3 months, Lifespan, MHRI, and WIH, required CP
The clinical chemistry laboratory offers comprehensive training to residents in pathology. Thus, there is an opportunity for each resident to establish her/his own goals in consultation with the laboratory supervisors. The rotation consists of segments at individual hospital laboratories in the Brown system that have special expertise in particular areas of chemical pathology. Clinical pathology call by pager is a key component of this rotation and provides residents with the opportunity to act as clinical consultants. Daily participation in QA/QC activities is also a key component of this rotation that follows the following approximate schedule:
Segment 1 (at least 1 week)
- introduction and training for CP call
- review of physical and chemical principles
- introduction to instrumentation
- review of QC and statistical procedures
- definition of normal and abnormal values
Segment 2 (2 weeks)
- maintenance of homeostasis (renal, hepatic, electrolyte, pH)
Segment 3 (2 weeks)
- endocrine biochemistry
Segment 4 (2 weeks)
- chemistry laboratory results as indicators of disease in specific organs/tissues including
- cardiovascular disease and neoplasia
Segment 5 (2 weeks)
Segment 6 (1 week)
- special procedures in prenatal, perinatal and neonatal clinical chemistry
Segment 7 (2 weeks)
- laboratory organization and management
Residents are expected to gain a thorough knowledge of the organization of the clinical biochemistry laboratory and how it interfaces in both clinical areas and other sections of the Department of Laboratory Medicine. Residents should be aware of the kinds of material the laboratory handles and the sources of those samples. They will understand what constitutes a STAT specimen, a 'routine' specimen and a 'send-out' and on what grounds these categories have been established. They will become familiar with the equipment in the laboratory and understand the principles of their operation. In addition, they should become familiar with the principles underlying the operation of other types of major equipment that they are liable to encounter in other clinical laboratories. They will discuss the reasons for the choice of particular instruments with the clinical chemists.
Residents are expected to develop a working knowledge of the technical operations of the laboratory. The resident will learn the underlying principles of spectrophotometry so as to appreciate both why this is the most common analytical system and the limitations on its use. The resident will learn how both gamma and liquid scintillation counters operate and the statistical nature of counting process. They will become familiar with the basic principles underlying the numerous electrophoretic methods. The resident will become familiar with the theory of potential measurements and their application in combination with selective electrodes for measurement of blood gases, pH, and ions. They will learn the basis of ion measurements by means of flame emission and absorption instruments, specification electrodes and the reasons for the choice of instrument in particular cases.
Residents are expected to acquire an understanding of the chemistry and biochemistry underlying commonly performed clinical biochemistry measurements. The resident will become familiar with the most commonly used reagent systems. These are used on 'type cases' from which the reason underlying the application of a particular reaction may be studied and understood. The principles underlying the use of enzymatic methods and how coupled reactions are chosen and used are taught. The differences between end-point and kinetic methodologies should be studied. The resident will understand the principles of competitive binding studies and their application to RIA. The resident will use the literature and the daily laboratory work experience to become familiar with the mechanisms underlying common separation techniques including GLC, HPLC, and simple column chromatography.
Quality control and quality assurance in Chemical Pathology are emphasized in all aspects of the rotation. The resident will learn to calculate statistical parameters from data sets and how parameters are applied to quality control. From this s/he should be able to appreciate the meaning of the terms 'positive and negative predictive values', 'precision,' 'accuracy,' 'reproducibility,' and 'coefficient of variation.' In turn the application of these concepts to the choice and development of methods will be studied. Having understood the objectives in (a) the resident should then be able to appreciate the application of statistics to the ongoing control of the quality of laboratory output. By working with supervisors s/he should gain insight into the factors that enter the professional judgment regarding the quality and validity of the daily clinical service work.
Residents must also expand their knowledge of the clinical significance of chemical laboratory tests. The resident will become familiar with the derivation of the 'normal range' and the meaning of this expression in the laboratory as well as its application of clinical medicine. Because of the frequency with which 'profiles' appear in the clinical record, the residents will become familiar with the most commonly occurring test groupings which form profiles; the patterns which these show in specific diseases or organ dysfunction; and (relating back to (a) the relative significance of changes in single components in these profiles. The resident will begin to collect an individual database of those single tests that are most useful in the specific diagnosis of particular pathological processes. Comparisons between findings in the clinical chemistry laboratory and those in other sections of the laboratory, including anatomic pathology are made. Finally, the resident should become familiar with the clinical chemistry literature, particularly sources dealing with the interpretation of tests and those texts that deal adequately with the ever present problems of interferences and sources of error. Useful integration of the Chemistry Laboratory with the LIS and HIS will be emphasized.
In clinical biochemistry, specific procedures related to OB/GYN patients such as estriol determinations, amniotic fluid bilirubin scans, lecithin/sphingomyelin ratios, and phosphatidyl glycerol determinations are taught to evaluate fetal well-being. The microsample techniques are emphasized and differences in neonatal reference values are evaluated by the trainee. Rapid determination for bilirubin is stressed along with other tests for neonatal jaundice.
Goals and Competencies
a. The resident should be familiar with gathering essential and accurate clinical information about the patients, including:
Where applicable discussion of history with clinical house staff and/or attendings, Review of laboratory reports of previous pathologic specimens Review of the online medical record when applicable such as those provided by Cerner and Lifelinks.
b. Residents should be able to handle clinical questions with increasing degrees of independence including:
Researching and reviewing medical information. Preparation and interpretation of Chem/Immunochemistry testing including cardiac markers, cancer markers, endocrine assays, vitamin assays, therapeutic drug monitoring, toxicology assays, serum protein electrophoreses. Timely and effective communication with clinicians.
c. Residents demonstrate competence in the methodologies and performance of procedures considered essential for the understanding of all Chem/Immunochemistry assays performed, including:
Automated chemistry testing. Interpretation of Chem/Immunochemistry tests. Toxicology assays and therapeutic drug testing. Cardiac and cancer markers. Review of daily Q.C. and work center activity reports
d. Residents should be able to suggest to clinicians diagnostic workup including:
Consideration of specialized testing, etc. based on patients' clinical history, up-to-date scientific evidence gleaned from textbooks, journal articles, internet-based searches, and clinical judgment.
e. Residents should be able to use available information technology (hospital and laboratory information systems, internet-based literature searches)
To support workup and use Chem/Immuno chemistry assays for diagnostic purposes. To help educate clinicians by providing relevant literature references.
f. Residents should be able to work with health care providers, in the generation of accurate and clinically useful Chem/Immunochemistry reports and effective communication of results to clinicians.
Residents should be able to demonstrate competency in handling practical problems related to laboratory operations and management through involvement with basic issues of laboratory management, such as evaluation of analytical instrumentation, laboratory staffing, cost accounting of a new analytical method relative to an older one, and new method evaluation for technical performance.
2. Medical Knowledge
a. Residents should be able to demonstrate an investigatory and analytical thinking approach to clinical situations, including:
Development of reasonable and complete differential diagnoses for Chem/Immuno cases based on the available clinical information, laboratory tests, and current published information. As part of their workup of cases, suggesting appropriate additional testing (isoenzymes, immunofixation studies, and further clinical testing such as serology, etc.) if applicable. encouragement to participate in at least one research project, such as clinicopathologic studies, or case reports with literature review.
b. Residents should be able to discuss the basic and clinically supportive sciences which are appropriate to the specialty of Chem/Immunochemistry testing, including:
Discussion of pathophysiology of various diseases, drugs metabolites, and metabolic disorders in the light of discussion of Chem/Immuno assays performed. Discussion of basic statistical principles in order to analyze quality control and quality assurance data, to calculate normal ranges for new assays, and correlate methodology and instrumentation. Explaining the clinical presentations and manifestations of various diseases during discussion of Chem/Immunochemistry testing performed. Explaining the basic chemistry assays and instrumentation methodology, principles and applications.
3. Practice-Based Learning and Improvement
a. Residents should have the ability to analyze, practice experience and perform practice-based improvement activities using a systematic methodology, including:
Participating in Clinical Pathology Quality Assurance Committee meetings, learning how to identify and report on a variety of QA monitors (case turnaround time, mislabeled/unlabeled specimens, clotted specimens, etc.)
b. Residents should have the ability to locate, appraise, and assimilate evidence from scientific studies related to patients' health care problems, including:
Performing literature search and review to find relevant scientific references to aid in the workup of Chem/Immuno cases (computer-based searches). Obtaining information about their patient population (via COPATH and computer searches and medical records chart review) for clinicopathologic study of selected diseases.
4. Interpersonal and Communication Skills
a. Residents should be able to demonstrate effective communication with other health care providers, patients by:
Presenting cases at in-house and conferences under direct faculty supervision. Interacting with clinicians when providing support to clinicians during on-call assignments.
a. Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to confidentiality of patient information. Residents should be able to:
Demonstrate highest respect, compassion, and integrity and responsiveness to the needs of patients and professional staff with prompt response to calls from the clinical Chemistry lab, faculty and clinicians during their Chemistry and on-call rotations. Exhibit a commitment to excellence and on-going professional development by reading of text books and journals for their own professional advancement. Demonstrate appropriate behavior with the faculty, clinicians, their peers, and the administrative, technical and clerical staff of the hospital. Systems-Based Practice
a. Residents must demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to call on system resources to provide pathology services that are of optimal value.
Residents should become familiar with LIS "Cerner" for the review of complete chart, to track specimen status and during trouble shooting of a specimen. Residents should become familiar with the use of LifeLinks to review all laboratory results, Pathology and Radiology findings. Practice cost-effective health care and resource allocation that does not compromise quality of care, understanding the need for and cost of special studies, extended testing, and other send-out testing. Residents may also inspect the section of Chem/Immunochemistry during a CAP inspection.
- Consultation: Residents will actively participate in clinical consultations at the discretion of the medical director.The level of participation and responsibility is determined by the medical director based on the documented skills and abilities of each resident. Faculty backup will always be available and resident consultations are reviewed by the medical director. Residents will also attend selected medicine morning reports to provide consultative services for medical residents.
- Clinical Correlation: Clinical correlation is provided through consultation with clinicians and by comprehensive review of patient laboratory data and clinical history.
- Quality Assurance: Residents are expected to actively participate in the quality control and quality assurance aspects of the laboratory and to take on a defined role in the collection and analysis of data including chart review.
- Graduated Responsibility: Residents are expected to gain substantial technical expertise in the performance of routine and special chemistry testing. They will participate in clinical consultations at the discretion the medical director depending on their level of ability and documented responsibility.
- Required Departmental Conferences: Daily Staff QA/QC conference; Departmental QA meeting
- Required Interdepartmental Conferences: Medicine morning report as appropriate
- Objective Evaluation: Written examination at the completion of the rotation in an essay format in response to specific topics in clinical chemistry.