Pathology's Stepchild

Clinical chemistry (CC) isn't very alluring! The paper entitled “Attitudes and Beliefs of Pathology Residents Regarding the Subspecialty of Clinical Chemistry: Results of a Survey” by Haidari et al¹  in this month's Archives of Pathology & Laboratory Medicine tells us that residents do not have a positive attitude toward clinical chemistry, do not feel that they are being taught well, and do not feel that they will become competent in clinical chemistry with a residency alone. Surveys of community hospital pathologists²  as well as potential pathology employers and recent graduates of pathology residency programs³  confirm that pathologists who are new in practice are not well prepared to practice clinical chemistry.

Much effort has been expended in delineating the specific roles and behaviors of the ideal clinical pathology practitioners. More than 20 years ago, the Graylyn Conference, a joint effort of the Academy of Clinical Laboratory Scientists and Physicians (ACLPS), the American Society of Clinical Pathology (ASCP), the Association of Pathology Chairs (APC), and the College of American Pathologists (CAP), had as its goal the creation of scientifically oriented clinical pathology practitioners who are capable of serving as consultants to other physicians, managing laboratory resources, and playing leadership roles in an increasingly complex health care system.⁴  The 2006 proposal for Curriculum Content and Evaluation of Resident Competency in Clinical Pathology⁵  states: “The overall goals of a training program in clinical pathology should be to develop a pathologist who understands the science and technology of the clinical laboratory and assures the quality, clinical appropriateness, and usefulness of the data produced by that laboratory and who is capable of communicating as a medical consultant to clinicians about test utilization and interpretation for the clinical management of patients.” Similarly, the recent Pathology Milestone Project,⁶  a joint initiative of The Accreditation Council for Graduate Medical Education and The American Board of Pathology (ABP), addresses clinical pathology, specifically including test selection, consultations, and interpretation and reporting as a patient care competency. Why is there this discrepancy between well-reasoned basic principles and goals, and the reality of training in clinical chemistry? The above guiding principles provide a vision for what a successful clinical chemist/clinical pathologist looks like. The destination is specific; the journey is not and is fraught with challenges.

The perceived demand for pathologists/clinical chemists is low, largely because of reimbursement patterns. The Tax Equity and Fiscal responsibility Act of 1982 and the Social Security Amendments of 1983 instituted diagnosis-related groups, put an end to bundled payment for the professional and technical portions of clinical laboratory tests, essentially abolished any reimbursement for pathologists' involvement in clinical pathology, and made payment for the so-called Professional Services to the Provider (Part A) extremely problematic. Since then, most pathologists' income has been from anatomic pathology (AP), and vacancies in community hospitals (where 80% of pathologists work) were filled by someone who could generate revenue by doing AP and who could also “supervise” the chemistry laboratory on a part-time basis, rather than a PhD or a pathologist with expertise only in CC who could not do frozen sections and therefore could not be on-call evenings and weekends and who would not be able to generate AP revenue. Therefore, the academic centers where 80% of pathologists are trained received very few, if any, calls for graduates with expertise in CC.

Genzen and Krasowski⁷  contend that residency training in CC differs among programs depending on variations in curriculum, for example, time allotted for CC, hidden curricula, and cultural norms with respect to anatomic pathology, as well as the numbers of MD, PhD, and medical technologists available to teach CC. Could the residents' complaint that they do not experience a supportive learning environment in CC be in part due to who is teaching them? And could that influence the content of the teaching programs? If most of the supervision and teaching in CC rotations is done by medical technologists (clinical laboratory scientists) or PhDs, it will naturally concentrate on the science, technology, and operations of the chemistry laboratory rather than on clinical application.

Further, it may well be that what is being taught in residency is not what is needed in practice. In academic centers, where most residency training occurs, CC is primarily concerned with laboratory operations and with the science, technology, and quality assurance in the chemistry laboratory. In the community hospital practice, the pathologist's involvement in CC consists mainly of consultation with clinicians regarding test selection and interpretation. In the academic center, the professor of medicine does not need any help in deciding which tests to use and does not need help in interpreting the results. In community practice, however, the general internist or primary care physician needs help in test selection and interpretation all the time, and the pathologist in charge of CC becomes, first and foremost, a consultant, participating in patient care. The need for a pathologist's guidance in the use of the laboratory for the solution of clinical problems is becoming even greater in community practice and integrated health systems now that physician's assistants, nurses, and other physician “extenders” are often ordering and interpreting tests. The rapidly growing numbers of molecular and genomic tests, which in the community hospital are often in the CC section, will also require a higher level of selection guidance and result interpretation. Although the above-referenced guidelines address consultation, that does not appear to occupy a dominant niche in most training programs. Furthermore, an unfortunate current training strategy is to “teach to the test,” so we need to ask, What do the ASCP's Resident In-Service Examination and the ABP examinations emphasize? Is that what most programs are teaching? And is that information congruent with what the practicing pathologist needs to know?

Although it may seem counterintuitive, another reason for CC's lack of appeal is the remarkable recent technologic progress. New instrumentation with machine-based, self-correcting standardization and quality assurance systems is so sophisticated that day-to-day professional input and even technical judgment are often not needed. The instrument manufacturers have also taken over much of the innovation and the scientific and technologic development in clinical chemistry; the introduction of advanced technologies using miniaturization, nanoscale analysis, microfluidics, and biochips, as well as in vivo monitoring of critical analytes, further reduces need for the pathologist to be involved in the science and technology of CC.

How can the Graylyn Conference goals be met? How can we address the concerns of the residents in this month's article? And how can training programs meet the needs of the community hospital?

It must first be emphasized that pathology is the practice of medicine, and all of our sophisticated technologies, including those in CC, are merely tools to help us take care of patients. The guidelines, checklists, and milestones that have been created are fine, well conceived, and well articulated. A good example is the new instructional resource guide titled Pathology Informatics Essentials for Residents. Perhaps the creation of a similar collaborative instructional resource for CC could help streamline educational efforts and emphasize practical CC.

Additionally, pathologist educators should identify opportunities that connect our sophisticated science and technologies to the bedside—the bridge from the laboratory to the patient. How can that bridge—an essential component of the infrastructure of medicine—be built? What should residents read? Certainly they need to read the classic pathology textbooks and journals, but they should also read, or at least skim, the Journal of the American Medical Association and/or the New England Journal of Medicine every week! By reading these journals religiously the residents will gain a very good idea of what is happening in the basic sciences, what's new in diagnosis and therapy in all medical and surgical specialties, and what is current and pertinent in the business, politics, and regulation of medicine—all of which are essential for becoming and maintaining competence as a credible consulting pathologist. Next, residents rotating in clinical pathology should, instead of taking their vacations or studying for their board exams, make daily ward rounds with the appropriate clinicians—for example, intensive care unit rounds when on CC, infectious disease rounds when on microbiology, etc. They should attend and volunteer to participate in clinical conferences, including medical grand rounds or morbidity and mortality conferences. Participating in a Laposata type of diagnostic management team⁸  during training would be an excellent experience for subsequent community hospital practice. An even more immersive learning experience for residents would be a 2- to 3-month elective rotation in a community hospital, experiencing the real world of pathology practice. For example, a routine procedure in one community hospital was “proactive consultation.” Every morning the chief technologist would print out a list of patients who had new “critical value” test results; the list would then be scrutinized for necessary action. For example, if the test result were a calcium level of 13.5 mg/dL in a patient with diverticulitis and the admitting physician was a general surgeon, there would be an immediate call to the clinician and an immediate consultation. If, however, a patient were found to have a calcium level of 13.5 mg/dL but had an admitting diagnosis of parathyroid adenoma and the admitting physician was an endocrinologist, there would be no call by the pathologist.

This is not to say that the knowledge of basic science and the thorough understanding of the sophisticated technology in the chemistry laboratory are unimportant—these are essential for becoming a credible consultant. Similarly, experience in translational or bench research teaches pathologists-in-training how to ask the right questions; how to gather, analyze and present data; and how to evaluate the literature, all of which are invaluable in the daily practice of pathology and CC.

Clinical chemistry need no longer be pathology's stepchild; in fact, using the type of broader training suggested here, CC can be the catalyst for pathologists to recapture their pivotal role in medicine by becoming the integrators of medical information and providing consultations that link anatomic and clinical pathology, including CC, with patient history, physical examinations, imaging, and other diagnostic data for optimum patient care.