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

[Davide Costanzo]

Very well spoken. You will note that neither of us raised this subject, but
did respond to a post previously entered. And, as I clarified to another
person here privately, the problem with CLIA does not just mean we are
going after HT's that gross - CLIA allows ANYONE with those very minimal
requirements to gross. Most gross techs are not HT's, most are off the
street people with the bare bones required by law, that are taught on the
job to toss biopsies into cassettes. And, many of these people do much
larger cases as well - all legally under CLIA "88. It's a problem, and it
is not meant to upset anyone on here. Most of those techs, as I stated, are
not HT's and are not on this site anyway. The proper forum of course is to
reach out to government officials and try and get that law changed. Perhaps
we will. A lot of progress has been made in the area over the years, now we
just need to modify the laws to reflect the times within which we live.

I did want to point out one thing though - there was a comment about saving
money in healthcare, and that was a valid reason to employ a grossing tech.
Let's be clear on this subject - there is a BOAT LOAD of money in the
technical component of AP services. This is why you see GI docs and
Urologists all over the nation opening their own histo labs. They want to
cash in. The reimbursement for technical charges is public knowledge - look
it up and you will find the Medicare rates for your area very publicly
posted by Medicare. It's not a secret. Take those rates, multiply by 80%
because even Medicare does not really pay what they say and then multiply
it out for your volume. Be sure to include all your 88305's and other
standard charges, and add all the fees for your stains, frozen sections,
decalcifying, etc. When you see just what Medicare pays your site, then
look at your paycheck and ask yourself "Is my lab really suffering
financially?" Probably not. And that is based upon Medicare rates, the
truth is the lab makes more than that because most insurers pay higher than
Medicare. Where does the money go? I don't think I have to tell you.






On Wed, Apr 25, 2012 at 2:28 PM, Joanne Clark <jclark <@t> pcnm.com> wrote:

> 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.
>
> Respectfully
> 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>
> Message-ID:
>        <CA+F+Rhqo7GuohqTLXtA1Ffd2yhda0bR1Hefi3rdH2wOji35YUg <@t> mail.gmail.com
> >
> Content-Type: text/plain; charset=ISO-8859-1
>
> Joanna,
>
> 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.
>
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> 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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-- 
*David Costanzo, MHS, PA (ASCP)*
Project Manager
*Blufrog Path Lab Solutions*
9401 Wilshire Blvd. Ste 650
Beverly Hills, CA 90212