family doctors on call?

[onelove]

Hey guys,

 

I just have a question about family doctors?

Are all family doctors on call after they finish their residency, or are only the ones working in hospitals on call?

 

Thanks!

[da_birdie]

Many community FPs don't do call. There are ones that join a call group (with several other FPs) to provide on-call service to their patients.

 

I work 50% of the time in subacute hospital setting and do one-in-seven weekly-call (home-call).

 

I don't do call for my community practice.

 

Rural FPs almost always are involved in a call schedule.

 

Hope that helps

[Mourning Cloak]

This is something I've always wondered about.

 

How can a family doc NOT be on call (or at least have someone on call for their call group?)

 

For example:

 

You send Old Mrs. So and So to have her routine INR. It's processed at the hospital lab, and as it's routine, it doesn't get spit out of the machine until 2 am. At that time, her INR is 8.

 

The tech (of course) tries to report the panic result to the physician who ordered it, but he isn't on call, nobody answers at the office at 2 am, and he doesn't have a call group. So there's no one to receive the result.

 

What then?

[Satsuma]

An INR in the community isn`t going to be reported at 2am. And even if it was and the INR was 8, what would you like to do about it? The pt would have already taken their coumadin dose for the day. Unless they are bleeding, you are just going to tell them to hold their coumadin for the next few days...which you can do in the morning. And if they are bleeding and they need it reversed...they should know to go to the emerg.

 

If you aren`t doing obstetrics or hospitalist work, there is really little reason why a family doc should do call. If your patient is having an emergency at 2am....they should go to the emerg. Even if they were able to call you, what would you do for them? You don`t have access to the ressources to work up whatever their emergency is or treat their emergency if your office.

[Mourning Cloak]

An INR in the community isn`t going to be reported at 2am.

 

That's when they come off the machine in our lab. The routine community stuff is low priority, goes on last, and runs overnight. Or Friday night at 6 pm. Or the weekends. The panic values always come in on the weekends.

 

The pt would have already taken their coumadin dose for the day. Unless they are bleeding, you are just going to tell them to hold their coumadin for the next few days...which you can do in the morning. And if they are bleeding and they need it reversed...they should know to go to the emerg.

 

How would you know that she wasn't bleeding without talking to her? How would you tell her on Friday night to hold her warfarin if you won't get the result until Monday morning when you return to the office?

 

Is it defensible if the old lady strokes overnight/over the weekend?

 

Who's responsible for her preventable death if the lab tried to report the result to the ordering physician, but s/he was unavailable to receive it (and had no one covering him/her)?

[A-Stark]

I'd say the lab's responsible... or rather that it's unreasonable to expect a primary care physician to be held responsible for her patients' statuses at all times. A better question is whether such a delay til morning is likely to lead to adverse events.

[Mourning Cloak]

it's unreasonable to expect a primary care physician to be held responsible for her patients' statuses at all times

 

But if YOU order a test on your patient, YOU are responsible for interpreting and responding to those results.

 

A better question is whether such a delay til morning is likely to lead to adverse events.

 

But if the old lady DOES die, who is going to be at fault?

 

Not the lab. The lab's responsible for trying to get the result to the clinician.

 

BUT . . .

 

If the clinician ignores it, that's the clinician's problem.

 

If the clinician doesn't understand it/doesn't realize what the test s/he ordered means, that's the clinician's problem.

 

If the clinician is unavailable, that's the clinician's problem.

 

For God's sake, pathologists do call. And those patients aren't even ALIVE anymore!

[Satsuma]

That's when they come off the machine in our lab. The routine community stuff is low priority, goes on last, and runs overnight. Or Friday night at 6 pm. Or the weekends. The panic values always come in on the weekends

 

Well that is interesting. I have always gotten my INRs in the community the same day. I think if I was working in a community where I knew the labs ran these tests after hours, then I wouldn`t have my pts go for routing INR checks on Fridays. I am not sure I would agree with the idea that doctors need to be on call at all hours to have lab values reported. I think a better solution is for the lab to run INRs and have the results to the doc during working hours. Especially if the lab is noticing that "panic values always come in on the weekend", maybe they aren`t prioritising properly. Like run lipid profiles or something on the weekend.

 

How would you know that she wasn't bleeding without talking to her? How would you tell her on Friday night to hold her warfarin if you won't get the result until Monday morning when you return to the office?

 

I wouldn`t ...but she would, and she should know to get herself to the hospital. If your gums start bleeding, or you have blood in your urine, or nosebleeds, large bruises everywhere AND you are on coumadin...you don`t need to call your family doc to know you should go to the emerg.

 

Yeah, it would be crappy if the old lady had a brain hemorrhage in her sleep. But has this ever happened because an MD was unable to follow-up on lab results...I don`t know...maybe you do.

[Lactic Folly]

That is a good question - do labs contact patients directly if the ordering physician is unavailable? Surely there is an established procedure for critical results, as Satsuma said.

 

And just to clarify - most of pathology deals with patients who are very much alive and awaiting lab and biopsy results that will change their management!

[Mourning Cloak]

I think if I was working in a community where I knew the labs ran these tests after hours, then I wouldn`t have my pts go for routing INR checks on Fridays.

 

Most clinicians aren't that forethinking.

 

Especially if the lab is noticing that "panic values always come in on the weekend", maybe they aren`t prioritising properly. Like run lipid profiles or something on the weekend.

 

We prioritize our specimens based on ACUITY. In general, if you're dying, you're STAT. If you're kinda dying, you're 2. And so forth. All specimens below a 4 (most outpatient specimens, unless marked STAT/URGENT) go on in the order received. We also batch expensive tests (so some prioritizing based on cost control). Our weekend/late night panics usually come out of routine bloodwork. We do all basic testing at all times. Shutting down INRs over the weekend would piss off the ER, most likely (and separating out the outpatient specimens, holding them for 72 hours, then testing them on Monday would just mess up the work flow beyond all belief - assuming the test in question could still be performed on the specimen.)

 

Unfortunately, prioritizing the heme/chem labs based on the convenience of the FPs is not an option.

 

do labs contact patients directly if the ordering physician is unavailable?

 

How? (Unless they're inpatients, we don't have access to their phone numbers).

 

And say what?

 

Surely there is an established procedure for critical results, as Satsuma said.

 

The established procedure for critical results is to report them to the ordering physician IMMEDIATELY.

 

You call the office first, cellphone, then you page. I can't imagine a doctor not being available for critical results. EVERYBODY - from the OBs to the surgeons to the radiologists - is either on call or has a call group. It's sheer laziness - every other sort of doctor can be reached for reporting panic results (as can MOST FPs in Canada); this is an incredibly expensive law suit waiting to happen. (Belatedly: And somebody's mom is dead).

 

You don't want to have to deal with critical results at 2 am, stop ordering tests. (Or only order lipid profiles).

 

PS - This doesn't mean you have to be on call for everything. But the lab HAS to be able to get a hold of you.

[Mourning Cloak]

And the House award goes to everyone who thinks that the lab should hold the Friday specimen of the old lady with the INR of 8 over the weekend - she goes on popping her warfarin, of course - so that the result doesn't come out before Monday and unduly inconvenience them.

 

Are you doctors or bankers?

 

(My dentist is in a call group. My veterinarian has call coverage).

 

Doesn't anybody care about their patients? Doesn't anybody want to know if their patient might be critically ill?

[xyz]

And the House award goes to everyone who thinks that the lab should hold the Friday specimen of the old lady with the INR of 8 over the weekend - she goes on popping her warfarin, of course - so that the result doesn't come out before Monday and unduly inconvenience them.

 

Are you doctors or bankers?

 

(My dentist is in a call group. My veterinarian has call coverage).

 

Doesn't anybody care about their patients? Doesn't anybody want to know if their patient might be critically ill?

 

That is just inflammatory. Of course physicians want to know if their patients are critical. Of course physicians don't want their patients to bleed out. But at some point there has to be a hand off of responsibility. You don't work 24/7 either. Shared call I agree is a good idea.

[chemgirl]

Calm down, you are talking to medical students and premeds, not doctors or even residents. Some of us could be thinking through this scenario for the very first time, especially if we haven't done our family med rotation and seen how these issues are actually handled.

 

And the House award goes to everyone who thinks that the lab should hold the Friday specimen of the old lady with the INR of 8 over the weekend - she goes on popping her warfarin, of course - so that the result doesn't come out before Monday and unduly inconvenience them.

 

Are you doctors or bankers?

 

(My dentist is in a call group. My veterinarian has call coverage).

 

Doesn't anybody care about their patients? Doesn't anybody want to know if their patient might be critically ill?

[Mourning Cloak]

Calm down, you are talking to medical students and premeds, not doctors or even residents. Some of us could be thinking through this scenario for the very first time, especially if we haven't done our family med rotation and seen how these issues are actually handled.

 

And I'm the tech who's holding the hot potato. (And no, I'm not gunning for med school).

 

However, the point is well taken. I should have been more specific. I should have specified that I wanted suggestions from FPs & FP residents as to how they actually ensure patient care. I thought the answers were the actual thoughts and opinions of actual MDs.

 

So, patients don't really fall into these cracks? Our lab turns up 0-3 critical values from FP-ordered outpatient bloodwork per night, and our FPs are all part of call groups, so this is the first I've ever heard of a MD who didn't do call (in some form or another). I really am interested in new and fresh ideas about handling overnight/weekend call amongst FPs* (bf is a FM PGY-2).

 

*that doesn't result in lawsuits

 

(And yes, I really am up at 5 am. Techs do call, too!)

[Satsuma]

So, patients don't really fall into these cracks? Our lab turns up 0-3 critical values from FP-ordered outpatient bloodwork per night, and our FPs are all part of call groups, so this is the first I've ever heard of a MD who didn't do call (in some form or another). I really am interested in new and fresh ideas about handling overnight/weekend call amongst FPs* (bf is a FM PGY-2).

 

*that doesn't result in lawsuits

 

(And yes, I really am up at 5 am. Techs do call, too!)

 

If your bf is PGY-2 FM why don`t you ask him how docs manage critical values instead of posting in the medical student general discussion section. And how is it that you appear to have such little respect for MDs if your bf is one!

 

ALL your FPs where you live are part of call groups? Community FPs or FPs that do hospitalist work?

 

I have worked with 3 FPs and none have done call (one did call since she did hospital work...but it was call for the inpatients and to admit pts from the emerg...not call for the clinic). Maybe there is some sort of set-up for the odd critical lab value...that nobody has talked about...but I don`t know. Family practice is not a hospital...there is no obligation to provide service 24/7. You aren`t required to be sitting around waiting for an unlikely critical INR to get called through at any hour of the day (because the lab appears to not want or be able to work within the system and provide the needed service during working hours).

 

I have been told the pay to follow a pt on coumadin is $8/month...I don`t think that covers needing to be on call at all hours.

 

And frankly, I am having a hard time thinking of scenarios where a pt of a fam doc in the community is gonna come back with critical lab values...without having signs/symptoms that they should be going to the ER.

Sure there is the INR scenario...a sudden INR of 8 is probably unlikely to occur but if it did, there isn`t anything to do about it except hold the coumadin if there is no bleeding. What else would there be that is critical and can`t wait until morning...Hb? well if it was so low they needed a transfusion, they would have had Sx that told the fam doc they should tell their pt to head to the ER. Critial T4? Well if someone was in thyroid storm, the fam doc would have sent them to the ER. What kind of critical lab values are you talking about?

 

I have not really heard of any deaths that resulted from family docs not being available to get lab values. So somehow the system is working.

[da_birdie]

Responsibility for follow up of investigations

An article for physicians by physicians

Originally published June 2008 - Canadian Medical Protective Association

 

http://www.cmpa-acpm.ca/cmpapd04/docs/resource_files/infoletters/2008/com_il0820_1-e.cfm

 

Physicians are generally aware they are responsible for following up on results of investigations they order. Due to the widespread shortage of family physicians, an increasing number of patients are obtaining episodic care through walk-in clinics and emergency departments. There may be some confusion regarding physicians' responsibility for follow up in these circumstances. The following are examples of calls from members seeking the CMPA's advice on this issue.

 

 

While the report to patients is usually the duty of the ordering physician, the laboratory or facility may be expected to take necessary steps to notify patients in cases of emergency when the ordering physician is not available.

 

In one legal action involving a hospital lab and a gynecologist who had performed a Pap smear, and the results of which were not received in the doctor's office, the judge ruled:

 

" ...the physician and the lab should both have reliable and effective systems with an audit trail to follow-up and confirm that significant tests have been reported in a timely manner."

 

Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable efforts to ensure appropriate follow up is arranged.

 

When physicians order an X-ray or any other test – whether in their own office practice or in a hospital – they need to be satisfied there is a system in place to follow up on the results.

 

Any physician who becomes aware, even incidentally, of an abnormal test result may be seen by the courts to have a duty to make reasonable efforts to inform the patient or the patient's physician of the result.

 

Physicians are reminded of their professional responsibility to make reasonable efforts to ensure that patients receive the appropriate care when they order tests or become aware of abnormal test results. The more serious the abnormality and possible consequences on the patient's health, the more urgent it is for the physician who is aware of the result to act appropriately.

 

I work part-time in community setting, the clinic opens 7 days a week so there's always a FP reviewing bloodwork daily.

However, where I trained for residency, they did have an "after-hours clinic" and also residents are expected to provide home-call coverage, but the calls we dealt with were pretty much patient-originated, just patched toward us through the local nurse line. I don't remember having to deal with lab results much afterhours. Usually the lab results are dealt with by the preceptor /residents the next business day. Again, most labs ordered in the community does not have the kind of "urgency" that need to be communicated to patients right away. A lot of numbers marked with "critical result" by the lab's computer are actually within the patient's baseline. Also, it is usually in the hospital-setting that a blood test will have the kind of acuity to warrant a physician to be on-call 24H (eg CBC for the acute hemorrhage, Trops/CKMB for the suspected MI, etc). In the community, most physicians are careful enough to Not order INRs for Fridays, most patients have a standing order for INRs at certain day(s) of the week, so that it gives the MD time to contact the patient. I have on occasion ordered Trops/ECG at outpatient setting (for the patients who probably just have MSK chest pain); I usualy just send the higher-acuity pts to ER/urgent care for work-up. I have ordered an ECG on a symptomatic pt where the lab picked up a new A Fib, they called me first, but they were gonna send him to ER anyway. I agree with CMPA that both MD and lab should have reliable means to contact the patient.

[Mourning Cloak]

If your bf is PGY-2 FM why don`t you ask him how docs manage critical values.

 

They answer their pagers. Even the FPs.

 

And how is it that you appear to have such little respect for MDs if your bf is one!

 

I have enormous respect for MDs. They are some of the most amazing people I have ever met. They come in nights, weekends. The transplant guys at my centre will do a liver at night and then the next one less than five hours later because that's how the livers come in. The FPs are up all night with their labouring patients and then they're in the office the next morning. I think these people are laudable.

 

But I would really be taken aback by an MD who wasn't accessible after hours. Can you imagine a general surgeon who wasn't part of a call group? Or an obstetrician who sent their labouring patients to the ER to be delivered? I'm shocked to find out that there are any doctors who refuse to do a reasonable amount of call. I've never seen it before (except for the very elderly).

 

ALL your FPs where you live are part of call groups? Community FPs or FPs that do hospitalist work?

 

I'm assuming they are all available, since all physicians who order tests in the city are accessible. Even the NPs are reachable. We've only one instance in recent memory when we couldn't reach a physician. She was in the CCU with a massive inferior MI.

 

You aren`t required to be sitting around waiting for an unlikely critical INR to get called through at any hour of the day (because the lab appears to not want or be able to work within the system and provide the needed service during working hours).

 

The lab is functionally unable to provide everyone in the hospital district lab values between 9 am and 5 pm. That is correct.

 

And frankly, I am having a hard time thinking of scenarios where a pt of a fam doc in the community is gonna come back with critical lab values...without having signs/symptoms that they should be going to the ER.

Sure there is the INR scenario...a sudden INR of 8 is probably unlikely to occur but if it did, there isn`t anything to do about it except hold the coumadin if there is no bleeding. What else would there be that is critical and can`t wait until morning...Hb? well if it was so low they needed a transfusion, they would have had Sx that told the fam doc they should tell their pt to head to the ER. Critial T4? Well if someone was in thyroid storm, the fam doc would have sent them to the ER. What kind of critical lab values are you talking about?

 

All critical values are reported. A critical value is value that is either critically high or critically low. Thus critical values exist for almost test ordered. Your question seems to be about the clinical relevence of the critical value, but the lab cannot determine the clinical relevence of a critically abnormal value. Only the physician who ordered the test (i.e. is familar with the patient and knows why s/he ordered the test) can do so.

[Mourning Cloak]

Responsibility for follow up of investigations

An article for physicians by physicians

Originally published June 2008 - Canadian Medical Protective Association

 

This is very helpful.

 

The Bottom Line from the CMPA was:

 

Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable efforts to ensure appropriate follow up is arranged.

 

When physicians order an X-ray or any other test – whether in their own office practice or in a hospital – they need to be satisfied there is a system in place to follow up on the results.

 

Any physician who becomes aware, even incidentally, of an abnormal test result may be seen by the courts to have a duty to make reasonable efforts to inform the patient or the patient's physician of the result.

 

Physicians are reminded of their professional responsibility to make reasonable efforts to ensure that patients receive the appropriate care when they order tests or become aware of abnormal test results. The more serious the abnormality and possible consequences on the patient's health, the more urgent it is for the physician who is aware of the result to act appropriately.

 

* * *

 

So the onus is on the ordering physician to ensure that results are followed up on. However, if another physician (which I am not, BTW) becomes aware of the results, they have a duty to try and contact the patient or the patient's physician. And finally, they remind physicians of their professional responsibility when ordering tests.

 

Presumably, if you were unable to contact the FP the medical director of the lab would attempt to contact the patient (we typically don't have phone numbers for outpatients). Bf says the pathologist would probably be obligated to send the patient to the ER because he would never try to diagnose some random, unknown patient over the phone. We'd be sending up to three patients a night to have their labs reviewed by the ER docs!

[A-Stark]

But I would really be taken aback by an MD who wasn't accessible after hours. Can you imagine a general surgeon who wasn't part of a call group? Or an obstetrician who sent their labouring patients to the ER to be delivered? I'm shocked to find out that there are any doctors who refuse to do a reasonable amount of call. I've never seen it before (except for the very elderly).

 

I can't imagine those things, but the issue here is what sort of procedures exist for results ordered by FPs. I don't know them myself, but I have a sense that too many hypotheticals are being thrown out here without reference to actual practice.

[The_B]

Haha reading this thread makes me laugh.

 

Mourning cloak, you seem to think that Family physicians should live in Hospital. That seems to be the only option for those who aren't part of a group. I've known of some docs with a roster over 3000 patients. If those physicians ran to help with every single problem their patients had, they would never have a moment to themselves. Comparing the call of any other specialty to that which family medicine would have if they had to cover for all of their patients is crazy.

 

If there is an emergency, or a value that comes back from the lab that is urgent, they have a place that deals with emergent cases, it's called Emergency department. There is no reason why the lab tech couldn't do the exact same job that the family doc would do in those cases, and tell the person to go to the ER.

 

This reminds me of something a preceptor once warned me about. Every profession will try to dump information onto the next level up so that they are no longer responsible. It is part of their job, as they are often not allowed to make decisions as to how to use the information, and it is the physicians job to be prepared to only accept information at times they can use it. This sounds like one of those cases.

[Mourning Cloak]

If those physicians ran to help with every single problem their patients had, they would never have a moment to themselves.

 

I don't care if you abandon your patients at night/weekends/holidays to the ER. (Although I still don't see why any doctor would consider themselves above doing a reasonable amount of call).

 

However, on point: Since the only person who can contact the patient is the MD who ordered it, it behooves them to be available to the lab, if not to anyone else.

 

If there is an emergency, or a value that comes back from the lab that is urgent, they have a place that deals with emergent cases, it's called Emergency department. There is no reason why the lab tech couldn't do the exact same job that the family doc would do in those cases, and tell the person to go to the ER.

 

This is not the lab tech's job - I don't get paid to do "the exact same job that the family doc would do in those cases"

 

You want to pay me as a family doctor, then I'll do your job.

 

This reminds me of something a preceptor once warned me about. Every profession will try to dump information onto the next level up so that they are no longer responsible.

 

Agreed. That's what gets me upset - docs dumping information up to the techs so that they are no longer responsible. How can an MD expect to transfer responsibility for his patient to a tech?

 

It is part of their job

 

No it's not. It's yours.

 

From the CMPA guidelines: "Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable efforts to ensure appropriate follow up is arranged."

 

Note that it does not say "the tech" or "the lab" or "the radiologist". It says the "physician ordering investigations".

[The_B]

I don't care if you abandon your patients at night/weekends/holidays to the ER. (Although I still don't see why any doctor would consider themselves above doing a reasonable amount of call).

 

Abandon? The family doc is still going to be there in the morning. And reasonable? Everyday is reasonable to you? My example was for those not part of a health team. If that is the case, with a roster in the numbers I suggested (which are not unreasonable) then they would likely get called nightly about something.

 

However, on point: Since the only person who can contact the patient is the MD who ordered it, it behooves them to be available to the lab, if not to anyone else.

 

I disagree, if a lab tech sees an INR of 8, they can just as easily (and more quickly I'd add) call a patient and tell them to go to the hospital. They are still part of the health care team.

 

 

This is not the lab tech's job - I don't get paid to do "the exact same job that the family doc would do in those cases"

 

You want to pay me as a family doctor, then I'll do your job.

 

But that isn't a family doctors job, that is the point of this thread. You want it to be.

 

Agreed. That's what gets me upset - docs dumping information up to the techs so that they are no longer responsible. How can an MD expect to transfer responsibility for his patient to a tech?

 

Ordering a test isn't dumping information, it is gathering new information that is unknown to anyone.

 

No it's not. It's yours.

 

I was referring to the fact that part of a techs job is to dump information onto the physician.

 

From the CMPA guidelines: "Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable efforts to ensure appropriate follow up is arranged."

 

Note that it does not say "the tech" or "the lab" or "the radiologist". It says the "physician ordering investigations".

 

I don't disagree with this, however, it also says reasonable. You and I simply disagree what reasonable means. I don't think it is reasonable to expect a family doctor to be on call 24/7 for all of their patients. This isn't surgery, where one may have at most a hundred plus patients in hospital at once, this is in the order of thousands.

[Satsuma]

Wow...feels like this thread is getting a little out of hand.

 

I am not clear why this debate is even occuring. I am unaware of any adverse pt outcomes occuring because family docs aren`t on call...and so far nobody has given any examples even. So it would seem the system is working. Why is there argument about it!

 

The points brought up by the CMPA are valid, however, were made in an attempt to address the issue of docs doing locums and walk-in clinics and ermeg shifts. So cases where a doc might order a test for a pt and then not be back (ever in the case of a locum) or for a week or 2 weeks for walk-in clinics and ERs. Who is responsible...the ordering doc or the doc on the next shift, or the doc taking over the locum position. How is the initial ordering doc to get the results of a test ordered when they are no longer at that clinic...etc. These are the issues being addressed by the CMPA statements posted and these are different than the issue of waiting to interpret and inform pts of lab results during working hours. Nobody said that the family doc who ordered the tests weren`t responsible for the results..it is just about the time delay.

 

And I am not sure that I agree the lab tech should be calling pts regarding results. But lab techs work in a lab that is under the direction of a pathologist. The techs aren`t responsible for those results, but the pathologist certainly is. And I see nothing wrong with the pathologist contacting the pt to inform of a critical value and to go to the emerg. And why is it that a pathologist would not be able to contact the pt?? It isn`t like the samples come in anonymously. All the pt info is on the req.

[chemgirl]

I agree with Satsuma. Color me confused as to why this debate is even occurring. Mourning Cloak, you said to me that you wanted to talk to family physicians and FP residents about this, and then you say your boyfriend is an FP resident. So why the need to carry this debate out on this board, (mostly) with people who aren't in a position to answer your question because we are still learning?

 

We've seen and read the CMPA position now which has been informative, but still you insist on debating the point ad nauseum, complete with dramatic bolding and font changes throughout your post... seems like you are looking for some drama and are deliberately being oppositional to create it. You seem to believe that YOU are the only one around who has patients best interests at heart and you are valiantly defending them (these theoretical people with an INR of 8 on a friday afternoon) come hell or high water. Why the need to continue to flaunt the moral superiority you believe you posses on a bunch of strangers?

 

I doubt any of us are as bad as you seem to think we are. If anything, this has given me a window into the animosity that some lab techs must have for family physicians and it does nothing to foster an environment of support and collaboration between the two professions.

[Guest Buffy Pool]

OK. Here's the answer to the original question.

 

3 AM. Critical value. MD MIA. Tech calls pathologist. Pathologist sends patient to ER.

 

It's a bad system (patient panicked, tech upset, pathologist grumpy, and ER annoyed). But we deal. And besides, it doesn't happen that often.

 

INR lawsuit

 

*BP has left the building*