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Editorials: Michael Laposata Patient-specific Narrative Interpretations of Complex Clinical Laboratory Evaluations: Who Is Competent to Provide Them? Clin Chem 2004; 50: 471-472 [Full text] [PDF]

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interpretative commenting: do not forget the patients

Joseph C Watine   (23 March 2004)

Response to Dr. Joseph Watine

Michael Laposata   (23 March 2004)

interpretative commenting: do not forget the patients 23 March 2004
Joseph C Watine, Consultant, Laboratory Medicine Hôpital de Rodez, France Send letter to journal: Re: interpretative commenting: do not forget the patients j.watine{at}ch-rodez.fr Joseph C Watine	We have read with interest Lim et al’s report regarding the quality assessment of interpretative commenting in clinical chemistry [1]. Its editorial by Michael Laposata is very interesting too [2], but I think it should be examined. Of course, this letter aims at being constructive rather than critical. In Lim et al.’s survey [1], out of the 3059 interpretative comments made by laboratory professionals, 1372 comments (45%) were satisfactory, 1221 (40%) were less relevant, and 466 (15%) were unacceptable, and therefore potentially dangerous. Before interpreting such figures, I’d like to underline three important facts: 1) The people who were asked to comment were provided with very few clinical data; thus it seems to us that 45% of satisfactory comments is not as bad a result as that. 2) In real life, many laboratory professionals would certainly be much more cautious than they were in Lim and al.’s virtual survey, and they would probably avoid posting comments if they were not quite sure of their clinical validity. The above figures of 40% and 15% of less relevant or unacceptable comments would probably drop significantly. 3) There is a very high proportion of physicians who do not react when they receive abnormal laboratory results. For example, in a very recent study, 62% (yes indeed: 62%) of physicians did nothing after receiving high results of blood glucose in patients who were screened for diabetes [3]. Therefore, we cannot agree with Michael Laposata’s view that the number of errors of interpretation observed in Lim and al.’s virtual survey would be too high to allow this service to survive. At least a “real life” study would be necessary to demonstrate such a thing, not a virtual one. On the contrary, the results obtained by Lim and al.’s are very encouraging and clearly demonstrate that many laboratory professionals have got the required competence to comment on laboratory results. Of course Dr Laposata is perfectly right to stress that only competent laboratory professionals should be authorized to comment on laboratory reports. Being a member of several patients’ associations, I think it obvious that patients’ information and satisfaction can improve when, in addition to laboratory results, they receive interpretative comments. Recent publications tend to confirm this impression [4-6]. Many patients in our associations could have been diagnosed and treated many months and often many years earlier for their diabetes or for their hemochromatosis if their results had been taken into account by their physicians. All these patients have thus scandalously suffered for many months and even years though their physicians had all the necessary laboratory results to diagnose and relieve them. It is quite clear to us that not only are physicians more likely to react when interpretative comments are joined to the laboratory results, but also that most patients who receive these comments are going to react if their own physicians don’t [7]. French patients probably do not react differently than others, as suggested, for example, by the messages that some English-speaking patients post in the excellent discussion list “ExcessIron” [www.irondisorders.org]. Thus, in our own laboratory for example, when no clinical information is available, the three following ready-made comments are used systematically: 1) For transferrin saturation above 50% in male patients: “Except in case of secondary iron overload (cirrhosis, liver cytolysis, excessive iron intake, hemolysis, dyserythropoiesis, cutaneous porphyria...), and if no transfusion or iron therapy has been recently administered, a transferrin saturation above 50% may lead, after a control on a second blood sample, to look for C282Y mutation in order to diagnose genetic hemochromatosis. In addition, at least the following laboratory tests may have to be measured when iron overload is suspected: blood cell counts, transaminases, ferritin, and CRP. In case of venesection therapy, ferritin and tranferrin saturation must remain below 50 µg/L and 20% during the initial phase of therapy, and then below 50 µg/L and 40% during maintenance therapy, provided blood hemoglobin does not drop below 11g/dL.” 2) For blood glucose above 1.26 g/L: “Diagnostic criteria for diabetes mellitus (ADA 1997/WHO 1999): fasting blood glucose > or = to 1.26 g/L (to be confirmed on two independent blood samples).” 3) For elevated transaminases: “Main causes of elevated transaminases: - viral hepatitis (check for antibodies), - liver steatosis (ALT – TGP > AST – TGO; check for blood glucose and triglycerides), - ethylism and other causes of toxicological injuries (including drugs and food additives...), - auto-immune diseases (check for auto-antibodies if necessary), - hemochromatosis (check for transferrin saturation), and other genetic disorders (alpha-1 antitrypsin deficit, Wilson disease...), - extra-hepatic origin: celiac disease, muscular cytolysis, macro- transaminases...” Dr Laposata may be right to think that patient-specific reports are better than ready-made comments. However, is it possible to be sure that ready-made comment such as those made in our laboratory would be woefully inadequate? On the contrary, in the patients’ best interests, such ready- made comments are much better than no comments at all. Author: Joseph WATINE, Acknowledgements: To Marie-Laure Zago, for her excellent assistance in translating this letter. References: 1) Lim EM, Sikaris KA, Gill J, Calleja J, Hickman PE, Beilby J, Vasikaran SD. Quality Assessment of Interpretative Commenting in Clinical Chemistry. Clinical Chemistry 2004;50:632-7. 2) Laposata M. Patient-specific Narrative Interpretations of Complex Clinical Laboratory Evaluations: Who Is Competent to Provide Them? Clinical Chemistry 2004;50:471-2. 3) Ealovega MW, Tabaei BP, Brandle M, Burke R, Herman WH. Opportunistic screening for diabetes in routine clinical practice. Diabetes Care 2004;27:9-12. 4) O'Driscoll BR, Koch J, Paschalides C. Copying letters to patients: Most patients want copies of letters from outpatient clinics and find them useful. BMJ 2003;327:451. 5) Roy D. Copying letters to patients: Mental health professionals are in fact likely to support this initiative. BMJ 2003; 327:450. 6) Ziebland S, Chapple A, Dumelow C, Evans J, Prinjha S, Rozmovits L. How the internet affects patients' experience of cancer: a qualitative study. BMJ 2004;328:564. 7) Wykurz G, Kelly D. Learning in practice. Developing the role of patients as teachers: literature review. BMJ 2002;325:818-21.
Response to Dr. Joseph Watine 23 March 2004
Michael Laposata, Director of Clinical Laboratories Massachusetts General Hospital and Harvard Medical School Send letter to journal: Re: Response to Dr. Joseph Watine mlaposata{at}partners.org Michael Laposata	Dr. Watine makes some very important points about the editorial I authored in Clinical Chemistry regarding quality assessment of interpretative commenting in clinical chemistry. Dr. Watine suggests that the “test situation” for the interpretative commenting in the Lim et al study showed more errors than would be expected in “real life” because the interpreters would have been more cautious with their comments if the assessments had involved actual patients. I agree that this is a reasonable speculation, and I would be further convinced if there were data to support it. I also agree with Dr. Watine’s comment that some physicians, even when provided with a narrative interpretation of abnormal results, may neglect to take appropriate action. One point of disagreement relates to considering 50% correct comments and 50% non-contributory or incorrect comments a success. I must say that I still find it hard to consider the “half full” view as acceptable. In this era where we are making great effort to minimize medical error, a 50% error rate is troubling, and I think we must be vigilant about how much of the cup is empty. Despite our different positions on this matter, Dr. Watine and I concur that only competent laboratory professionals should be authorized to comment on laboratory reports. Dr. Watine also notes that the interpretive comments should be provided to the patient. I made no comment regarding this matter in the editorial, but this is an excellent point. I believe there is some danger in patients seeing reports that may indicate the presence or absence of cancer, for example, before discussing the results with their physicians. On the other hand, a patient’s review of the majority of test results prior to physician review does enhance the role of the patient in the care delivery process. Dr. Watine challenges my statement that prepared or “canned” comments that are not patient specific are “woefully inadequate” compared to a narrative evaluation that is patient-specific and contains clinical details and relevant laboratory data. I can only refer to my own anecdotal experience over 9 years of generating patient-specific narrative reports as an expert in coagulation for physicians in my own institution and comparing them with “canned” comments in reports not generated by us. The difference to my colleagues is obvious, and I believe it is intuitive that consideration of the full clinical and laboratory picture of the patient greatly enhances the clinical value of the narrative interpretation.