Monthly Archives: December 2016

“Resolutions.”

As this year draws to a close, I had a look back at my 2016 resolutions, posted in January this year, to see how I got on…

  • Get book published! – Yes, managed this one. “The Art of Clinical Microbiology” was published in April, and copies have gone to many different countries in the world. I am still pondering on how best to write a sequel to it…
  • Drive across USA.– Suceeded on this one also. With the family, we did a 5 week road trip across the USA from Los Angeles to New York. A fantastic experience, and worth spending the money on as opposed to decorating the house.
  • Do another ultramarathon.– Failed on this one. Ultra-marathon training takes heaps of time, which was a commodity I unfortunately ran out of. Would still love to do a 100k ultra. Unfinished business!
  • Keep working on my French.– I sat and passed the DELF diploma A2 earlier on this year, my first formal exam for years. Quite nervewracking actually.
  • Get back to Paris, even if it is just for a holiday! -Got to Paris in November this year with my two oldest children, combining it with a conference in Scotland, and visiting my parents in Ireland.

So 4 out of 5 isn’t bad, considering I am inherently quite a lazy person.

So what are my goals/resolutions for 2017?

  • Get the Microbiology Matters Youtube channel established with at least 15 video tutorials uploaded. I am extremely camera shy so this will be a real challenge! Hopefully my 12 year old son will help me.
  • Do at least three marathons – This is probably  a more realistic goal for this year. The ultra-marathon will need to wait for Tarawera 2018…
  • Sit the DELF B2 French exam.- Hopefully B1 in May and B2 in October, all going well.
  • Visit 5 countries I have never been to before. – Not sure how I am going to manage this one, or which countries I plan to go to, but the USA road trip has definitely re-ignited the travel bug.
  • Get the house re-carpeted. -This resolution is definitely a sure sign of my advancing age. This would never have made it onto the list a few years ago. But we have a carpet from hell. so it has to be done!

I look forward to looking back on these resolutions at the end of 2017 to see if I can go one better and achieve all 5 this time…

Michael

“Are Medical Laboratories becoming Factories?”

 

When we think of the word “factory” in its industrial sense, we normally think of things like large buildings, mass manufacturing, automation, production lines, and a hierarchial employment structure.

Most medical laboratories don’t have big smoking chimneys! However with recent changes in medical laboratories in terms of centralisation and automation, it is easy to see why some people might start to make such an assertion.

In what ways could the medical laboratory of today be seen or perceived as “a factory”?

  • High throughput: There are not that many medical laboratories these days which process less than 500,000 samples per annum. Centralisation has seen to that. This obviously has advantages (more exposure to a greater variety of conditions, & facilitates sub-skilling), but the number of samples mean that the sheer size of the laboratories can make them resemble “factories”
  • Increased automation: Haematology and Biochemistry have been automated for quite a while now, but this automation is increasing yet further with the introduction of automated processing “tracks”. Bacteriology automation systems like the Kiestra TLA and large scale molecular platforms are increasing automation rapidly in microbiology labs. With such systems in place, many samples barely touch human hands on their way through the laboratory. This has very clear advantages in terms of standardisation and error reduction, but it can certainly sometimes feel like a production line, with each staff member often having a very specific (and repetitive) task to help the sample along from receipt to result.
  • Noise: Automated platforms can be noisy, and because laboratories are generally big now, there are often many people on the shop floor at one time. This can create a lot of background noise.
  • Clocking in and out: An increasing number of medical laboratories have implemented or are looking at implementing “clocking in” systems to monitor employees time in the laboratory. The modern version of these systems usually involves biometric tracking by recording your fingerprint (I remember working in a hotel in Belfast and “punching a card”…).  I see the benefits to management, but personally I am not a big fan of clocking in systems. For me the ability to perform well at work should be based on trust, not forensics. Clocking in gives the medical laboratory a little bit of a factory feel.
  • Tendered contracts: In New Zealand anyway, medical laboratory testing for a region is usually tendered out to interested providers for a fixed term period. This to some extent “commoditises” the work. Factories tend to produce goods. We produce results…

So there are definitely some reasons as to why medical laboratories might be regarded as factories. In other ways they are definitely not. For example, unlike in most factories, medical laboratory staff are highly skilled. Laboratories are also very clean and well organised. This may not always be the case in factories.

It is during the analytical stage of the laboratory process that I believe it is actually very  important that the laboratory has at least some features of a factory. Analytical processes should be highly automated (and standardised), and less human interference means less errors are made.

And on the other hand, it is during the pre-analytical and post-analytical phases that it is most vital that medical laboratories do not behave like factories.

Pre-analytical:

  • Is this test necessary for this particular patient?
  • Are these the correct tests for this patient given clinical situation?

Post analytical:

  • How should this test be interpreted given the clinical context?
  • How quickly do we need to notify the clinician of this result?
  • Can we advise any extra tests on the patient on the basis of the result?

The pre-analytical and post analytcial phases are where the focus should be on making laboratories less factory-like.

These phases are when the personalisation of the testing process to each individual patient should remind us that we still work in a laboratory, and not a factory…

Michael

 

“Quality, not quantity…”

Whenever I am thinking about a new test Y, which is superior to the old (incumbent) one X, but costs more money, then the first thing I do is calculate the “disease budget”. i.e. I will find out the cost of our current test to diagnose that condition (and any other related tests) and multiply it by the number of tests we do to get the total amount of money spent on that specific disease/infection.

I can then work out how many tests we can perform with new test Y, and consider implementing selective testing criteria in order to focus testing on those patients that most require it.

Short of getting more money from lab funders for the “disease budget”, which is occasionally necessary, but very difficult to achieve , this is one of the few ways that we can introduce better (but more expensive) tests into our armoury. (Another possible route is utilising other disease budgets which have become redundant, i.e. rotavirus testing dramatically decreased due to childhood vaccination, so the money used for rotavirus testing could be used to fund the diagnosis of another faecal pathogen.)

We know that a combination of poor sensitivity and long turnaround times affects a lot of the traditional tests that we currently use in the microbiology department.

But it is not good enough to simply say, “These new tests are just too expensive for our budget”.

We owe it to our patients to play the system and work out ways of getting better, albeit more expensive tests on to the menu.

I prefer to use good tests well, on the right patients, and where real-time results can make real-time differences to patient management.

When strict clinical “qualifying” criteria are set up for certain tests, there will always be a few grumbles from requestors “Why can’t my patient get test Y”. This is when the 3Es, empathy, education, and explanation of the criteria are required. Even then, you can be sure that you will never keep everybody happy…

It is very rarely that we, in the microbiology department, audit how often the hundreds of results that we report out actually make a real time difference to the patients.

I suspect we shy away from this type of audit because the results would probably scare the living daylights out of us, and our funders…

Quality, not quantity.

Michael