Clinical Chemistry 43: 167-173, 1997;
(Clinical Chemistry. 1997;43:167-173.)
© 1997 American Association for Clinical Chemistry, Inc.
Report of the Third Conference on Education in Clinical Chemistry
Alan H. B. Wu1,a and
Edward W. Bermes, Jr.2
1
Clinical Chemistry Laboratory, Hartford Hospital, Hartford, CT 06102, and President, Commission on Accreditation in Clinical Chemistry.
2
Department of Pathology, Loyola University Medical
Center, Maywood, IL 60153, and Past President, Commission on
Accreditation in Clinical Chemistry.
a Author for correspondence. Fax 860-545-5206.
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Introduction
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The Third Conference on Education in Clinical Chemistry was
organized by the Board of Directors of the Commission on Accreditation
in Clinical Chemistry (COMACC) and was held at the Sheraton Gateway
Suites, O'Hare Airport in Chicago, IL, on September 29–October 1,
1995.1
The two previous conferences had been held in Columbus, OH, in
1973 (1) and Chicago, IL, in 1975 (2); the
1975 conference had 75 attendees representing 50 institutions.
The Third Conference was cosponsored by the American Association for
Clinical Chemistry (AACC), the American Board of Clinical Chemistry
(ABCC), and the National Academy of Clinical Biochemistry. Directors of
postdoctoral training programs from each COMACC-accredited program were
invited to attend, as were Jay McDonald, University of Alabama at
Birmingham, who provided the keynote address, and guest speakers
representing clinical chemistry opportunities within industry. A total
of 30 program directors and guest speakers were present, representing
all but 2 of the 19 postdoctoral programs accredited by COMACC at the
time. A current listing of COMACC-approved graduate and postdoctoral
programs in clinical chemistry is included in Table 1
.
This conference was organized in response to new educational needs
brought about by dramatic changes in the delivery of laboratory
medicine. Many groups have documented this reform. In 1995, the AACC
Board of Directors formed a Task Force to examine the current practice
environment, estimate future practices, list professional
qualifications necessary to meet anticipated practices, and recommend
programs to enable clinical chemists to gain the required competencies
(3). As listed by the Task Force, the skills needed today
are in the areas of clinical (for test logic, appropriateness, and
consultation), scientific and technical (in automation, informatics,
and robotics), and management (for multidisciplinary team-building and
leadership). A new task force (Delta) has been created and its members
are now meeting to address specific means by which core competencies
can be achieved. Almost simultaneously, a second group of clinical
chemists, naming themselves the Athena Society, met in Rhodes, Greece,
in September 1995, and Fullerton, CA, in July 1996. While they came to
the same general conclusions as the AACC Task Force, they listed
specialty areas where the core competencies were needed
(4). The Athena Society stressed the need for reform in
basic training programs for students and the establishment of programs
for the retraining of practicing clinical chemists. Because COMACC is
responsible for accrediting clinical chemistry training programs in the
US, the Third Conference on Education was convened to discuss how the
existing curriculum of postdoctoral clinical chemistry training
programs could be expanded to meet the changing practice environment
and to make graduates of accredited programs more competitive for
employment opportunities within the field. (A similar multiorganization
effort was recently conducted for modification of clinical pathology
residency training programs (5).)
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Keynote Address: Need for Interdisciplinary Training (Jay McDonald, Speaker)
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The future economics of healthcare no longer allows anyone the
luxury of hiring specific individuals to head a single laboratory
subspecialty (6). As chairman of a Department of
Pathology, the keynote speaker stated that, when positions are vacant
in his department, he seeks the most qualified individuals irrespective
of their doctoral degrees (e.g., M.D., Ph.D., D.Sc.). Those who are
capable of applying their training to all areas of the laboratory, and
who can make contributions outside the department (e.g., through
committees on managed care, medical quality assurance, physician
utilization of services) are particularly desirable. There appeared to
be a consensus among participants that training should be
expanded from clinical chemistry to "clinical laboratory science."
Because of their training and experiences in management, quality
control and assurance, data reduction and automation, Dr. McDonald felt
clinical chemists may be uniquely qualified to provide the additional
services needed to the institution as a whole. He also believed that
each fellow would still need to identify a subspecialty
area within clinical chemistry or in one of the emerging areas such as
molecular pathology, information science, or epidemiology. An
entry-level instructor or assistant professor in a medical school would
likely not be successful in competing for external support with only a
broad-based fund of knowledge and skills.
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Presentations
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opportunities in reference laboratories and industry (chair: alan
h.b. wu, hartford hospital, hartford, ct)
Job requirements
(Wendell O'Neal, SmithKline Beecham
Clinical Laboratories, Collegeville, PA, and Susan Evans, Dade
International, Deerfield, IL). Postdoctoral training objectives must be
broadened in scope to meet the current needs of industry, particularly
in nontechnical areas such as management, fiscal and policy
development, and regulatory affairs. Job opportunities currently
present in industry include product development, systems integration,
clinical evaluations, research and reagent programs, quality assurance,
regulatory affairs, quality control, and customer technical support.
Reference laboratories, like every other segment of healthcare, are
also undergoing considerable consolidation and realignment of testing
as a consequence of changing customer needs. Training should be more
directed towards establishing a "quality product mentality."
Traditionally trained chemists who enter industry have little
supervisory training experience and often do not know how to stay
within budget limits and time deadlines. The importance of management
training was stressed by both speakers. The participants of the
conference felt that one mechanism to address this need was to
develop and (or) sponsor a professional course on business
management training, to be made available at an annual meeting.
This topic will be explored further by COMACC.
Industry externships
(Hermant Vaidya, Dade
International, Newark, DE, and Pauline Lau, Boehringer Mannheim
Diagnostics, Indianapolis, IN). An externship industry rotation
involves sending a postdoctoral fellow offsite to a diagnostics company
or reference laboratory after at least 1 year of clinical chemistry
training in an accredited program. The fellow would then return to the
laboratory for completion of the fellowship. During the externship, the
corporate sponsor would be responsible for the fellow's stipend and
training expenses. It may also be necessary to arrange for temporary
housing if the fellow cannot commute from his or her primary residence.
Because most fellows have no prior experience in the corporate
environment, an externship could be the first step towards acquiring a
permanent position within industry. On the other hand, the potential
industry employer would get an opportunity to work with a fellow
without having to make a long-term commitment to that individual. Other
potential benefits of an externship to both parties are listed on Table 2
.
Fellows would ideally be exposed to the product development process,
beginning with product definition and proceeding through research and
development, regulatory and marketing concerns, and manufacturing.
Clinical chemists are also needed for product support, technology
assessment, new business development, and strategic planning.
Postdoctoral fellows interested in industry often have a general lack
of business training and marketing experience and may have narrow
research interests. An externship could give fellows the insights
needed to compete in this area. The estimated time needed for an
effective exposure would be 6–12 months.
The merits of having industry scientists and marketing individuals
spend some time within a hospital laboratory were also discussed as a
means to foster collaborations between industry and academia and to
provide some alternative funding sources for the teaching institutions.
Several members of COMACC voiced positive experiences in exchange
programs between their institution and private industry.
training in nontraditional testing areas (chair: roland valdes,
jr., university of louisville, ky)
Point-of-care testing
(Mary Burritt, Mayo Clinic,
Rochester, MN). Leadership in this area is lacking in many hospitals
and medical centers. Point-of-care (POC) testing is a growth
opportunity for clinical chemists and doctoral scientists. A broad
background is needed for successful supervision of this testing.
Competency is needed in areas such as testing for critical care
medicine, the technology of POC monitoring and testing devices, and
clinical and laboratory experience in the areas of coagulation testing,
hematology, urinalysis, and microscopy. Equally important is the
knowledge in quality control/assurance, financial management, outcomes
assessment, cost/benefit analysis, and information transfer technology.
Trainees must also be current with regard to the rapidly evolving
regulations that surround these testing services. Effective delivery of
POC testing requires individuals who understand patients' needs. POC
testing is a unique opportunity for laboratory scientists to get
acquainted with patients, physicians, and all members of the healthcare
team.
Core laboratory concept
(Frank Sedor, Duke University
Medical Center, Durham, NC). A core laboratory provides all continual
laboratory services necessary to a hospital on a 24-h basis,
irrespective of traditional boundaries of laboratory medicine
subspecialties. As such, a typical core laboratory would combine
chemistry, hematology, coagulation, urinalysis, and serology into one
facility (7). Intuitively, the core laboratory should
require less administrative, supervisory, and technology personnel.
Moreover, turnaround times for reporting test results should be
improved with the establishment of a central processing area at or
adjacent to the core laboratory. Many large hospitals have reengineered
their space and supervisory responsibilities to adopt the core
laboratory concept, and many more hospitals are in the planning stages
for such a development.
For years, small hospitals have operated under a single-laboratory
concept: Because of low testing volumes, it was not cost effective to
diversify the management responsibility. Such institutions, however,
are generally not involved with postdoctoral clinical chemistry
training. Even if the host institution does not actually operate a core
laboratory, program directors must begin to develop formal goals and
objectives for teaching clinical chemistry fellows the basic concepts
in these nontraditional areas. Expansion of the program's teaching
faculty will probably be necessary to provide the expertise needed to
instruct in this area. Training should be focused on the information
needed to direct the delivery of "stat" laboratory services and
should not attempt to train fellows to become specialists in these
areas. Individuals trained as a laboratory scientist should not
directly compete against specialists in microbiology, hematology, and
immunology for jobs. Nevertheless, the conference participants felt
that there will be some degree of resistance by the
non-clinical-chemistry faculty to provide this education to clinical
chemistry fellows.
Molecular diagnostics
(Lawrence Silverman, University of
North Carolina Hospitals and Clinics, Chapel Hill, NC). One field open
to subspecialization for clinical chemists is molecular diagnostics.
The training objectives of the University of North Carolina program are
as follows: meeting eligibility requirements for the American Board of
Medical Genetics; research and development (fellows must develop at
least one molecular test); teaching (in the medical genetics course for
second-year medical students); cross-training in other areas of
molecular pathology (microbiology, hematology, HLA tissue typing,
genetics rotation); and research in a selected area, leading to
presentation and (or) publication. This 3-year program contains 6
months in general clinical chemistry, 6 months in a selected area, 1
year in the DNA diagnostic laboratory, and 1 year in a genetics
rotation (including cytopathology, biochemistry, and clinical
genetics). The third year is necessary for applicants to qualify for
the American Board of Medical Genetics certification examination.
Program directors should direct rotations within molecular diagnostic
laboratories, irrespective as to where (within the hierarchy and
politics of the Department of Pathology) such testing is being
conducted. Other areas of molecular pathology that could be part of a
training program for clinical chemists include infectious disease,
cancer diagnoses, identity testing (forensic and paternity), and tissue
diagnosis. Some changes may be necessary in the qualifications of
candidates applying to postdoctoral fellowships that have a molecular
diagnostics component. The COMACC and ABCC currently require fellows to
have at least 1 year of a graduate school-level biochemistry course.
Additional training and (or) experience in molecular biology may also
become a requirement for future fellows.
research training (chair: mitchell g. scott, washington university,
st. louis, mo)
Research continues to be important in the training of postdoctoral
fellows. Knowledge and hands-on experience of investigative principles
and techniques are important for assessing and improving laboratory
services in the current practice environment of clinical chemistry.
Fellows should have experience in critical literature review,
experimental design, statistics, data analysis, and presentation.
Research expertise is essential for getting jobs in academia and
industry (including reference laboratories), the two areas where
employment opportunities continue to exist for recent graduates
(8). The majority of recent graduates of the Washington
University program have obtained employment largely because of their
demonstration of research productivity. The ability to obtain external
funding is also important in securing employment, although this should
not be a major focus of the training program. Issues under
consideration regarding research include what types of investigations
make the clinical chemist most attractive in the job market (i.e.,
basic science, applied research and development, or clinical trials),
and what percentage of time should be allotted for conducting research
and for attending research seminars, journal clubs, and scientific
meetings. Most programs continue to maintain considerable research
involvement, especially during the second year and beyond, with an
expectation that results of such work will be presented at scientific
meetings and submitted to peer-reviewed journals.
training in medical informatics and laboratory management
Informatics and automation
(Robert Burnett, Hartford
Hospital, Hartford, CT). Management of medical laboratory data is
essential for the effective delivery of services. Medical informatics
is a broad field that incorporates computer science, decision science,
library science, cognitive science, and various aspects of engineering.
Management of data is critical to the success of any clinical
laboratory. Trainees in clinical chemistry, in particular, must have
exposure and working knowledge in hospital and laboratory information
systems, database management systems, networked systems, and
application software for word processing, spreadsheets, presentation
graphics, statistics, electronic mail, and literature searching. In the
era of limited managed-care reimbursements, there will be an increasing
emphasis on the effective utilization of testing services through
research in outcomes analyses. Laboratory scientists will be
responsible for generating utilization data and controlling
physicians' test-ordering patterns. Expert systems are being developed
to deliver information in the most efficient manner possible.
Conference participants recognized that formal training of medical
informatics is currently lacking in the majority of COMACC-accredited
programs.
Total laboratory automation is an emerging science and will be central
to the efficient delivery of laboratory information. Initial hardware
and software designs are tasks for engineers and computer science
personnel, but effective implementation will require the collaborative
efforts of clinical laboratory scientists and administrators. Although
robotics has been fairly successful in large Japanese clinical
laboratories, implementation in the US has been largely limited to
reference laboratories, with a few large hospitals now considering
total automation (9). If robotics becomes a mainstay of
laboratory operation, it will be necessary for postdoctoral fellows to
have experience in this area. Until more hospitals and medical centers
commit to automation, however, an off-site externship may be the only
route by which postdoctoral fellows can enter this emerging field.
Laboratory management training
(Michael G. Bissell,
University of Texas Medical Branch, Galveston, TX). Specific curricular
objectives that could be included in future postdoctoral training
programs of laboratory management are: basic management concepts,
history of the clinical laboratory industry, applied healthcare
economics, problem-solving and decision theory, human resource
management, legal and regulatory affairs, psychology of laboratory
management, and quality improvement and futuristics. Basic management
includes organization theory and concepts. Effective management of
human resources and an understanding of labor principles is the
pinnacle for laboratory administration. Knowledge of business and labor
law, and of regulations and licensure, is also part of management that
must be conveyed to the trainee. Theories and practices of total
quality improvement are basic to any service or business environment.
Laboratory management has always been a major objective for
postdoctoral education, although different COMACC programs display
great variability in the delivery of this training. Because most
fellows consider management education a low priority, innovative
teaching techniques are needed to motivate postdoctoral fellows to
learn these concepts.
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Discussion
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Whereas funding and lack of qualified candidates were the major
concerns for directors of clinical chemistry training programs a decade
ago, the major issue in the US today is the lack of jobs for graduating
fellows. In the past, fellows completing postdoctoral programs had
several offers in different geographic locations and types of
positions; now, positions for clinical chemists in private hospitals
are essentially nonexistent. Many clinical chemists who have retired
from academic positions have not been replaced. Reference laboratories
are consolidating and have greatly reduced their technical and
supervisory staffs. Even industry has felt the downsizing of healthcare
delivery. Unemployed clinical chemists with many years of experience
now compete against recent graduates for the few vacant positions that
open each year.
In light of these realities, many fine long-standing institutions
such as Louisiana State University (New Orleans) and Ohio State
University (Columbus) are no longer offering COMACC-accredited graduate
(masters and doctoral) programs in clinical chemistry. Many
postdoctoral training programs have either temporarily suspended
attempts to fill their vacant slots or reduced the numbers of trainees
enrolled. Although the total number of COMACC-accredited training
programs has remained remarkably steady over the past decade, the
number of students entering the field of clinical chemistry has
decreased. Until there is stabilization of the healthcare industry,
this trend is likely to continue.
The inclusion of several new objectives (such as those listed in this
document) into the curriculum of clinical chemistry training programs
may help make clinical chemistry fellows more marketable in today's
practice environment. It may be necessary to extend the duration of
current COMACC-accredited programs from 2 to 3 years. Many programs are
already 3 years long (e.g., Washington University, University of
Louisville, and the former program at the Health Science Centre in
Winnipeg, Manitoba, Canada). The Washington University and Louisville
programs are geared to train fellows for teaching hospitals, with the
third year being largely devoted to research. In the pioneering
Winnipeg Health Science Centre program, the additional year was spent
exposing fellows to anatomic pathology (including the autopsy service)
and many of the nontraditional areas of the clinical laboratory
discussed above. For programs that have only an occasional fellow,
increasing the duration to 3 years will require an additional upfront
commitment for funding. For programs that have a continual enrollment
of postdoctoral fellows every 2 years, a 3-year training program will
reduce the total numbers of graduates who finish and enter the field
but will not require additional financial support. Considering the
decrease in employment listings for clinical chemists over the past few
years, the slowing of graduates entering the field was viewed as being
favorable. After subsequent discussion, commissioners of COMACC and
program directors decided that COMACC could not move to
require programs to adopt a 3-year curriculum. Nevertheless,
COMACC will be encouraging an expansion of training objectives to meet
the needs of the current practice environment. As before, it is
incumbent on individual fellows to seek a program that best suits their
needs.
Alterations in the training of clinical chemists will have an impact on
certification of graduates by ABCC. Of particular issue is the role
ABCC may play in certification of competency for molecular diagnostics.
In the most recent meeting, the Board ruled that future chemistry
examinations will contain questions on molecular diagnostics. Another
issue discussed by the group was the qualifications of candidates who
sit for the ABCC clinical chemistry examination. Under the current
regulation, any individual who has been engaged in full-time practice
of clinical chemistry in the US for 5 years is qualified to take the
certification examination. However, the majority of the group felt
that, after a "grandfathering" period, only graduates of
COMACC-accredited programs (or foreign training programs deemed
equivalent by COMACC and ABCC) should be allowed to take the
examination and become certified. Such a practice would be consistent
with the majority of other medical certification bodies (e.g., the
American Board of Pathology). A recommendation to this effect was
forwarded by COMACC to ABCC for consideration, and the recommendation
was motioned and approved by ABCC at its last meeting.
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Footnotes
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1 Nonstandard abbreviations: COMACC,
Commission on Accreditation in Clinical Chemistry; ABCC, American Board
of Clinical Chemistry; and POC, point-of-care. 
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References
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Introduction
Keynote Address: Need for...
