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The Knowledge Hub for Pathology was created to provide authenticated and validated knowledge for United States and Canadian Academy of Pathology members and pathologists worldwide with access to the Web. Using the material presented at the annual meeting of the United States and Canadian Academy of Pathology with existing selection and review procedures ensured that these criteria were met without added costly procedures. Further submissions for courses and research papers are provided in electronic format and funded by universities and hospitals for their creation; thus, the principal costs borne by the United States and Canadian Academy of Pathology are Web site-posting costs. Use has escalated rapidly from 2 million hits in 2002 to 51 million in 2009 with use by 35,000 pathologists from now a total of 180 countries. This true "freemium" model is a successful process as are more traditional continuing professional development course structures such as Anatomic Pathology Electronic Case Series, a "premium" model for learning electronically also sponsored by the United States and Canadian Academy of Pathology., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Faculties (i.e., schools) of medicine along with their sister health discipline faculties can be important organizational vehicles to promote, cultivate, and direct interprofessional education (IPE). The authors present information they gathered in 2007 about five Canadian IPE programs to identify key factors facilitating transformational change within institutional settings toward successful IPE, including (1) how successful programs start, (2) the ways successful programs influence academia to bias toward change, and (3) the ways academia supports and perpetuates the success of programs. Initially, they examine evidence regarding key factors that facilitate IPE implementation, which include (1) common vision, values, and goal sharing, (2) opportunities for collaborative work in practice and learning, (3) professional development of faculty members, (4) individuals who are champions of IPE in practice and in organizational leadership, and (5) attention to sustainability. Subsequently, they review literature-based insights regarding barriers and challenges in IPE that must be addressed for success, including barriers and challenges (1) between professional practices, (2) between academia and the professions, and (3) between individuals and faculty members; they also discuss the social context of the participants and institutions. The authors conclude by recommending what is needed for institutions to entrench IPE into core education at three levels: micro (what individuals in the faculty can do); meso (what a faculty can promote); and macro (how academic institutions can exert its influence in the health education and practice system).

Pathologists are under siege by corporate medicine, managed care systems, or varieties of government-initiated health care restructuring. The pressure is on us to attend at least equally to fiscal pressures, as well as to our patients' medical needs. These pressures must be accommodated within the limits of our professional duties and responsibilities. We must have more than an intuitive sense of what it is to be a professional and to work in a system that is overseen typically by a directorate and that includes managers and innovators. The example of the failure of the corporate managers and directors of a national blood transfusion service highlights the need to balance the inter-relationships of managers, professionals, and innovators by a directorate knowledgeable in these complex systems.

Although most individuals who head clinical laboratories are still named Director of Laboratories, their training for this has focused principally on management training in addition to their postgraduate medical education. The implicit assumption seems to be either that direction and management are synonymous or that management is the most important aspect of laboratory administration. Common usage, albeit imprecise, fosters both of these paradigms. The proposition of this article is that directing and managing are two discrete activities of sufficiently different orientation as to require different training, attitudes, and values. Management as a generic phenomenon was codified early in this century through the works of F.W. Taylor (1), whose concepts of scientific management were embraced with zeal during World War I and were also an important conceptual basis for the managed economy of the Soviet Union as proposed by Lenin. Gradually, management with concern for efficiency and hierarchic control structures has diffused throughout social as well as business systems. Many will remember the introduction of the corporate governance system into hospitals beginning in the 1930s and its spread throughout the medical system until at present administrators of hospitals, for example, are called CEOs or presidents. Management, as narrowly defined and as traditionally practiced, is based on control of a system by adherence to prescribed standards for uniform production, to particularized timelines for delivery of product or service precisely when needed, and to predetermined budgets for efficiency and predictability. All of these are laudable and essential to the internal administration of any system. They also require a specific set of values and a set of behaviors that center on adaptability and compliance.

Expenditures on laboratory tests have increased by 468% in real dollars in two decades although the cost per test has remained constant. Cost of labor has doubled over that period, with an approximately similar increase in personnel productivity as the offset. Part of the increased labor cost relates to increased pay for technologist work of apparent increased complexity. We found that technologists perceived less than 20% of all work and less than 4% of all tests performed to be highly complex or of moderately high complexity. Implications of these findings for test complexity analysis and for technologist training are discussed.

The clinical laboratory is described as a system with an enquiry component or demand side, where control of test utilization is the mandate of the clinical physician or surgeon, and a production component or supply side, where answers to clinical questions are generated and control of test data production is the mandate of the laboratory physician. Supply side unit costs are maintained by increased production effectiveness brought about by the judicious manipulation of supply costs; labor costs; and capital expenditures for automated equipment, robots, and information technologies. The pathologist's prime role as controller of the supply side is outlined, as are the clinical physician's prime role and pathologist's subsidiary role in control of test use on the demand side.

A new method for analyzing factors that contribute to the rising costs of hospital laboratories was used to analyze data from a Canadian teaching hospital for the period of 1971 to 1981. Results indicated that real cost per acute care admission has doubled, primarily because more tests are performed and the factors of production in laboratories are costlier. Increasingly sophisticated technology in the laboratory has increased productivity, and thus reduced cost per test; however, increased intensity of testing apparently has not been accompanied by reduced length of stay.

With simple microbiologic and fluorescent tests, we detected two cases of classic galactosemia, confirmed by specific enzyme assays, in the first 25 000 newborn infants in British Columbia screened for this disorder. The results were equivocally abnormal for another 31 infants, and a second blood sample was requested from each, either for repeat screening or for enzyme assays. The two infants with galactosemia were in hospital with an undiagnosed acute illness and had only a trace of non-glucose reducing substances in the urine when the screening tests were done. Screening for galactosemia fits well with our established programs of screening for phenylketonuria and hypothyroidism and costs less than $1 per infant tested.

The effects of five iodinated contrast media and of physiologic saline on bladder capacity were studied. It was found that a significantly greater volume of sodium chloride was tolerated than of Cysto-Conray, Conray 30. Hypaque meglumine 30, Hypaque sodium, and Dimer X. Dimer X was tolerated in the smallest volume. The reason for the difference in volume tolerated is not known. The bladder mucosa showed dehydration changes 6 hr after saline cystogram with no change at 24 hr, 48 hr, 7 days, and 3 months. The contrast media produced dehydration and hydropic and desquamative changes in the bladder mucosa with at least one of these changes persisting up to 3 months. There was no significant difference in the severity of the changes produced by the various contrast media. No evidence of inflammatory changes was seen in the bladder mucosa or wall or in the ureter with any of the agents.

1. Between 1971 to 1977, 74,521 urines, collected on filter paper and mailed in, were screened by the Metabolic Screening Program of the Children's Hospital. These represented 45.9% of live births in B.C. hospitals were the program has been available. The mean age of the infants was 4.4 weeks. Urines were examined by chromatography with ethyl acetate-pyridine-water for sugars. 1423 (2.13%) had an abnormal pattern necessitating a repeat urine card. A persistent abnormality was noted in 167 (0.22%) and from these a liquid urine sample was obtained for two dimensional amino acid chromatography and/or a repeat sugar chromatography. 2. In 47 (0.06%) of these a definite metabolic abnormality was confirmed. These included cases of Iminoglycinuria (8), Hartnup trait (4), Nonketotic hyperglycinemia (2), Histidinemia (1), Cystathioninuria (5), Argininosuccinic aciduria (1), Maple Syrup Urine Disease (1), Diabetes Mellitus (1), Renal glycosuria (1) and Persistent galactosuria (3). 201 infants had a slight increase of cystine and/or lysine, and 19 of these were documented to be heterozygous for cystinuria.

In this review we have tried to identify some of the management issues affecting laboratories in the past, present, and future. In particular, we have focused on the increases in utilization and cost and have attempted to demonstrate some of the factors affecting the supply and demand sides of these issues. In the absence of a price mechanism to allocate resources, alternative strategies to evaluate and regulate laboratory use were discussed. Although promise is held out by some of these approaches, they are not, in our view, fully workable at this stage. We suggest that, in the interim, sound medical direction and management of the laboratory as a production function can be of benefit in inhibiting, if not actually controlling, cost increases. In particular, we recommend concentration on the management of technology because of its crucial role in laboratory costs and utilization. Emerging trends in clinical laboratory and monitoring technologies suggest that issues relating to decentralization, quality control, and funding will have to be addressed in the near future. The prime motivation for clinical laboratory use, i.e., the generation of answers to clinical questions, seems destined to continue and expand. The challenge for practitioners, researchers, and policy-makers is to harness, evaluate, and manage the technologies that can best contribute to both medical practice and health.

The study reported in this paper examines clinical reasoning styles with a focus on laboratory utilization. A stratified sample of 80 physicians participated in the solution of a simulated patient management problem. The analysis focuses on variation in the portfolio of laboratory tests ordered as a function of practice setting (e,g., physicians in practice versus physicians in training). The study also examines the response of physicians to the imposition of constraints on ordering, as well as behavior, when unlimited ordering capacity is provided. Overall, the data profiles emerging from the analysis indicate the variety inherent in physician decision-making strategies, and point to the necessity of employing a cautious and flexible approach toward any general scheme of constraints upon medical diagnostic procedures;

The scope and magnitude of bedside testing by personnel without formal laboratory training have recently increased. There has been some question about the reliability of bedside test results produced by nurses, physicians, and other ward staff that are used in clinical decisions. Glucose testing is currently the most widely performed bedside test. Because of the likelihood that the use of bedside testing will increase in the future, this article discusses various issues concerning bedside glucose analysis, including the scope of such testing, staff responsibilities, training and supervision, testing frequency, work flow and result reporting, and the reliability of bedside glucose results, in three institutions. We also suggest an approach to bedside testing quality management.

The concept of structuring complexity is described as a process in which, during medical investigation, intensity of laboratory examination is escalated as the perceived complexity of diagnostic need increases. Application of this concept to laboratory controlled testing protocols is discussed. A clinical chemistry protocol for thyroid testing of ambulatory care patients in British Columbia resulted in a 15% reduction in test use and a 12% reduction in laboratory charges to the third party paying agent over a two-year period. The need to develop medically acceptable laboratory protocols that encourage selective test utilization and reduce cost is emphasized.

We assayed more than 5000 blood spots dried on filter paper and approximately 1000 serum samples for immunoreactive trypsin, with commercial reagents (Behring and Sorin). The assay procedures were modified so that newborn screening is technically feasible. Both kits are satisfactory for serum assay, but the Sorin materials are better adapted for blood spot analysis. Immunoreactive trypsin in blood spots rapidly decreases with specimen age, but is stable in frozen serum. Values for premature infants do not differ significantly from those for full-term babies. Children with cystic fibrosis were readily distinguished from those without, up to at least one year of age.

A computerized decision-support system has been developed and implemented to assist in the economic evaluation of alternative clinical chemistry equipment configurations. The capabilities, structure, and relative merits of the system are discussed. This decision-support system is now being used extensively by hospitals in British Columbia. An alternative equipment configuration, identified with the aid of the system, resulted in one hospital alone saving an annual $200,000 in consumables and reagents costs. Further development of computerized economic evaluation systems is encouraged.

A conceptual framework is outlined as the basis for analysis and evaluation of laboratory test-ordering patterns. This framework highlights the input, process, and output phases of the laboratory inquiry system. Data are presented from a contemporary Canadian study to show that the cost of laboratory testing is escalating and represents a sizable proportion of hospital costs. Practical policy interventions intent on reducing the costs in this complex system will require thorough analysis within a conceptual framework such as is outlined here and will require ultimately sophisticated control programs at various levels in the laboratory inquiry system.