All In a Day’s Work

We’ve all seen newspaper headlines that make sensational statements: “Overwork blamed for medical error!” “As hospital probe widens, are pathologists overworked?” “Pathology errors spark concern over hospital laboratories!”

But how sensational are these claims really? In my opinion, not especially. Many pathologists are indeed overworked – which can cause diagnostic and medical errors and be detrimental to both doctors and patients. As an anatomic pathologist in active practice for nearly three decades, I’ve worked in a number of medium- to large-sized, hospital-based laboratories. At one point in the late 1990s, my colleagues and I were trying to convince our administration to hire additional staff members – but because there were no good workload models, our needs were compared to institutions that, although similar, were not identical, and as a result we weren’t granted the support we so desperately needed. Comparisons were done based on accessioned surgical cases, which was like comparing apples to oranges. Our department had a significant exclusion list (specimens removed in the operating room, but not submitted to pathology by mutual agreement) that decreased our accessioned number by up to 25 percent, whereas our counterpart had no such issue. At the time, the Royal College of Canada had a guideline for tissue pathologists’ workload that was based on population served. In contrast, the Royal College of Pathologists in the United Kingdom and Kaiser Permanente in the United States based their guidelines on total accessioned surgical and autopsy cases, with modification for academic and non-academic centers. Why were their approaches so different? My curiosity prompted me to do a study. The question: what is the best and most practical way to determine the workload of anatomic pathologists?

The study evaluated readily available parameters, namely population served, total accessioned cases, number of specimens, blocks and slides, the Royal College of Pathologists’ model, and a metric we called “level 4 equivalent,” or L4E (weighted based on specimen type). Any of the parameters measured could be used but the L4E was statistically the best, and was adopted by the Canadian Association of Pathologists. I did a comparative study and showed that the different workload models, though using different units of measurement, gave almost identical recommendations (annual workload/FTE).

How does the L4E model work? Each specimen is weighted based on the time it takes to sign out, medical value to clinicians and patients, clinical urgency, degree of difficulty, and medico-legal responsibility. Specimens are categorized into six types (levels). Many biopsy specimens are categorized as level 4, which we use as a baseline and which is assigned a weight (or L4E) of 1. Other levels are weighted against that baseline; for example a radical resection will be at least one level 6 (L6) and will be weighted as the equivalent of ten L4s – that is, 10 L4E.  The latest version of the model, published in 2014 (1), also integrates quality assurance, academic activities (teaching, training and research) and administration (regular and medical oversight). Last, but not least, the 2014 update defined nine simple rules for workload coding that cover about 95 percent of all cases. These are rules for:

1. Regular biopsies,
2. Core biopsies,
3. Curettings,
4. Tissue resections (other than radical resections),
5. Mandated synoptic reports,
6. Extra-levels and blocks,
7. Diagnostic stains,
8. Special studies, and
9. Radical resections.

Coding can be adjusted for the presence or absence of pathologist assistants, cytotechnologists, and resident trainees to meet the needs of different practice patterns.

How fatigue hides

My former department head once told me something I’ve never forgotten: “Administration understands dysfunction only.” At the time, we were discussing the need for new pathology positions in our department. Pathologists are unique among the various medical disciplines, because unlike others, we don’t have obvious rate-limiting factors that set an upper bound on our workload. In most disciplines, the main factor is time – whether that means consultation hours, availability of facilities or equipment, or scheduling around other specialties like radiology or anesthesiology. But in pathology, most samples can be processed within a few hours. The rate-limiting factor is the pathologists’ ability to review and sign out the case – which is why so many pathologists work after hours or on weekends. That allows them to avoid undue delays in reports and hide any “dysfunction,” but the chance of error increases as fatigue sets in.

Worst of all?  Fatigue and overload are often only noticed when there is a crisis – an unhealthy situation for not only the patients, who bear the brunt of any errors, but for the pathologists themselves.

Obviously, not every pathologist can review and sign out cases at the same pace. Variations can stem from an individual’s speed, degree of training, experience in a particular area, or general factors like the laboratory information system (LIS), use of voice recognition software, and technical and secretarial support. So with all these factors to consider, what is a safe workload for a pathologist? Despite plenty of discussion (2), there is no consensus yet. My own study using L4E (3) indicated that recommended workload ±7 percent (two standard deviations) will give a reasonable guideline for the minimum and maximum annual workload. It may be possible to increase that amount (up to as much as a 25 percent excess) for temporary situations like sick leaves or recruiting periods, but only if the timeframe is short and careful attention is paid to pathologist well-being.

A multifaceted workload

Pathologists have a vast array of duties. Not only do we engage in direct patient consultation via surgicals, cytology, autopsies, bone marrows, protein electrophoresis, and infection management, but we also have a medical oversight function that other medical disciplines don’t – and our administrative duties are more demanding than most.

Many people view pathology as similar to our sister diagnostic discipline, radiology. But unlike radiologists, who review almost every procedure before sign-out, pathologists and even lab technologists don’t have direct input into the finalization of many laboratory reports. This makes our “medical oversight” duties essential to ensure that reports are accurate, timely, consistent, and delivered to the right individuals. The degree of oversight varies with each laboratory discipline – highest for biochemistry, followed by microbiology, hematology and tissue pathology – but in all cases, inadequate oversight can lead to disaster. In fact, the Commission of Inquiry on Hormone Receptor Testing (4)indicated the lack of medical oversight and quality assurance as major contributing factors to delays and errors.

Administrative duties are closely linked with medical oversight. It’s to the peril of the institution when pathologists become advisors rather than participants in administration. For example, take the LIS. In cases where administrators have chosen systems without input from – or against the advice of – pathologists, those systems have sometimes needed to be abandoned or replaced at great cost to the institution. In cases where inadequate systems are implemented, essential activities like synoptic reporting and quality assurance, must often be carried out manually or by expensive add-ons. But the LIS isn’t the only potential pitfall; the same principle holds true for budgets, equipment purchase, and more.

The function of the medical laboratory is to produce accurate, timely and consistent laboratory information for patient management – from screening to diagnosis to autopsy – so it’s hard to overstate its ultimate impact on patients. My recent survey of the practice patterns of Canadian pathologists (5) showed that, like all physicians, our first priority by a large margin is patient care. So what happens when our total workload becomes unmanageable? We devote the time we have to patient care – at the expense of quality assurance, medical oversight and administration. That inevitably leads to system failures in the laboratory test cycle, which in turn have a greater impact on patient care than even diagnostic error. Whereas an error usually affects only a single patient, a system failure in something like fixation, sample collection, labeling, or equipment function will continue to affect people until it is recognized and corrected.

Our own worst enemy

I think that we ourselves are our own worst enemy. Most pathologists will work overtime, without compensation, to ensure that we sign out the work that arrives on our desks within a reasonable timeframe. But laudable as that may seem, it’s not good news for patients. We end up working while tired and ignoring our medical oversight and administrative duties in the process. In the short term, though, there’s no apparent dysfunction in the laboratory – which makes it easy for administrators to ignore the situation even as pathologists ask for more resources. For example, one group of pathologists working in a rapidly growing city functioned with the same number of staff members for 15 years, with requests for more staff denied. Finally, contract negotiations broke down and the contract for the whole group was terminated. Now, a decade later, the department is approved for over three times the original number of staff! That’s how easy it is to miss the signs of pathologist overload, and how easy it is for pathologists to slip into habits that put both us and our patients at risk.

To avoid this, we need a workload model that takes into account the multiple duties of the pathologist – direct patient care, medical oversight, administration, and in some cases, academic activities like teaching, training or research. It also needs to adapt to our evolving profession, with technologies, standards, and expectations leaping ahead. The Canadian Association of Pathologists (CAP-ACP) is making an effort to do just that by updating the workload model every three to four years, and by trying to ensure that it can accommodate the wide variations in pathology practice between institutions with vastly different attributes and needs.

The great majority of pathologists – at least in Canada – are on fixed payment schemes linked to work hours. Thanks to our “professionalism and sense of responsibility,” many of us work longer hours without pay or postpone the duties we deem least pressing. I’ve kept an eye on workloads throughout my career, and my experience tells me that the average workload increases by about 5–10 percent annually. That may not seem like much, but the compounding effect is significant – and in larger groups (with 20 or more full-time staff), it can mean two or three new staff members every year!

The side effects of overwork

Although there are no good double-blind studies for pathologists, plenty of studies in other medical disciplines and occupations have shown that fatigue is detrimental to job performance and results in increased errors. This is borne out by one of the best studies regarding pathologists (6), which discovered that adverse events – defined as increased turnaround time, quality compromises, patient care compromises, or damage to pathologist wellbeing – increase exponentially when we work more than 39 hours per week (see Figure 1).

The burden of responsibility

Most pathologists separate the laboratory test cycle into three phases: pre-analytical, analytical and post-analytical. I think it is best divided into five phases (see Figure 2) each of which has unique issues and requires unique solutions:

1. Pre-laboratory
2. Laboratory, pre-analytical
3. Laboratory, analytical
4. Laboratory, post-analytical
5. Post-laboratory

Most discussions combine the first two phases into “pre-analytical” and the last two into “post-analytical.” But the pre- and post-analytical laboratory phases are directly under the control of the laboratory and solutions to problems are laboratory-based. For instance, frequent contamination of blood collections can be solved by altering laboratory practices. The pre- and post-laboratory phases are out of our control; they take place either before the specimen reaches us, or after our report leaves the laboratory. These issues – things like labeling errors, fixation issues, or misinterpretation of surgical reports – can involve multiple departments, and require cooperation and coordination to address. That’s not to say that we don’t have a role, though; in fact, we’re in an ideal position to lead remediation initiatives especially in the pre-laboratory phase. Most errors in the testing cycle occur before the specimen arrives in the laboratory (see Figure 3). Issues in that phase come to our attention regularly during the different laboratory phases, so we can collect and analyze the errors. It won’t be easy, but with a systematic approach, we can tackle these problems.

And tackle them we must, because with personalized medicine on the rise, the issue is more critical than ever. Nowadays, the collection, fixation and processing of specimens are vital for accurate analysis of the biomarkers we use for prognosis and treatment. Problems with these processes are difficult to detect unless they’re being systematically monitored and analyzed – and yet, we know that they can significantly affect treatment decisions. For instance, improper fixation and processing can yield false negative results in estrogen receptor, progesterone receptor and HER2/neu status in breast carcinoma. The same is probably true for most of the molecular tests we use to guide cancer treatment, so it’s clear that we need to be on the lookout for not only our own potential errors, but also those that may occur before patient samples ever reach us.

Unfortunately, we have less information on the post-laboratory phase. Multiple studies have shown that what the pathologist means and what the clinician understands can be quite different! Understandably, that can negatively impact patient care and follow-up. Other post-laboratory phase issues include rolling out new TNM staging (with increasing frequency), new reporting systems (e.g., Paris urine cytology), new concepts (e.g., non-invasive follicular thyroid neoplasm with papillary-like nuclear features), and new classifications for various tumors. In addition, test results may be delayed, lost, or missed by the ordering physician if they receive several reports at once. According to Walz and Darcy (7), “The breakdown in the handoff of information in the care of patients is a common underlying cause of medical error.” The researchers identify communication breakdowns as the most common cause of treatment delays, and failure to follow up test results as a common cause of malpractice suits. I have personally been told by administrators that the laboratory’s responsibility ends as soon as the result has been signed out and reported through the LIS – which may be legally accurate, but doesn’t necessarily lead to the best possible patient care. We all need to work as a team to prevent miscommunications and keep our patients from falling through the cracks.

My confession; my advice

I am one of the “stupid” pathologists who believe that they can work when fatigued without making errors – so I frequently catch myself putting in extra hours to finish my work. This has been the ethos for most physicians in the past, but now that the dangers of fatigue and overload are widely recognized, residents and house staff in most specialties are limited to more reasonable working hours. Not pathology, though! Administrators often fail to recognize the high volume of work that arrives on our desks – and our desire to finish in a timely fashion leads us to work overtime, neglect other duties, become fatigued, and potentially make dangerous errors.

Nevertheless, experience has taught me that I am not superhuman. I tend to hurry late in the afternoons when I am tired and may not be at my best for working with difficult cases. In the past few years, I have learned to stop looking down the microscope when I am tired; instead, I review and sign out reports or catch up with correspondence late in the day. Every pathologist is different, and what works for me may not be the right solution for someone else – but it’s vitally important for each of us to recognize our own weaknesses and fatigue points, and to learn to accommodate them.

At least at the national level – if not internationally – we need to agree on a workload model. It’s the only impartial way to determine the appropriate safe output for the average pathologist. And once that safe output is determined, how do we ensure that pathologists don’t exceed it? That’s down to the individual institutions. If they knowingly allow their pathologists to work overtime, then they should be held responsible for any errors that may occur – whereas right now, it’s the pathologists themselves who bear that burden.

We need administrators to understand just how important our many duties are and to give us the resources and authority we need to deliver good laboratory information. It’s easy to overlook the medical oversight and administrative aspects of our work, but in the long run, that will negatively impact laboratory services. Our unique and multifaceted role must be clearly understood, and our workloads adjusted to ensure we can carry out every part of it to the best of our abilities. That’s how we ensure the best possible health – for our patients, and for ourselves.