Resident Manual

Clinical Pathology Resident Rotation in Chemistry

General Objectives

The focus of this rotation is to instill in the resident an understanding of the medical decision-making that is the fundamental contribution a pathologist brings to this laboratory.  The resident will be exposed to the issues and decisions that the practicing pathologist must address as the advocate for the patient to the laboratory and the advocate for the laboratory to the clinical service.  As part of this exposure, a fundamental understanding of the different procedures and instrumentation in clinical chemistry will enable the resident to appropriately interpret both the meaning and appropriate clinical use of clinical chemistry tests and will help the resident develop the tools to function as a medical director of clinical chemistry in a hospital laboratory setting.  However, the emphasis will not be the specific procedures in this laboratory setting, which may very well change over time and over different settings but rather on the common principles to the testing done in the clinical chemistry laboratory.  Although the primary interaction will be with the Director of Clinical Chemistry, the resident will also interact with laboratory personnel, both in an educational format and as part of the patient-care team.

The resident will meet on a routine basis, typically daily as schedule permits, for a series of discussions on laboratory procedures, regulatory issues, and medical decisions related to the testing under discussion.  These discussions will integrate the core competencies of Patient Care, Medical Knowledge, and Systems-based Practice in the day-to-day activities of the chemistry laboratory.  The experience is based on three one-month rotations, each with specific goals and objectives:

During this month, the resident will be responsible for appropriate consultative activities, with the laboratory personnel and with the clinical service.  The resident will also provide the medical support for testing that requires patient intervention, such as red blood cell mass.  The resident will also follow a specimen through the laboratory, preferably obtained from the resident, to see the workflow through the laboratory and be exposed to the actual methods used in the processing and testing of a sample.  The testing will include a lipoprotein profile and serum immunofixation on the sample as being representative of high-volume automated testing and electrophoresis, respectively.  The resident will follow the specimen from order, through collect and receipt in the laboratory, processing, automated analysis, manual testing, and reporting.  The laboratory personnel will discuss the issues at each step of the processing and introduce the issues of quality control, workflow and instrument maintenance at each bench.  The results will be discussed with the medical director in the context of the other learning experiences of this first month rotation.  The resident will be evaluated for Interpersonal and Communication Skills and Professionalism during these activities and, as necessary, appropriate approaches to the laboratory staff, clinical service, and the patient will be reviewed and discussed.

The resident will act as an intermediary between the clinical staff and the clinical chemistry section to handle day to day problems and inquiries which pertain to chemistry test selection, interpretation and clearance of unusual chemistry procedures.  Supervision for this function will come from the Director of Clinical Chemistry.

Interpretation of electrophoretic patterns (protein and immunofixation, hemoglobin) will be part of the residents’ sign out on days that the Director is on service.  All residents on Clinical Pathology are expected to participate.

The resident will continue to have responsibility for consultative activities and medical support for patient testing during this month.

Month Three:

This is intended to be tailored to the specific needs of the resident, focused on areas of concern or future goals.  On the first day of the rotation, the resident and Director will discuss the direction of the month.  Options have included directed review of standard resources in Clinical Chemistry, review of questions from example examinations, review of prior topics, or, if the resident has shown particular interest, formal responsibility for the day-to-day issues in the laboratory.  The resident is expected to emphasize Practice-based Learning and Improvement and Systems-based Practice in reviewing their needs and designing the month’s experience.

The resident will continue to have responsibility for consultative activities and medical support for patient testing during this month.

General Knowledge To Be Gained From Clinical Chemistry Rotation

1. Specimen collection, handling, preservation and dispersion. 

2. Data handling and reporting, learn computer system, Quality Control, Delta and limit checks, survey result interpretation.

3. Chemical Calculations
   Solutions, Beer's Law, creatinine clearance, blood gas calculations, Immunoassay calculations, amylase clearance, iron binding capacity. 

4. Assay Principles
   End point, methods of standardization, kinetic, enzyme standardization.

5. Instrumentation
   a.  Basic
           Spectrophotometry
           Fluorometry
           Nephelometry
           Fluorescence polarization
           ELISA and chemiluminescence
           Electrodes, pH and ion select
           Osmometry
   b.  Automated
           Chemistry analyzers
               - Automated multichannel chemistry platforms
               - Benchtop immunoassay analyzers
               - Automated multichannel immunoassay platforms
           Blood gas instrumentation
               - Blood gas/whole blood analyzer
               - Cooximeter

6. Immunoassay Techniques
   a.  Competitive
   b.  Immunometric
   c.  Tracers

7. Separation Techniques
   a.  Electrophoresis
   b.  Solvent partitioning
   c.  Chromatography
           HPLC
           Column, Liquid

8. Laboratory Data Interpretation
   a.  Quality Control
           Survey programs
           Control materials
           Standard materials
   b.  Reference range
   c.  Precision and accuracy testing
   d.  Predictive value and prevalence

9. Laboratory Administration

Reading for Residents in Clinical Chemistry

1. Burtis C, Ashwood E and Bruns D (2007)  Tietz Fundamentals of Clinical Chemistry.  Saunders, Philadelphia, 5rd Edition.

2. McPherson RA and Pincus MR (2007)  Henry’s Clinical Diagnosis and Management by Laboratory Methods, 21st Edition, Saunders, Philadelphia.

3. Wu AHB (2006)  Tietz Clinical Guide to Laboratory Tests, 4th Edition.  Saunders, Philadelphia.

4. Kaplan L, Pesce A and Kazmierczak S (2003)  Clinical Chemistry.  Mosby, St. Louis.

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