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In the early 1990s when I was at the Massachusetts General Hospital as director of clinical laboratories, I was invited by Ramzi Cotran to join him and Stan Robbins at the Brigham and Women's Hospital for a meeting. In that meeting, they indicated to me that the Robbins Pathologic Basis of Disease, primarily an anatomic pathology book, would greatly benefit from a parallel book in clinical pathology (laboratory medicine). At that time, areas such as coagulation and toxicology were expanding rapidly with new disorders and new tests to diagnose them. Because there was little anatomic pathology in these fields, the discussions of these major areas of diagnostic medicine in the Robbins book were limited. In addition, as the test menu in the clinical laboratory was growing in complexity and cost, many important clinical laboratory tests for common disorders, such as the troponin test for myocardial infarction, were also discussed only briefly in the Robbins book. Both Robbins and Cotran understood that a discussion regarding the threshold for diagnosis of myocardial infarction, as troponin testing rapidly evolved and improved, was necessary to fully discuss the topic. There were many twists and turns from that meeting about 20 years ago to the development of this second edition of Laboratory Medicine: The Diagnosis of Disease in the Clinical Laboratory in the prestigious Lange series by McGraw-Hill. With this second edition, I believe we truly have a book that is essential for education of medical students and residents studying clinical pathology, and importantly, for practitioners in a clinical setting. By selecting the correct tests and interpreting the results correctly, physicians using this book should be able to optimize patient outcomes and reduce the cost to achieve a diagnosis.

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This second edition is a great step forward from the first edition. It contains information about genetic tests now in common use. Additional descriptions of test methods with simply illustrated figures have been added to this edition. The authors of the individual chapters have all taken significant steps to make the tables that indicate the diagnostic tests for different clinical conditions more concise and easy to understand. It is now clear that significant morbidity and mortality occur on a daily basis, affecting thousands of patients, because incorrect tests are ordered, important tests for the diagnosis are omitted, and/or the interpretation of test results by the physicians who ordered the tests is incorrect. A survey of medical schools currently underway has shown that the teaching of laboratory medicine over the full 4 years of medical school includes (as a mean value across the US medical schools) only about 10 hours of formal training in laboratory medicine. This study also shows that, unlike virtually every other medical discipline, laboratory medicine is commonly not taught by experts in the field, even if they are present in the institution. As a result, medical schools graduate physicians who have had almost no training in something they do virtually every day—order laboratory tests and interpret the test results. Surprisingly, the patients and the medical institutions suffer cost and care disadvantages quietly and unknowingly. There are surely hundreds of patients every month in the United States who present to an emergency room with shortness of breath, for whom a diagnosis of pulmonary embolism is overlooked, and an appropriate test (the D-dimer test for pulmonary embolism) is not ordered. Such patients are discharged from the emergency room without ever being anticoagulated, and for some, to die shortly thereafter, from an expansion of the pulmonary embolism. Like surgical errors or medication errors, the error of the healthcare provider who did not order a necessary test results in a preventable death—but unlike surgical and medication errors, the fact that such a case represents a preventable death is rarely recognized by the patient, the patient's family, fellow physicians, and often even the physician who failed to order the correct test.

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There are several groups of healthcare providers who would benefit significantly by using this book to correctly order laboratory tests and correctly interpret the test results. Certainly, there is every reason to believe that medical students can learn the histopathologic changes associated with a disease using a textbook such as the Robbins Pathologic Basis of Disease, and learn laboratory tests associated with that disorder, using this book, at the same time.

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Medical technology students would greatly benefit by a thorough understanding of the methods that are illustrated in Chapter 2 of this book. In addition, it would be of immense benefit for medical technology students to more fully understand the clinical significance of the test results that they generate so that they can more knowledgeably interact with physicians who are confused about laboratory test results. Interactions between medical technologists and physicians ordering tests that result in improved performance in test selection and result interpretation would greatly increase the respect for the medical technologist (also known as clinical laboratory scientist) from physicians who use the clinical laboratory.

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In conversations with primary care physicians attempting to select the correct laboratory tests, they often indicate that one of their first inquiries about which laboratory tests to select is to search Wikipedia. It is most likely that there is a table in this textbook, written by a prominent expert in the field, that will tell a practicing physician exactly what test to order, and importantly, how to interpret the result as well by describing common interpretation mistakes – with a much higher reliability than virtually all of what is available on the Internet.

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It is my greatest hope that the use of this textbook, which presents the entire field of laboratory medicine to a large audience of future physicians, medical technologists, and healthcare providers ordering laboratory tests, will result in better clinical outcomes for patients at a greatly reduced cost.

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Michael Laposata
Galveston, Texas

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