Clinical Chemistry 52: 969-971, 2006.
First published April 13, 2006; 10.1373/clinchem.2006.068023
(Clinical Chemistry. 2006;52:969-971.)
© 2006 American Association for Clinical Chemistry, Inc.
Point: Developing a Curriculum in Clinical Pathology
Eline T. Luning Prak,
Jason Park,
Gordon Yu and
Irving Nachamkina
1 Department of Pathology and Laboratory Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA.
aAddress correspondence to this author at: University of Pennsylvania School of Medicine, Department of Pathology and Laboratory Medicine, 4th Floor Gates Building, 3400 Spruce St., Philadelphia, PA 19104-4283. Fax 215-662-6655; e-mail nachamki{at}mail.med.upenn.edu.
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Introduction
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Developing a comprehensive and robust curriculum for residency programs in clinical pathology (CP;
1
also known as laboratory medicine) has been a goal for residency program directors for many years. Although there are many excellent training programs in CP, it is well recognized by faculty and residents that CP training is usually the weakest area of most combined training programs. The proposal by Smith and colleagues on behalf of the Academy of Clinical Laboratory Physicians and Scientists (ACLPS) addresses some of the major reforms needed to upgrade training in Clinical Pathology (1). Although this proposal attempts to be an all-encompassing roadmap to train clinical pathologists in the 21st century, many issues are still apparent that we would like to address here.
The ACLPS proposal is an extensive and detailed document. It is not practical to address the fine details of the proposal; rather, we would like to discuss several issues at the mile-high level. First, what defines a clinical pathologist? The answer to this question provides the foundation for defining residency training goals. Second, what, at a minimum, should be included in the CP residency curriculum? Finally, how should knowledge and technical competence be evaluated as part of a CP residency?
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What Defines a Clinical Pathologist?
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One can argue whether clinical pathologists are "clinicians, first and foremost" as promoted by the ACLPS proposal. Clearly, one major role for the clinical pathologist is to serve as a consultant to physicians and other healthcare providers in other medical specialties. Of course, a clinical pathologist should have considerable knowledge of medicine, but in our view, the primary expertise and focus of CP residency training should be on clinical laboratory testing and its integration into the practice of medicine. Clinical pathologists can have direct patient interactions in some disciplines of CP, such as supervising therapeutic apheresis and, increasingly at some institutions, providing cellular therapeutics. However, even in these settings, clinical pathologists function as specialists performing procedures. Rather than having primary responsibility for the medical management of patients, clinical pathologists serve a different yet critical role in patient care. A clinical pathologist is an expert on clinical laboratory testing and a consultant to the clinician. On the basis of the above considerations, the ACLPS proposal [Table 2 in Ref. (1)], and the Graylyn Conference recommendations (2), a clinical pathologist should, in our view, achieve competence in 4 key areas: - Selection and interpretation of appropriate laboratory tests in clinical screening, diagnosis, and monitoring;
- Evaluation, implementation, validation, and continued quality assurance of clinical laboratory tests and instruments;
- Organization, staffing, and management of the clinical laboratory, including training of personnel, proficiency testing, and regulatory compliance;
- Communication of laboratory findings to promote superior healthcare delivery, including participation in clinical conferences, serving as a consultant to clinicians, and keeping abreast of advancements in information management.
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Minimum Requirements for the Curriculum
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Requirements for the CP curriculum, as outlined in the ACLPS proposal, are context dependent. They depend on the career track and choice of subspecialty; they also depend, to a large extent, on local expertise at the training institution. From the standpoint of credentialing, it seems reasonable to consider first what the minimum level of competence should be across all residency training programs regardless of career goals for the individual trainee.
Achieving the knowledge and skill sets outlined in the ACLPS proposal during a CP or AP/CP residency seems overly ambitious and unattainable for many existing programs. Rather, we suggest setting goals that can be achieved by most programs, small and large, during the short period of CP or anatomic pathology (AP)/CP training. Well-trained pathologists do achieve many or most of the skills described in the proposal, but they would typically do so after more years of training. In this connection, it should be noted that only a small percentage of residency trainees enter private or community practice immediately after residency, according to the American Medical Association FREIDA (Fellowship and Residency Electronic Interactive Database) Database for Anatomic and Clinical Pathology (3). Rather, most trainees pursue additional training after residency (3). Although a strong curriculum is needed to ready some trainees for immediate entry into practice, considerable additional training beyond residency will be required to become expert in the various CP disciplines.
In an effort to provide a series of graded activities with increasing skill and responsibility, Smith and colleagues (1) provide 2 skill levels (I and II). Although this is a laudable goal, grading skill levels by seniority in the residency is inherently problematic. CP residency is short to begin with, and residency programs often divide training into blocks. Furthermore, some skill levels seem to overlap in content (for example, pharmacokinetics I and clinical enzyme kinetics II). Perhaps it would be more useful to stratify skill levels between residents and fellows.
A significant challenge lies in defining curricular training requirements. In their proposal, Smith and colleagues (1) outline the curriculum in broad strokes (for example, "understand hematopoiesis"). It now falls to the subspecialties within CP to clarify this. Another important component of residency training is career development. As in any medical specialty, faculty in CP serve not only as role models, but also as mentors to residents.
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Evaluation of Competency
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There are, in addition to medical, scientific, and technical knowledge, skills that derive from the application of this knowledge. Although the former can be evaluated by the use of standardized tests such as the resident in-service examination, the latter are more difficult to assess objectively. We believe that it is worth giving the following areas of competency explicit treatment in the CP curriculum: bench skills, data analysis, problem solving, communication, consultation, and laboratory management. As most of these areas of competency have been described in the ACLPS proposal, we will focus on 2 that we think are most worthy of further comment.
There are few examples in the ACLPS proposal that actually require hands-on competency for clinical pathologists. Rather, the vast majority of the curriculum focuses on "understanding" various concepts. How much of the curriculum should consist of residents actually performing laboratory tests? Each subdiscipline within CP should define certain skills that could be deemed essential to a clinical pathologist’s training. Examples include achieving expertise in Gram stain evaluation and interpretation, preparation of a blood smear, and performing differentials, including identification of abnormal cells, amplification of DNA by PCR, performance of an ELISA, fluorescence microscopy, and so forth. It is difficult to serve as a consultant unless you are thoroughly familiar with the technical aspects of tests. Unfortunately, CP training has become less of a hands-on experience and more observational, relying on limited interactions with medical technologists to understand the real technical details of laboratory testing. Considering that 75% of pathologists practice in the community-hospital setting, most pathologists are very adept in AP (4). In CP, however, there is sometimes an overreliance on supervisors or senior staff to run laboratory operations. This shortcoming can be remedied in part by insisting on substantial competencies, gained by hands-on experience at the bench.
A second area of competency worth further comment is data analysis. In a broad sense, test interpretation falls under this category, but it is not clear from the current curriculum how "active" this type of learning would be. Ideally, residents in every CP subspecialty rotation would participate directly in the analysis of the raw data and would sign out their interpretation of those data with faculty supervision. In addition, as Smith and colleagues (1) aptly point out, there are specialized data interpretation skills (for example, analysis of flow cytometry data in hematopathology or Bayesian calculations in genetics) that need to be incorporated into a training curriculum. In some cases it may not be possible for residents to master these skills without additional training. There are also basic mathematical and statistical skills associated with data interpretation that residents should master by doing.
If one takes these areas of competency and melds them with the 4 key areas defined above, a list of core competencies can be compiled that includes the following: medical knowledge, scientific knowledge, technical knowledge, bench skills, data analysis, communication, clinical consultation, and laboratory management.
Rather than trying to force these competencies into the clinician-driven rubric of the Accreditation Council for Graduate Medical Education (ACGME) evaluation form, focusing on the above 8 skills will, in our opinion, provide a more balanced and accurate view of what a clinical pathologist should be learning during residency.
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Acknowledgments
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We thank Drs. Brad Johnson, Robert F. Thomas, Jr., and Malek Kamoun for helpful discussions. Drs. Luning Prak, Yu, and Nachamkin are Co-Directors of the Pathology Residency Training Program at the University of Pennsylvania School of Medicine. Dr. Park is Chief Resident of Clinical Pathology (Laboratory Medicine).
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Footnotes
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1 Nonstandard abbreviations: CP, clinical pathology; ACLPS, Academy of Clinical Laboratory Physicians and Scientists; and AP, anatomic pathology. 
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References
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- Smith BR, Wells A, Alexander CB, Bovill E, Campbell S, Dasgupta A, et al. Curriculum content and evaluation of resident competency in clinical pathology (laboratory medicine): a proposal. Clin Chem 2006;52:917-949.[Abstract/Free Full Text]
- Graylyn Conference Report. Recommendations for reform of clinical pathology residency training: conjoint task force of Clinical Pathology Residency Training Writing Committee. Am J Clin Pathol 1995;103:127-129.[Medline]
[Order article via Infotrieve]
- American Medical Association FREIDA (Fellowship and Residency Electronic Interactive Database) Database for Anatomic and Clinical Pathology. http://www.ama-assn.org/vapp/freida/career/0,1238,300,00.html (accessed January 2006)..
- American Society for Investigative Pathology. http://www.asip.org/career/career.htm (accessed January 2006)..
The following articles in journals at HighWire Press have cited this article:
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M. G. Scott and D. E. Bruns
Improving training in laboratory medicine.
Clin. Chem.,
June 1, 2006;
52(6):
915 - 916.
[Full Text]
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