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Clinical laboratory practitioners today are found in many settings-almost everywhere professional health services are provided. Opportunities exist here and abroad and in traditional (e.g., hospital) and nontraditional settings, such as the Peace Corps or emergency care facilities.

That was not always the case. In earlier days, the laboratory professional worked exclusively in a hospital-based laboratory as an aide to a physician called a pathologist, who is a specialist in medicine concerned with the study of disease, its causes, and its consequences.

Today, thanks to rapid advances in testing technology and the need for laboratory services, laboratories are no longer confined to hospitals, and laboratory professionals fulfill much broader responsibilities.



Laboratory Distribution

Most laboratory tests are performed in one of three categories; hospital laboratories, independent laboratories (e.g., referral laboratories), and laboratories in physician offices. (See Table 4) Most laboratories are found in physician offices. In fact more than half of all U.S. clinical laboratories are found in these settings. Hospital laboratories (8,518) make up only 5 percent of all laboratories, yet they perform the greatest percentage of tests. Hospitals and laboratories offer a large number and variety of tests. They also hire and continue to employ individuals educated as laboratorians. For complex testing, these institutions tend to hire greater numbers of baccalaureate-level personnel. They have also been highly regulated since 1966.

In HMOs and clinics with simple, standardized testing and a relatively healthy clientele, whole year technicians may predominate, under the supervision of a laboratory technologist. What then are the usual work settings for laboratory personnel? Brief descriptions follow:

Laboratory Settings

Small Hospitals

Most clinical laboratories, such as those in hospitals, are organized into sections by the type of work performed there. In small hospitals, those with fewer than one hundred beds, the laboratory may be divided into the following four areas (see Chapter 1 for a more detailed explanation of these laboratory areas):
  • chemistry and urinalysis

  • hematology and coagulation

  • microbiology including bacteriology, parasitology, and mycology

  • blood banking and serology (also called immunology)
In a small hospital, all laboratory sections would most likely be in one large room, with specific areas delineated for each kind of analysis, for example, chemistry or hematology. In the small hospital, laboratory staff would probably include a baccalaureate-level laboratory administrator who also performs procedures, one other baccalaureate technologist, three laboratory technicians, and a part-time secretary. All laboratory personnel would be expected to perform all tests, work evenings and weekends, and take "call" on a rotational basis.

Medium Hospitals

In a medium-sized hospital, one hundred to four hundred beds, the laboratory most likely would be divided into sections discrete from one another. Typical staff size will vary based on the patient clientele and mission of the hospital (see Table 5).

For example, a suburban hospital of 150 beds would be expected to have laboratory tests performed for residents in that geographic area in need of diagnosis, surgery, or rehabilitation. Thus a 150-bed suburban general care hospital may employ only twenty-seven persons in the laboratory. In contrast, an acute care pediatrics hospital of the same size would employ considerably more laboratory personnel. This hospital requires a larger staff due to the intensity of care and laboratory data needed for very ill infants and children.

Large Hospitals

In a large hospital, one would expect many specialty and subspecialty areas. For example, the chemistry unit might include drug analysis, enzymology, endocrinology, electrolytes, a "stat" (emergency) lab, and urinalysis. Laboratory personnel would vary in number from eighty to more than five hundred and likely would work on fixed shifts, either day, evening, or night. (Most laboratories pay differentials-hourly increases in pay-for evening and night shifts.)

Independent Laboratories

If one chooses an independent (commercial) laboratory in which to work, one would expect a profit orientation, staff specialization, sophisticated instrumentation, and perhaps a production line approach to test performance. Patient contact would be limited, because specimens are obtained elsewhere and brought to the lab oratory. Normally there would be little weekend or evening work, although more independent laboratories are operating twenty-four hours each day, seven days a week. In such cases, staffing needs would be met through rotating or fixed assignments.

Research

Research-both basic and appHed-is an intriguing area of work and is chosen by a number of laboratorians. Basic research may involve, for example, the DNA sequencing of an epithelial cell membrane protein. Applied research may be concerned with evaluating the best chemotherapy regimen to use in treating leukemia or in understanding the immunologic changes that occur with aging. Research provides in-depth expertise in a small area of scientific inquiry; it also provides the opportunity to perform tests, analyze resultant data, and determine the significance of those data. Research may involve only a small amount of patient contact, and interaction with others is usually less frequent than in a health care setting.

Public Health

Another area in which laboratorians work is in public health. Here the identification of organisms causing outbreaks of infectious and communicable diseases is made. A variety of immunologic tests also are performed to determine ones prior exposure to mumps, measles, the HIV virus, or other microorganisms. Laboratory analyses for water purity, food safety, and environmental hazards are performed as well. Duties of personnel vary according to the needs of the public, and they are usually determined by a state department of health.

Blood Banks

In blood banks, such as those of the American Red Cross, blood is drawn, typed, and checked for any unexpected antibodies as well as for the absence of infectious agents such as the hepatitis or AIDS virus or syphilis spirochete. Usually there is a strong community spirit within blood banks, as physicians, nurses, and laboratorians work together to provide safe blood for citizens of the region.

Industry

Industry is attractive to laboratorians who have an entrepreneurial spirit. Here they can work in "research and development" (R & D) developing new tests or instrumentation, as a technical specialist assisting users who are having problems (e.g., troubleshooting instrumentation), or in sales.

Small Health Care Facilities

If one works in a clinic, health maintenance organization, or physician office laboratory, the kind and volume of testing depends on the size of the laboratory. The central laboratory of a large HMO, for example, might be very similar to that of a large hospital. However, the lab in a three-physician practice may offer only ten or twenty laboratory tests.

Organization of Laboratories

Laboratories are typically organized in a chain-of-command model, at the top are directors and administrators; in the middle is supervisory staff; and on the front line, performing the actual tests, are the staff technologists and technicians, together with others, including phlebotomists, obtaining blood. (See Figure 1 on the next page.) Of course there are variations on this basic structure. In a hospital, for instance, the laboratory's organization depends on size, the types of patients it serves (pediatric, psychiatric, acute care), and its objectives. Most hospital laboratories are headed by a medical director. That individual usually is a physician specializing in pathology. In smaller hospitals, however, qualified nonphysicians, including clinical laboratory scientists and other personnel, assume administrative responsibility. They usually work with a consulting pathologist, who assumes medical responsibility.

In another model, usually larger, a physician (often a pathologist) holds the title medical director, and a clinical laboratory scientist holds the title administrative director. Under this arrangement, the physician is responsible for medical interpretive and consultative functions and for anatomical pathology tests, while the administrative director colleague actually manages the laboratory.

In the independent laboratory sector, it is quite common for non-physician professionals to own, direct, and operate full-service laboratories.

According to standards affirmed by the American Society for Clinical Laboratory Science and under the shared medical and administrative director model, responsibilities are divided to draw most fully on each professional s expertise. In this model, the physician director is in charge of physician-patient services as well as a number of other important functions,

A physician director may also assist in establishing test proto cols and policies. He or she will likely consult with medical personnel regarding tests and help interpret results and data. As team leader, the physician director will probably represent the clinical laboratory staff at conferences and may be expected to teach in primary and continuing education programs for medical and laboratory staff.

The laboratory administrator (often a clinical laboratory scientist) who, like the medical director, also reports to a senior member of the hospital's administration, has responsibility for laboratory operations. He or she will prepare and maintain up-to-date laboratory procedures and quality control operations. Each category of service provided by the laboratory requires a procedural manual that the laboratory administrator prepares and keeps current. Super vision of other personnel, keeping work schedules in order, and ensuring proper performance of all procedures are also a part of the laboratory administrator’s job duties. This requires proper orientation, training, and continuing education for all technical and supervisory staff. The administrator makes sure duties are assigned to capable personnel. Budgetary functions are usually part of the job, as are regular consultations with medical personnel.

The technical supervisor in each of the departments of the lab oratory implements quality control practices to ensure accuracy and validity of test results and procedures. He or she prepares daily work schedules to provide adequate coverage and good use of available personnel. Supplies of reagents and other materials need to be commensurate with the workload, so the technical supervisor must be aware of each work areas needs. Employees must be trained and supervised to ensure that they follow laboratory policies, procedures, and safety practices.

Technical personnel include clinical laboratory scientists (medical technologists) and technicians. Duties performed by baccalaureate-level laboratory scientists (technologist) include those tests that require the exercise of independent judgment and responsibility with minimal supervision by the director or supervisor. Certain procedures like report results, equipment maintenance, record keeping, and other quality control requirements related to test performance would also fall to the trained laboratory scientist.

Another important duty is the direct personal supervision of trainees, technicians, and other supportive technical personnel employed by the laboratory.

Laboratory technicians, who normally possess a two-year technical degree, typically perform procedures that require limited exercise of independent judgment. They execute procedures under the supervision of a supervisor, or director, and they are expected to follow directions detailed in the procedural manual for each designated duty. Duties are assigned to technicians based on their qualifications and experience.

Advantages and Disadvantages of Working in Various Laboratory Settings

Today many options for the delivery of services exist. Some independent laboratories perform rare procedures on referral from physicians and hospital laboratories-procedures that hospitals and large group practices find too costly to offer. Examples include hair arsenic analysis, HLA-B27 typing to aid in the diagnosis of ankylosing spondylitis, or the identification of TA-4 marker for carcinoma. Other independent laboratories provide routine types of tests.

On the other hand, some hospitals refer many of their tests to commercial facilities and keep only an emergency laboratory operation, which is generally staffed round the clock and equipped to provide only a limited range of tests. Other hospital laboratories have entered the testing market quite aggressively. They not only do almost all their own tests; they also serve as referral laboratories for other health care institutions and act almost like independent lab oratories. Test volume can vary from a few thousand tests a year (in a small physician office laboratory (POL) to millions of procedures (in large medical centers or independent facilities).

Although rapid specimen transit (by air or road courier) and computer technologies have made regional laboratories possible, not all testing can be done long-distance. The type of testing that a given facility offers depends significantly on the nature of the services provided and on the competition. Important factors for hospital laboratories are the patient caseload and whether or not the facility is a large, teaching hospital. A facility that serves predominantly cancer patients (an oncology hospital) or a psychiatric hospital would offer a menu of tests significantly different from each other, or from a multipurpose, acute care hospital. Similarly, a teaching hospital can be expected to offer a wider range of tests-including rare procedures-than a nonteaching hospital.

There is no laboratory that offers all employment advantages. As in every field, there are tradeoffs. Each type of facility has certain characteristics that may make it more or less attractive as a place to work.

Work Characteristics of Various Laboratory Settings

Small Hospital Laboratory attributes include: rotation among lab sections, making one a strong "generalist"; much patient contact; small test menu; small workforce; mandatory shift rotation and "taking call"; very strong patient care orientation; much interaction with other health care staff (optimizing a team spirit).

Teaching Hospital Laboratory attributes include; staff specialization; less patient contact; larger test menu; larger workforce; more new technology and instrumentation; usually fixed shift assignments; moderate patient care orientation; some interaction with other health care staff.

Independent (Commercial Laboratory) attributes include: staff specialization; no patient contact; profit-loss orientation (which may include bonuses); production line orientation; good advancement opportunities; limited contact with other health care professionals.

Research Laboratory attributes include: independent work; limited patient contact; opportunities to develop procedures and make decisions; flexible hours; development of in-depth knowledge of a specific area of inquiry; repetitive work; position may be dependent on grant money.

Public Health Laboratory attributes include: work heavily oriented to microbiology and immunology; very little patient contact; may involve routine testing; minimal weekend work; little interaction with other health professionals.

Blood Bank attributes include: strong commitment (organizational and individual) to providing safe blood and blood products for transfusion; specialized work; little direct patient contact; some donor contact; moderate interaction with other health care professionals, especially physicians and nurses.

Industry (example: development of or troubleshooting of new lab tests or instrumentation) attributes include: emphasis on scientific entrepreneurship and profit-making; may require knowledge of government regulations; work may be repetitive; no patient con tact; limited interaction with other health care professionals; good opportunities for advancement.

Clinic or Physician Office Laboratory (having a limited practice) attributes include: limited test menu; may include other work, for example, X ray or record keeping; much patient contact; usually does not include shift or weekend work; strong interaction with clinic physicians or other staff.

Health Maintenance Organization (kinds and volume of testing related to size of HMO) attributes include: large HMO may have one central laboratory for complex tests and other satellite laboratories for routine tests; some patient contact; work may be stream lined. Small HMO has few tests; much like a small physician office laboratory.

Physician office laboratories and group practice laboratories span a wide range of characteristics. Some physician office laboratories offer only ten to twenty of the most common tests, are housed in a space the size of an apartment kitchen, and are staffed by one or two individuals-characteristically not laboratory professionals. At the other end of the continuum, large clinics (such as the Mayo Clinic) can surpass a medical school facility in test variety, the sophistication of the equipment, and the size and diversity of its staff.

Laboratory Safety

Clinical laboratory professionals are meticulously educated in the safe management and handling of toxic and infectious substances because this is an integral part of the work they do. Therefore, very reliable, safe procedures are in place and continually being improved upon. Precautions have intensified, and the universal precautions mandated by the Occupational Safety and Health Administration (OSHA) have drastically minimized any risk of accidental exposure to the laboratorian.

Over time, plastics and disposables have replaced much glass ware. Chemical burns are extremely rare in health care laboratories because many reagents in use today are premixed and prepackaged.

Unpleasant odors, too, are rare. Thanks to changes in clinical laboratory practice itself, and to bio-safety shields and ventilated hoods, today’s clinical laboratory is likely to have a clean, astringent scent-if any at all.

Summary

Opportunities in clinical laboratory practice exist in a vast array of settings, both traditional and nontraditional. Depending upon ones interest and qualifications, there are opportunities for technical, supervisory, and management roles, as well as for a host of roles outside the laboratory itself As today’s health care industry continues to change in response to new economic pressures-including those pressures to control health care costs-and new discoveries in science, medicine, and clinical laboratory science itself are made, qualified clinical laboratory practitioners can look forward to an array of options within and outside of the conventional laboratory setting.

It is obvious that laboratory professionals can work in a variety of settings, although most work in hospitals. Other health-related sites include independent (commercial) laboratories, clinics, group practices, HMOs, blood banks, public health facilities, research laboratories, and industry.

In this chapter, duties and responsibilities of various laboratory personnel have been introduced. We can now move on to detailed descriptions of various laboratory personnel.
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