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Clinical Pathology and Reference Laboratories

The pathology laboratory is traditionally divided into anatomic and clinical pathology. Anatomic pathology encompasses tissue pathology such as biopsies, Pap smears, and resection specimens like breasts and colons. This is the pathology of the living, surgical pathology. It is also the domain of the autopsy and includes the subspecialty of forensic medicine and the coroner. Clinical pathology encompasses the blood work and is traditionally, although somewhat incorrectly, viewed as the laboratory. It is here that a patient’s blood work is measured for cholesterol, the throat swabs are placed on agar dishes for cultures, and the blood is typed and crossed so that one may receive the properly matched blood product. The laboratory is often viewed by the patient as a black box, a bewildering collection of sophisticated equipment where specimens are received and a diagnosis miraculously appears.  However producing these complicated interpretations and diagnoses are many highly trained professionals. Directing the laboratory sections are supervisors and directing the supervisors is the laboratory manager. The pathologist is the medical director overseeing all laboratory personnel and interacting with the hospital administrative and medical staff.

St. Louis Memorial, like many pathology training programs, divided its training program along anatomic and clinical pathology divisions. The first and third years were anatomic pathology and the second and fourth years were clinical pathology. The fifth year was an elective year which could be fulfilled either as a chief resident or as a fellowship. While such a division ensured that the resident would have undivided attention to the subject matter, it was increasingly viewed by the attending pathologists as an artificial separation, compartmentalizing pathology and exacerbating rather than minimizing the differences between the two divisions.

Cost cutting measures by the hospital had forced the outsourcing of many laboratory tests traditionally performed by the hospital. Every area of the laboratory was affected but the most severe cuts occurred in microbiology, chemistry, and coagulation. With reduced test volume there was the inevitable loss of laboratory personnel. The first round of cuts came four years ago with promises that no further lay-offs would occur. The downturn in the economy and decreased Medicare reimbursements trumped any administrator’s promise and within ten months, a second round of cuts occurred. Further lay-offs were avoided by attrition.

During the past decade, tremendous consolidation occurred in the outpatient reference laboratory business leading to two national laboratories, Birkman Laboratory and United Laboratory Services or ULS. Laboratory medicine, once largely provided by mom and pop operations in every major city, was now a commodity in a fiercely competitive market that took no prisoners. By sheer economies of scale, esoteric testing could be offered at substantially discounted prices to customers. These laboratory behemoths were publicly traded companies with a singular purpose, turn a profit at any cost.

Most hospitals had aligned themselves on either side of the battle but loyalty was fleeting and frequently turned on promises of faster turn around time and decreased prices. In some areas of the country, ULS was giving away free testing to gain market share, leading to accusations of violations of medical compliance. To counter this, Birkman began providing larger physician groups with their own phlebotomists so that their patients would not have to travel to remote draw stations to have their blood work done.

Memorial was aligned with ULS. It occupied a massive 90,000 square foot facility about one mile from the hospital. It was one of its several regional laboratory centers across the United States drawing its volume from Missouri and the immediate surrounding states. Aware of Memorial’s key role in residency training, ULS agreed to allow residents to rotate through their laboratory as part of their clinical pathology rotation. In addition, Memorial was contracted to provide anatomic pathology services for their increasing outpatient biopsy cases. These cases consisted of Pap smears and a wide selection of biopsies from the breast, skin, gynecological, and gastrointestinal tract.

Dr. Rosenthal, the chief resident, was searching for James. Clutching a folder with protruding letter and legal sized papers, an accelerated gait with heels clicking, he was a man on a mission. Spying James he yelled out, “Dr. Deeeeeetaaaaan! I need you now!”

James was in his office and had quietly closed his door except for a small crack when he heard the familiar gait of Dr. Rosenthal. The door quickly swung aside to reveal the long white coat and

Fall was beautiful in St. Louis. Leaves blazing orange, red, and yellow, whipped along by an ever colder wind. At that point, it was the only beauty he could find in the city. Before coming to the United States, James could only imagine the meaning of fall foliage. In the Philippines there were two seasons, rainy and more rainy. James had planned on spending the next few weekends traveling across Missouri, finding the “heartland of America”, a noble purpose he told himself.

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