Hi
Here is my ½p's worth on this subject!
Laboratory medicine functions in a number of distinct knowledge domains, within which practitioners and users of the discipline interact:
[1] metrological - measurands (analytes), standardisation, traceability, uncertainty
[2] analytical & technical - assessment of analytical validity, what measurements can be realised as practical tools for investigation - their strengths, weaknesses, characteristics and limitations
[3] physiological and pathological (diagnostic) utility - how things work in health & disease, what measurements improve diagnostic (Bayesian) sensitivity and specificity, what are useful in monitoring and screening
[4] clinical - presentation of disease, signs & symptoms, differential diagnosis - important questions to ask and how to ask them
A few nutters like me inhabit domain [1] - we are all pretty much self-taught because education in this field is lamentable, although international standards will require greater understanding of traceability and uncertainty in the future
Most EQA organisers and diagnostic manufacturers are pretty much pre-occupied with [2], but for a lot of people in labs, they are so piled with work that has to be got out of the door each and every day and night, and the kit is so complex and highly automated, that much has to be taken on trust or for granted. It is only when things go wrong, or results or units have to change, that they start to worry.
Clinical scientists have deep knowledge of [3] and sufficient knowledge of [4] to enable them to interact with clinicians. Their deep knowledge of [2] is declining.
Clinicians generally have deep knowledge in the order 4 > 3 > 2 > 1 on a steeply declining exponential curve, so that 2 is tiny and 1 is invisible.
But this is fine isn't it, providing that the knowledge bases join up and interact in a complementary way? Why should clinicians have to know the detailed ins and outs of tests and reference ranges, when there are knowledgeable people in labs to help them?
In thread 004454 (29 Jan 01) I discussed the 4 box request - Rule in, Rule out, Screen, Monitor.
The clinician has the patient in front of them, takes a history, does an examination, thinks a bit, decides what the likely differential diagnoses are and seeks help from diagnostic services by asking the appropriate questions and entering them in one or more of the four boxes of the request. "Does this lady have hyperthyroidism?" "Does this man's cholesterol present a risk?" "Is the Lithium dose OK?" "Pre-operative assessment?"
The decision support system parses those questions and decides what tests to request and what samples are required. This information goes to the phlebotomist (or pops up for the GP in real time) who takes the samples ready for the lab. The lab receives the requests, performs the appropriate tests (and others if it feel these are necessary) and generates results. If straightforward, an intelligent auto-validator system parses the results and answers the questions, if not - an experienced clinical scientist manually intervenes and completes the interpretation and reporting.
The report is an answer to a question not a series of numbers. The clinician does not need to know the ins and outs of every test, reference range and interpretation, or worry about why results from one lab may be double those from another!
The clinician concentrates on what he/she is good at and extensively trained for - recognising disease, knowing the right questions to ask to discriminate between disease states, and thereby improving knowledge of the pathological process in that individual and achieving a good clinical outcome.
The clinical scientist integrates deep knowledge of what tests are useful, what systems they have in house or elsewhere, what results mean (and their limitations) and provides expert answers to the questions asked as well as other advice and help
People like me rant on about understanding measurement and getting metrologically correct results, so that eventually in the fullness of time (hopefully before the sun goes red giant) results all agree with the reference measurement system and each other!
By working together, the best use of structured knowledge is made and the best outcome is achieved.
Pie in the sky??
Cheers
J
Dr Jonathan Middle
Deputy Director, UK NEQAS Birmingham
0121 414 7300, fax 0121 414 1179
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-----Original Message-----
From: Clinical biochemistry discussion list on behalf of Paul Eldridge
Sent: Thu 07/02/2008 10:01
To: [log in to unmask]
Subject: Re: Role of the clinical biochemist (medical or clin. scientist)
As a strong advocate of Gordon's and Keith's views I should be very interested in advice from others who have gone through the Pathology tendering/privatisation issue.
When it comes down to real cash does it get included in the specifications ?
Paul
Dr Paul Eldridge
Consultant Clinical Scientist &
Clinical Director of Pathology
University Hospital Lewisham
London SE13 6LH
UK
Phone: (44) 020 8333 3030 ext 6746
Mobile: (44) 07768 376 775
Fax: (44) 020 8333 3259
>>> Keith Wakelin <[log in to unmask]> 06/02/08 17:13 >>>
Dear All,
May I say that I agree with Gordon.
In view of the fact that clinical biochemistry is not covered appropriately in some areas of the country at undergraduate level, there is now even more need for " quality added value " to the services we provide. Like Gordon's experience, my clinical colleagues locally, both Hospital ( all grades including nurses) and GP's, value very highly this aspect. Whenever I have suggested that we might cut back we are strongly entreated to continue. I do not believe we should allow ourselves to become a numbers factory, despite short sited pressures and the fact that we may be considered an easy target.
May I suggest we should all engage actively where possible in such initiatives as the National Pathology Week, Pathology Matters etc., and encourage our colleagues to produce vingettes as examples of the clinical value of this part of our service, in order to educate the "powers that be" and the public at large.
Keith Wakelin.
----- Original Message -----
From: gordon challand
To: [log in to unmask]
Sent: Wednesday, February 06, 2008 4:00 PM
Subject: Re: Role of the clinical biochemist (medical or clin. scientist)
Dear Mohammad and the other contributors to this thread
May I make a few points. Locally, our Duty Biochemists (being a pedant, this includes medical as well as scientific staff) pore over many hundred reports containing abnormalities or oddities each day. The 'average cost' of this per abnormal report is around 30 pence or less (depending on who is doing it). It is fallacious to say that this is extremely expensive.
Second, both in our local surveys and in other surveys, there is overwhelming evidence that requesting clinicians value the input and comments made by Duty Biochemists (and want even more of this).
Third, it is incorrect to say that this is an almost entirely UK based practice. In my initial Cases for Comment, I had participants from 29 different countries: the only continent not represented was Antarctica. Some of the Cases were translated into French, Italian and Mandarin (and I have received a recent request asking if our Interpretative EQAS Cases could be translated into Spanish). And dare I suggest that the UK is in this leading the field, rather than being an outlier to the field? Those of you who attended the recent FiLM meeting in Manchester may recall the speaker from the USA who argued strongly for more laboratory interpretation (rather than simply giving out results with 'H' or 'L' affixed by computer) and possibly some EQA in this area, without being aware that in the UK we have been doing this for years.
I must admit I get tired of the argument 'I don't have time to do it/ I can't afford to do it/ I don't have the staff to do it, therefore it is not worth doing' (pace, Trevor)!
Apologies for the rant, but with best wishes to all
Gordon Challand
----- Original Message -----
From: Mohammad Al-Jubouri
To: [log in to unmask]
Sent: Wednesday, February 06, 2008 11:05 AM
Subject: Re: Role of the clinical biochemist (medical or clin. scientist)
Sorry to resurrect this old thread origintaed by Trevor Gray in 2004, as it is relevant to the current debate about learning in clinical biochemistry.
regards
Mohammad
Dr. M A Al-Jubouri
Consultant Chemical Pathologist
----- Original Message ----
From: Mohammad Al-Jubouri <[log in to unmask]>
To: Bell Ewan (North Glasgow University Hospitals NHS Trust) <[log in to unmask]>; [log in to unmask]
Sent: Thursday, 22 April, 2004 11:31:36 AM
Subject: Re: Role of the clinical biochemist (medical or clin. scientist)
I am glad that SpRs are participating in this debate. If you mean by evidence as RCT, then no. But equally no other medical speciality have published evidence to justify their professional existence. There are however some case reports to draw your own conclusion from:
1. L Zendron, J Fehrenbach, C Taverna, and M Krause
Pitfalls in the diagnosis of phaeochromocytoma
BMJ, Mar 2004; 328: 629 - 630.
2. S T M Krishnan, Z Philipose, and G Rayman
Lesson of the week: Hypothyroidism mimicking intra-abdominal malignancy
BMJ, Oct 2002; 325: 946 - 947.
3. D A Oleesky and R Fifield
Pitfalls in the interpretation of tumour markers
BMJ, Jan 1996; 312: 183.
Best wishes
Mohammad
"Bell Ewan (North Glasgow University Hospitals NHS Trust)" <[log in to unmask]> wrote:
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
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 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 (whethe 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 notours. 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 year 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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