What Do They Ask?

A question I commonly receive in my messages and emails is:

“What types of questions do physicians ask?”

It would be unreasonable to list every question I was asked by a physician because it would be boring after the first 50 or so, but I can certainly list a few of them. I will break them down into question complexity.

These are what I consider the “easy” questions. While these do not necessarily require any advanced training, these are questions that are asked nonetheless because the physician simply did not know the answer. In most laboratories, medical laboratory assistants could answer the questions should the physician call the laboratory to ask. The first set of questions below were ones that I received by phone call, email, or in-person while rounding with patient care teams.:

• What type of specimen do I need to collect for an alpha-1-antitrypsin phenotype?
• Is one mL of CSF sufficient for the viral studies we need?
• How will it take for that HIV genotype result to come back?
• How much does an INR cost for a self-pay patient?
• For a 24 hour urine, does the patient urinate into the container or the toilet when the clock starts?

This next set are questions that do require additional training. These could certainly be answered by bench-level medical laboratory scientists (if they had time to answer them!). Unfortunately, most bench-level scientists are so overwhelmed by the sheer volume of work they have to do, they simply do not have the time to process thousands of specimens and answer the phone. Again, these are questions that I received by phone, email, or in person:

• I ordered a BMP but only the potassium resulted. Where is the rest of the results and why didn’t they get run?
  • Because you ordered both a potassium and a BMP, but the nurse only sent the specimen with the potassium label so the instrument only ran and resulted the potassium. A potassium is included in the BMP, so ordering both is not necessary and can cause issues such as this.
• The lab rejected Mr. ___’s CSF for a cell count. Why?
  • Based on looking at the specimen, it was a traumatic tap because there is a large clot in the tube. Once the blood has clotted, the cells cannot be counted.
• Is PCR or the rapid kits better for flu testing?
  • Rapid kits tend have very poor sensitivity. If you get a negative result on a rapid flu test, you really don’t know if your patient doesn’t have the flu or did the test just not detect it. The molecular based tests, like PCR, have much higher sensitivity. While there is still a small chance for a false-negative, the chance is considerable smaller than it is for the rapid flu test kits.

Finally, there are the complex cases that do require advanced training. These often require review of the patient’s chart and take into consideration the patient’s clinical picture when answering the question. These are the questions a DCLS is critical to ensuring they are answered correctly, especially if a pathology is unable or unwilling to answer the question.

• I have a 14-week old with a spontaneous subdural hemorrhage and the parent don’t fit the profile of abuse. What coagulopathies could cause this? What tests do I need to order? Oh, the patient is going to neurosurgery now and will also need a transfusion later.
  • There are several coagulopathies that could cause this. My team and I will review the patient’s chart and make a personalized testing algorithm for this patient to give you an answer using the least amount of blood as quickly as possible. We will need to draw specimen prior to the transfusion, so please let us know as soon as the baby is out of neurosurgery. [This infant, by the way, had severe hemophilia A.]
• I can’t tell if my patient has TACO or TRALI; can you help?
  • Sure, let me me review the patient’s chart and I will get back with you my findings as quickly as possible. [The patient’s last transfusion was 3 days earlier and symptoms were just starting so it was not TRALI. Turns out, this patient did not have a transfusion reaction at all. Nursing had neglected to sign-off on infusion medications for 3-days since the transfusion and they were not be included in the patient I’s & O’s (inputs and outputs for you muggles out there). Once they were included, the patient was positive three liters of fluid so the were simply fluid overloaded.]

I hope this allows you to see the differences in complexity between the different types of questions and gives a glimpse into the wide variety of questions that are asked. Once most physicians realize there is someone they can turn to to answer laboratory questions, they want more. For any bench-level medical laboratory scientists out there who have answered physician questions, you have probably experienced physicians starting to call and asking specifically for you by name. It’s almost like a drug, one hit and they want more! Once they have a taste of effective laboratory consultation, they can’t stop!!!

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