[Histonet] RE: Histonet Digest, Vol 101, Issue 32

Joanne Clark jclark <@t> pcnm.com
Wed Apr 25 16:28:23 CDT 2012

Davide and Rene, you have very valid points and I do not necessarily disagree with you.  But the reality is that it is an accepted CAP/CLIA allowed practise and will continue.  You both have the right to voice your opinions on the issue, but perhaps histonet which is made up mostly of techs, many of whom gross (not by choice) is not the best place to do it without causing a lot of controversy.  You need to take your concerns where they might make a difference, to CAP or CLIA. If you believe in it strongly enough you will try and do something about it.  Just know that those of us who do gross, do everything within our power to do the job safely for those patients we serve.

Joanne Clark, HT
Histology Supervisor
Pathology Consultants of New Mexico

Message: 14
Date: Wed, 25 Apr 2012 09:34:29 -0700
From: Davide Costanzo <pathlocums <@t> gmail.com>
Subject: Re: [Histonet] RE: Qualifications for grossing
To: Joanne Clark <jclark <@t> pcnm.com>
Cc: "histonet <@t> lists.utsouthwestern.edu"
	<histonet <@t> lists.utsouthwestern.edu>
	<CA+F+Rhqo7GuohqTLXtA1Ffd2yhda0bR1Hefi3rdH2wOji35YUg <@t> mail.gmail.com>
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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

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

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