Commentary on NACB's First "Standards of Laboratory Practice"
It has been 17 years since NACB published its first “Standards of Laboratory Practice.” Dr. Lawrence A. Kaplan, pictured above, editor of "Laboratory Support in Assessing and Monitoring Nutritional Status" (1994), kindly agreed to provide us with commentary on the document’s inception, process and impact:
I became President-elect of the NACB in 1994. Having been watching my fellow clinical chemists for some 15 years, I understood that their full capabilities were being grossly underused. I wanted to develop a device that would showcase their knowledge and their scientific and practical know-how.
I needed to try out the idea beforehand and I looked for help from Larry Bernstein, who is one of the best chemists on laboratory aspects of nutritional issues that I know of. He was chairing an industry-sponsored meeting on nutrition-laboratory issues in South Carolina that I was able to participate in. I found that the meeting was well-focused with lots of back-and-forth discussion among the industry-invited participants, which included laboratorians, nutritionists, and physicians. The discussion was free-wheeling and truly, no question was so obtuse that it wasn’t fully answered. Dogma was both preserved and vigorously attacked. Given the high value of the final discussion, I asked if Dr Bernstein and I could turn it into an NACB standards document. No one objected and I drafted a document which went through a number of rounds of editorial revision. With Larry Bernstein’s encouragement I was able to publish this document in 1994 as the first NACB Standards of Laboratory Practice (SOLP), "Laboratory Support in Assessing and Monitoring Nutritional Status." It took about six months from the end of the meeting to publication and the basic approach of an open meeting with a publication of recommendations seemed feasible.
The “Nutrition” SOLP was controversial because this was the first time that a clinical chemistry society established a set of recommendations on a specific clinical topic. Probably the most stand-out recommendations were the firm assertions that nutrition is a major problem in American society and that serum albumin must be replaced by prealbumin (or retinol) as a marker for protein-calorie malnutrition. The NACB’s LMPGs have become international standards, and nutrition issues in specific populations are still a major problem, around the world and in this country, and should be recognized by the people who direct laboratories. Therefore, I would love to see the “Nutrition” topic re-visited as an LMPG.
I then asked the NACB board to have the 1995 NACB symposium follow this different, open format. With the help of a great meeting committee, led by Larry Demers and Carol Spencer, I was able to create a meeting format in which the experts would not lecture, but pose issues and let the meeting participants debate the points. Superb speakers were chosen by this committee and many have participated in later LMPGs on the topic of thyroid function testing. With the help of the speakers and committee members I was able to create the first SOLP derived from an NACB meeting, published about a year after the July meeting.
It is said (Lao-tzu, Chinese philosopher, 604-531 BCE) that “A journey of a thousand miles begins with a single step." While the “Nutrition” SOLP was a very small step, it provided a foundation for concepts that could be brought into a full NACB meeting: a focused topic, a group of experts, almost unlimited discussion by all meeting participants, a set of standards with literature justification, many rounds of editorial review, and a listing in the final standard of both meeting participants and commentators. This process was successfully applied to the 1995 meeting on thyroid disease to produce "Standards of Laboratory Practice: Guidelines for the Diagnosis and Monitoring of Thyroid Disease," which was extraordinarily successful; 50,000 copies of the published SOLP monograph were distributed.
We now needed to establish the SOLP as the routine NACB intellectual concept. Under the presidency of Myron Warshaw we had an SOLP on “Evaluation and Management of Newborns” -- and the NACB had now established itself as a standards organization.
The SOLPs and then the LMPGs have remained as NACB intellectual jewels, demonstrating the best of clinical chemists. If you have attended an LMPG meeting I am sure you have seen that the active participation of the audience is expected, nay, requested by the expert panel. I have been to many meetings where the discussion was very passionate indeed. Diverse views are taken into consideration by monograph editors and are often printed along with consensus recommendations.
So, 17 years later I am pleased to see that the basic concepts drawn from the “Nutrition’” SOLP are still in use and serve today’s LMPG processes. For a good parallel to the early hard going, I can recommend to you James A. Michener’s short story, “Milk Run,” from his “Tales of the South Pacific” (1946). Much of this background can be found at the AACC’s Website: http://www.aacc.org/members/nacb/Archive/Pages/History%20of%20the%20NACB%204.aspx; History of the NACB The National Academy of Clinical Biochemistry: A Historical Perspective, by Myron Warshaw, Ph.D., FACB, in commemoration of the Academy's 25th anniversary in 2001, updated and edited by Charles D. Hawker, Ph.D., FACB.