Dr. Tom Wheeler has an interesting blog post over at his blog Lab Line by the Doctor’s Doctor.
It starts "I was out of town attending a conference when I got an email from an infectious disease internist wondering if I had done the AFB stain on a bone biopsy that had been specifically ordered by the attending physician on the pathology requisition slip accompanying the specimen. On the surface this might seem as a reasonable request – the patient had been treated for active tuberculosis involving the bone for over one year and there was a desire to complete the placement of an artificial joint, but only if the tissue was negative for TB."
One of many comments received mentioned "You forget your place; yours is to perform a test at the direction of the attending physician (and in most cases that test is set up by a technician for you to review so you aren't in on the front end). You are not the physician of record and while you have an opinion and level of knowledge that the ordering physician may not (or then again they may have) you do not get to dictate to the "Customer of the Lab" whether or not you will perform the service ordered. Try that on a regular basis and they will take their business elsewhere and there are literally hundreds of labs looking for work. "
Dr. Wheeler goes on to explain that in communication with the clinician, justification for not ordering the stain was provided with an amicable resolution of the matter and reassurance to the clinician was provided and all ended well. The stain was not done; Dr. Wheeler exercised his right as a physician to use his judgement based on what he knew and saw of the case and did not perform the test, even though it was specifically requested by the ordering physician.
The anonymous comment above takes a different approach and one I must admit is more like I have thought and generally follow. If a specific stain is ordered, take congo red, to rule out amyloid, I could either a) after reviewing the case if I think it is warranted, order the stain; b) order the stain even if I do not think the histologic findings warrant doing so but performing the stain "just in case"; c) order the stain regardless of what I see on the histology to avoid a subsequent phone call, e-mail or text asking me why I did not order the stain; d) not perform the stain based on what I see on the histology and head off the question or another request to do so with my own phone call or e-mail.
Depending on the particular request, I must admit I sometimes take the easy way out and do the stain becuase I think if the clinician made the request, they may have some information I do not have in front of me or in the EMR (yes, this does happen — EMRs only contain information someone puts into them), unless I think the request if completely off the wall. This way when they ask about the stain, I can report it was done at their request and was negative.
To some extent, we do this already as standing orders, which in some cases, are not justified. Helicobacter stains on all "gastric" biopsies. Alcian blue stains on all "esophagus" or liver "panels". The problem is that for non-gastritis, non-Barrett's cases and liver biopsies to rule out tumors, you may still get stains that are not warranted. Why is this done? Because the clinicians usually requested it at some point — Dear medical diretor/chairman/group head — please do a Helicobacter stain on all stomach biopsies or an alcian blue on all esophagus biopsies so "you don't miss anything".
What do you do/does your practice do about specific stain requests? Which ones do you do routinely largely because, historically, a clinician or group of clinicians made a standing request at some time?
