Mohammad,

Can I ask you the opposite question? Can you show me evidence that patients who are being treated in health-care systems, that do not have an interpretative biochemist (most of the rest of the world), suffer as a consequence?

Ewan

Dr Ewan Bell
SpR Clinical Biochemistry
Gartnavel General Hospital

----- Original Message -----
From: Mohammad Al-Jubouri <[log in to unmask]>
Date: Thursday, April 22, 2004 10:00 am
Subject: Re: Role of the clinical biochemist (medical or clin. scientist)

> Trevor
>
> Before the interpretative/clinical role of the biochemist is
> written off, we must know how good are the interpretative skills
> of non-laboratory based clinicians of all grades including
> consultants. With the increasingly wide range of tests provided,
> do we know of a study or an audit (published or unpublished) of
> the competency of clinicians (in primary and secondary care) in
> interpreting various biochemical results.Are we assuming here,
> that providing a numerical result with a reference range in
> brackets and a computer generated H or L, is the best we can
> provide for patients.
>
> Kind regards
>
> Mohammad
>
> Trevor Gray <[log in to unmask]> wrote:
> Dear Colleagues,
>
> The comments from our transatlantic friends regarding the adding
> on of
> additional tests and the question from Craig bring up again the
> role of
> the laboratory and, specifically the clinical biochemist (whether
> medically or scientifically trained or, for pedants, both) in the
> authorisation function. Is it cost-effective to have expensive
> manpowerdevoted to poring over results looking for useful add-on
> tests (whether
> or not consent has been given), and adding comments, which may or may
> not be pertinent due to the lack of information. Our colleagues in
> other countries (most of Europe and certainly the USA) do not
> think it
> necessary.
>
> It can be argued that all that is strictly necessary is for the
> laboratory to be able to spot results which do not fit with clinical
> details or that have changed in an unlikely fashion (delta check)
> as a
> sort of QA, and to make sure that critical results are phoned. As has
> been mentioned, all that can follow computer protocols. Anything else
> is a luxury for which there is scant evidence base. In many DGH
> laboratories it isn't possible anyway, due to lack of staffing. We can
> all quote cases where we have made a brilliant diagnosis on the
> basis of
> a not quite consistent set of results and the add-on test has clinched
> it, although we have all probably missed twenty times as many.
> However,the patient is the responsibility of the requesting
> physician's not
> ours.
>
> It became clear when Pieter and I did the survey of laboratory
> computersand result authorisation (published in the annals a year
> or so back)
> that some computer systems do not have the fine tuning which enables
> this sort of authorisation practice anyway. This was particularly true
> for those originating from across the water, where only basic
> authorisation functions are built in, although costing functions are
> better developed.
>
> Craig's point is related in that the authorities (Trusts and
> directorates mainly) expect us to be gatekeepers, which is unrealistic
> in that, with electronic ordering (sorry requesting) we may be obliged
> to abandon that function as the whole point is to increase efficiency
> and the electronic order allows the sample to be processed more
> rapidlywith less operator intervention. Adding back manual
> surveillance of
> requests in order to "gatekeep" is perverse.
>
> I'm not arguing that we do not have a function but that we are in
> dangerof being left behind in the inexorable march of automation and
> "modernisation". More rational requesting and more directed
> guidance on
> interpretation is possible with the use of information technology as
> preached so eloquently by Jonathan Kay. Some of the simpler steps can
> come with problem based requesting such as Elliot Simpson has
> introducedin his northern neck of the woods. I confess that I have
> greatdifficulty locally getting even simple measures adopted (as
> for example
> when using Troponins) and the information technological hurdles
> seem to
> get worse not better when we go to newer technology (well Apex is a
> relatively new name though the basic system is about 20 years
> old). The
> challenge is to pool good practice in this area, before we all get
> dragooned into a national IT system that edits us out.
>
> In the meantime, I shall continue to teach rational requesting (we
> haven't much evidence yet to advocate evidence-based requesting) to
> junior medical staff and continue to comment on results as the punters
> (requesting doctors especially GPs) seem to value it. This will
> includeadding tests on when they can "add value" to the result
> provided by the
> laboratory. So trainees needn't worry, I shall continue to have a pool
> of "difficult" cases for the MRCPath ! Come to think of it, a strategy
> for rational requesting for a particular condition would make a good
> question......!
>
> But if we are going to continue to justify this use of expensive
> manpower in a function which is virtually exclusive to the UK, who is
> going to do the work to provide the evidence base for what is good
> practice in this area - and collect all these ideas ? Perhaps some of
> our dwindling academic colleagues in the profession could take up this
> challenge ?
> Trevor
> --
> Trevor Gray
> Dept. of Clinical Chemistry,
> Northern General Hospital,
> Sheffield S5 7AU
>
> 0114 271 4309
>
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> Dr. M A Al-Jubouri
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>
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