CouncilChat

I have been to a few institutions that have both made review of tests that are expensive, frequently misordered and or having limited diagnostic value.  It was made part of the training programs and served as valuable experience for both the resident and the laboratory.  The lab benefits from reduced costs and the resident develops communication skills with the clinical team as well as educating test users.  I saw a number of different approaches, from 'What will it take to get you out of this test' to 'I'm just a lowly resident, please explain to me how this test will benefit your patient'.  Both approaches were highly effective when applied appropriately.

Christopher McCudden, Ph.D., NRCC, FACB, DABCC

Jena Hudson
3rd year AP/CP resident
Department of Pathology and Immunology
Washington University/Barnes-Jewish Hospital
Saint Louis, MO

Thanks again for participating in the giveaway. I logged all of your names into an Excel spreadsheet and performed the RANDBETWEEN function. The lucky number that came up (19) corresponded with Pamela Steele! Congrats Pamela, your backpack is on its way via FedEx! Please continue to comment on the material posted in CouncilChat.

-Bob Sumner, Editorial Coordinator, Clinical Chemistry

Dr Sutirtha Chakraborty,MD
Consultant, Clinical Biochemistry
Peerless Hospital & BK Roy Research Centre
Kolkata 700094
India

Biomedical Science
University of Bedfordshire
England

Eric Vasbinder
Chemical Pathology
University of Michigan medical center
1500 E. medical center dr. UMH 2F453
Ann Arbor, Michigan, 48109

Clinical rotation for the clinical chemist is a must as it helps the clinical chemist to be in the same grid with the clinician. In my centre, our residents do rotations with endocrinologists as has been suggested by Mark. They also do rotations in the ICU, nephrology, clinical haematology ,clinical immunology and paediatrics deparments.Doing a rotation with the Paediatrics, helps us hone our skills on interpretation tremendously as the interpetation of paediatric reports is different from adults.

McMaster University
Hamilton, ON
Canada

Clinical Chemistry Trainee Council website is a great resource and I have learned a lot from it!

Teralee Burton
Diagnostic Services of Manitoba
Winnipeg MB Canada

Jesica M. Colón-Franco
Vanderbilt University Medical Center
Diagnostic Laboratory

Maria Diamandis Pasic
University Health Network
University of Toronto
Canada

Maria Diamandis Pasic
University Health Network
University of Toronto
Canada

I am Deresse Daka from Hawassa University Ethiopia. I appreciate all of you about your activity. Also I got a lot of information about clinical chemistry.
I want to comment on distance learning. Please for developing country make it free of charge. If you do like that a lot of professionals are waiting to register.
thank you
Deresse Daka
Hawassa University
College of Medicine and referral hospital
P.O. Box 1560
Hawassa Ethiopia

Dr. Cervinski ,
Ans 1. Yes, as part of our training as clinical chemists in India, we do read about Westgard rules. I use them for all my QC management. I use a software from Biorad that has an in-built Westgard advisor that helps me a lot with analysis and management of my QC data .
Ans 2. I have not done any of the Westgard courses online, but I refer to the website often and have printed out some of the essays which I refer to from time to time .
Sincerely ,
Dr. Puneeta Bhatia , MD
Dept. of Laboratory Medicine,
Columbia Asia Referral Hospital,
Malleswaram, Bangalore, India

Kellie A Farmer
Adelaide Pathology Partners

520 South Road
Kurralta Park  5037
Adelaide
South Australia

I don't think there's a single solution that works for everyone.

The key to achieving balance is to figure out where your personal balance point lies. Some people are happy with 50% work & 50% "life"; others are happy with 90% work & 10% life. Frankly, I think that if you're happy with your life then you have achieved the balance that's right for you. If you're unhappy, then you need to alter the relative proportion of each.
Once you've found your personal balance, I think the other issues will sort themselves out on their own.

Anna Fuezery, Ph.D.

Anna K. Fuezery
Clinical Chemistry Division
Department of Pathology
Johns Hopkins University, School of Medicine
Baltimore, MD

Department of Clinical chemistry
Faculty of Medical laboratory Sciences
University of Khartoum

Brian N. Kelly
University of Virginia
Charlottesville, VA

Bonny L. Van
Marion County Public Health Laboratory
Indiaapolis, IN

Thank-you for sharing this great example of how the laboratory can add value to the patient care pathway. In this particular case, it’s a shame that the patient had to endure mismanagement for a considerable amount of time before the laboratory was consulted.

Certainly in the UK, there is much variation in the approach of clinicians when managing “sub-clinical hypothyroidism”. Some advocate a trial of thyroxine at a low dose (as in this case) based presumably purely on the slightly elevated TSH level, even in the likely absence of clinical symptoms. Other clinicians will tend to monitor the TSH levels closely over the next few months (± TPO testing). Perhaps clinicians place too much emphasis on the TFT results and not enough on the clinical status of the patient. It is noteworthy in this case that withdrawal of therapy (unsurprisingly) resulted in an improvement in the patient’s condition.

Above all this case highlights the importance of the laboratory, and the extra value that we can bring to patient management. We must be proactive in this area and try to educate clinicians on the pitfalls of biochemical testing and the potential for assay interferences. Clinical chemists should be encouraged to use all means available to engage with our users and use our knowledge to help influence patient management.

Thank you for posting this Bob, what a wonderful topic for this forum.  The one thing that stuck out in my mind in addition to the differences in the availability of positions internationally was the need for trainee's to find an area of interest and begin specializing in that area.

This really should start in the training period in my opinion.  There are many demands on the time of new faculty members/laboratory directors and the time needed to cultivate an area of expertise is drastically shortened in my own experience. 

Mark A. Cervinski, Ph.D. DABCC
Dartmouth-Hitchcock Medical Center

Mark,

In the two hospital situations you mentioned, one offered beta-hydroxybutyrate (BHB)…did the other offer at least serum ketones, or just nothing?  Compared to nothing, I’d say BHB is much preferred, and also that BHB has is preferred over serum ketones methods.

Looking only at the anion gap may be sufficient if it is elevated and all of the other pieces of the puzzle are in place (glucose, acid-base status, history of diabetes, clinical presentation, etc…), but it is not as specific as BHB.  An anion gap can be composed of different anions, after all, and an elevated gap could be due to ketoacids (acetoacetic acid, BHB), lactate, or even glycolate (if someone ingested ethylene glycol).  Thus, once DKA is established, following pH and anion gap till they are corrected seems like a reasonable thing to do, but if things don’t correct, or there seems to be something else impeding improvement, having a specific test like BHB can help tell you whether or not the ketoacidosis itself is improving.

The old serum ketones methods, by the way, such as Acetest or ketostix, preferentially detect acetoacetate, and do not detect BHB.  In states of relative NADH excess (such as alcoholic ketoacidosis like this case, or severe DKA), BHB can be much more concentrated than acetoacetate. The result of a serum ketone test, therefore, could be only weakly positive, when in fact there was a rip-roaring ketoacidosis present.  Additionally, when DKA is treated, correcting the NADH/NAD+ balance can lead first to conversion of BHB to acetoacetate; this could make “serum ketones” rise, when in fact the metabolic derangement was improving. 

Yet another reason to look at BHB is that it is what the American Diabetes Association recommends (PMID: 14693938):  “Direct measurement of beta-OHB in the blood is the preferred method for monitoring DKA.” There is also a published study from Italy that shows a better outcome (less time in ICU) for children with DKA (PMID: 15000443); I have only read the abstract, as my library does not subscribe to the journal, so I haven’t closely read the study to evaluate its merits.

Hope this helps,
Geoff Baird

I think that shadowing supervisors and administrative directors is a great idea.  There are many regulatory issues and budgeting issues that could be helpful to discuss.

In the program I trained in, it was standard practice for each resident and fellow to spend time at each bench to get a real sense of the workflow and challenges that technologists work through.  Quite useful for the more hands on tests, but challenging with big automated analyzers. 

Some other people to consider shadowing are the supervisors and administrative directors, who may give a trainee exposure to budget and personnel issues.

Christopher McCudden, Ph.D., NRCC, FACB, DABCC

In Canada, the process differs from province to province.  Half of the provinces have their own accrediting organizations (for example, in Ontario, laboratories are required  to subscribe to Ontario Laboratory Accreditation (OLA) and External Quality Assessment (proficiency testing). 

Non-provincially accredited labs are accredited by the Canadian Counsel on Health Service Accreditation (CCHSA).  Accordingly, standards in each province differ, but all do include aspects of ISO 15189.  Some laboratories will also have CAP accreditation in order to perform clinical trials for FDA submissions or to serve as reference labs to US customers.  Peer inspections are similar to CAP and a valuable educational experience.

Overall, not entirely different form the US, where different labs may be accredited by CAP, COLA, AABB, JCAHO or even their own State entities.  I am curious to here how others are accredited on other continents.

Chris McCudden, Ph.D

I agree with Johnson that the private sector can implement new diagnostic tests but the real question remains that how rationaly these tests will be ordered so that the patient does not feel the financial burden.For example the clinical use of Procalcitonoin in evaluation of therapeutic response and prognosis of SIRS/Sepsis is excellent but these investigations are very expensive.In my opinion there should be guidelines based on clinical criteria regarding the first line,second and third line investigations in various clinical scenarios.This is very similar to the Antibiotic Policy and will thus help the tests to be ordered as well as interpreted in a more efficient manner.
I would be very glad to hear the views of my international colleagues regarding this.

Dr Sutirtha Chakraborty,MD
Peerless Hospital & BK Roy Research Centre
Kolkata,INDIA

In Indonesia, Government health insurance only covered those really unable to pay. Usually we will pay the health cost from our own or by the private insurance or by company coverage. We have already familiar to pay all the test including innovative tests by our own. Usually doctors will consider which tests will be given effectively.
Base on my own opinion, in here, the private hospital or private labs can generate and develop more innovative test compare to government hospital/labs, the main issue because private can accomodate and have more facility to develop the new test and to release it to the market.

Johnson Widjaja
Prodia Cliinical Laboratory
Indonesia

In China, our practice is the basic tests like Liver function, renal function and lipid profiles, blood and urine routine,and emergency test like cTnI are entirely covered by insurance. However, some tests like natriuretic peptides would be covered, if the doctors have clearly indicated the usage in the patients documents. It may prevent the overuse of testing, since the doctor will consider the patient financial status before ordering an uncovered test.

Lin Zhang,M.D,M.S
Peking Union Medical College Hospital

In my department, we have weekly case report and monthly journal club. Every Tuesday, some cases concerning clinical chemistry which has been encountered during our work, may raise some questions and answers or discussion. Journal club will held the last day of each monthly, 3-4 trainee will present the latest reports from the major journals(Clinical Chemistry, Lancet, NEJM, Diabetes,Blood,etc). And Every Wensday afternoon, 2 senior staffs of our department present the course of laboratory medicine in the clinical use for our trainees.We also join the national and international conferences for cutting-edge research information.

To my knowledge there is nothing as elaborate as the AACC website freely available.  The International Federation of Clinical Chemists Task Force for Young Scientists (IFCC-TF-YS) is working on centralizing resources for programs around the globe, but this will take some time yet. 

I do know there are some interesting differences between the training of laboratory professionals around the world.  In Europe, PharmD backgrounds are more common.  I'd be really interested to hear their experiences as well as those from other continents.