and they were
   reversed in the specimen containers by the biopsy tech? Would you be able
   to pick up on that mistake?
   4. How should you handle a skin punch for alopecia?
   5. If sent a skin for frozen, and it was a pilomatrixoma, would you know
   it, and would you still freeze it, or ask the pathologist first to avoid
   doing an unnecessary frozen?
   6. When are tangential margins more appropriate than perpendicular, and
   vice versa?

You can ask me the same types of questions as they pertain to histology, and there is no chance I can answer them as correctly, and with as much clarity as a well trained HT.

The bottom line is patient care and quality. I cannot provide the level of quality in histology as you can, and a grossing tech cannot provide that quality at the dissection bench. It just is not possible.

The deal is simple - I will never downplay the value of your education and training by suggesting anyone can do it. All I ask is the same in return.
Do not suggest that anyone can be trained on the job to do what it took me many years of college to learn, and perform that work at the same level.
And I could not do your job nearly as well as you do. I am always impressed with histotechs - they have a great body of knowledge and do a very detailed, intricate and challenging job. For me to suggest, that given a few minutes here and there of training, that I can do your job as well as you would be very condescending. I don't think for one minute you could make me as good as you are by spending just a little bit of time with me. I know I would make mistakes, and mistakes may be considered part of the learning process, but do we really want to accept that in healthcare?
Mistakes should happen in school, not with a real, live patients tissue.

We should all be aiming to provide the highest level of care possible. I want my surgical specimen (biopsy or other) grossed by a PA, or MD and I want that specimen cut and stained by an ASCP certified HT. Lowering standards is a slippery slope, and one that should not be embarked upon in the world of medicine.

I get crucified on this email server constantly. I have read and re-read the above. I see nothing in this to suggest condescension. For those of you that will see that no matter what, it is clearly personal for you, and for that I am sorry. Nothing here is meant to be offensive, just illustrative.

On Wed, Apr 25, 2012 at 7:41 AM, Joanne Clark <jclark <@t> pcnm.com> wrote:

> David, after reading your post I was not at all surprised to see that 
> you are a PA.  I am assuming that explains your vitriol towards techs 
> that gross.  Yes, CLIA does provide the educational requirements for 
> high complexity testing, but what on earth makes you think that a tech 
> with the proper CLIA qualifications can gross without proper training 
> by a pathologist?  CAP requires that as well as extensive 
> documentation of training AND a list of the specimens approved by the 
> Lab Director that a 'non-pathologist' is allowed to gross.  I'm sure 
> you can tell that I am a Histotech with an Associates Degree and I do 
> the grossing in my lab.  I can assure you that I do a good job and if 
> there is EVER any question regarding how to gross in a specimen I will 
> get a pathologist.  To make it clear, just because we tech's that 
> gross do not have a masters as a pathologist assistant, we care just as much about the patients we serve as a PA does.
>  Another point I would like to make is that very often we gross not by 
> choice but because it is what our pathologists demand of us and they 
> wouldn't put us there if we couldn't do the job. Believe me, when I 
> say that I do want to get my masters as a PA, but I haven't been able 
> to find a program that accommodates someone who is working full time 
> and can not afford to quit to go back to school.  I am currently 
> finishing up my Bachelors, because I still want to pursue it.
> Joanne Clark, HT
> Histology Supervisor
> Pathology Consultants of New Mexico
> ------------------------------
> Message: 8
> Date: Mon, 23 Apr 2012 16:32:34 -0700
> From: Davide Costanzo <pathlocums <@t> gmail.com>
> Subject: Re: [Histonet] Qualifications for grossing
> To: Glen Dawson <ihcman2010 <@t> hotmail.com>
> Cc: histonet <histonet <@t> lists.utsouthwestern.edu>
> Message-ID:
> <CA+F+Rhoy4DypX0MpOq65rRrVLDXObV_0aCSPZBGQRPv8ygVPMw <@t> mail.gmail.com
> >
> Content-Type: text/plain; charset=ISO-8859-1
> Glen,
> Below are the requirements for high complexity testing, as outline by CLIA.
> You can reference the CLIA '88 ruling, specifically look at Subpart M, 
> Section 493.1489
> The requirements are weak, to say the least. I am not alone in the 
> opinion that just because CLIA allows it, it is not necessarily 
> appropriate for the minimum qualified person to be grossing certain 
> specimens. Having someone other than an M.D., or ASCP certified PA do 
> anything larger than a skin shave is not good medicine. But, in answer 
> to your question - yes, the government allows inadequately trained 
> personnel to perform high complexity testing.
> Sec. 493.1489  Standard; Testing personnel qualifications.
>    Each individual performing high complexity testing must--
>    (a) Possess a current license issued by the State in which the
>      laboratory is located, if such licensing is required; and
>    (b) Meet one of the following requirements:
>    (1) Be a doctor of medicine, doctor of osteopathy, or doctor of
>      podiatric medicine licensed to practice medicine, osteopathy, or
>      podiatry in the State in which the laboratory is located or have 
> earned
>      a doctoral, master's or bachelor's degree in a chemical, 
> physical,
>      biological or clinical laboratory science, or medical technology 
> from an
>      accredited institution;
>    (2)(i) Have earned an associate degree in a laboratory science, or
>      medical laboratory technology from an accredited institution or--
>    (ii) Have education and training equivalent to that specified in
>      paragraph (b)(2)(i) of this section that includes--
>    (A) At least 60 semester hours, or equivalent, from an accredited
>      institution that, at a minimum, include either--
>    (1) 24 semester hours of medical laboratory technology courses; or
>    (2) 24 semester hours of science courses that include--
>    (i) Six semester hours of chemistry;
>    (ii) Six semester hours of biology; and
>    (iii) Twelve semester hours of chemistry, biology, or medical
>      laboratory technology in any combination; and
>     (B) Have laboratory training that includes either of the following:
>    (1) Completion of a clinical laboratory training program approved 
> or
>      accredited by the ABHES, the CAHEA, or other organization 
> approved by
>      HHS. (This training may be included in the 60 semester hours 
> listed in
>      paragraph (b)(2)(ii)(A) of this section.)
>    (2) At least 3 months documented laboratory training in each
>      specialty in which the individual performs high complexity testing.
>    (3) Have previously qualified or could have qualified as a
>      technologist under Sec. 493.1491 on or before February 28, 1992
> On Mon, Apr 23, 2012 at 1:19 PM, Glen Dawson <ihcman2010 <@t> hotmail.com>
> wrote:
> >
> > All,
> >
> > Can a histotech perform GROSSING if he/she has an associate's degree 
> > in Histotechnology from an accredited institution (Argosy in MN)?
> >
> > Any help would be appreciated.
> >
> > Thank-you,
> >
> > Glen Dawson BS, HT(ASCP) & QIHC
> > Histology Technical Specialist
> > Mercy Health System
> > Janesville, WI
> >  _______________________________________________
> > Histonet mailing list
> > Histonet <@t> lists.utsouthwestern.edu
> > http://lists.utsouthwestern.edu/mailman/listinfo/histonet
> >
> --
> *David Costanzo, MHS, PA (ASCP)*
> Project Manager
> *Blufrog Path Lab Solutions*
> 9401 Wilshire Blvd. Ste 650
> Beverly Hills, CA 90212
> _______________________________________________
> Histonet mailing list
> Histonet <@t> lists.utsouthwestern.edu
> http://lists.utsouthwestern.edu/mailman/listinfo/histonet

*David Costanzo, MHS, PA (ASCP)*
Project Manager
*Blufrog Path Lab Solutions*
9401 Wilshire Blvd. Ste 650
Beverly Hills, CA 90212
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