Clinical Chemistry 52: 917-949, 2006.
First published March 28, 2006; 10.1373/clinchem.2005.066076
(Clinical Chemistry. 2006;52:917-949.)
© 2006 American Association for Clinical Chemistry, Inc.
Curriculum Content and Evaluation of Resident Competency in Clinical Pathology (Laboratory Medicine): A Proposal
Brian R. Smith1,a,
Alan Wells2,
C. Bruce Alexander3,
Edwin Bovill4,
Sheldon Campbell1,
Amitava Dasgupta5,
Mark Fung4,
Barbara Haller6,
John G. Howe1,
Curtis Parvin7,
Ellinor Peerschke8,
Henry Rinder1,
Steven Spitalnik9,
Ronald Weiss10,
Mark Wener11 for the Academy of Clinical Laboratory Physicians and Scientists
1 Yale University, New Haven, CT.
2 University of Pittsburgh, Pittsburgh, PA.
3 Univeristy of Alabama at Birmingham, Birmingham, AL.
4 Univeristy of Vermont, Burlington, VT.
5 University of Texas at Houston, Houston, TX.
6 University of California at San Francisco, San Francisco, CA.
7 Washington University, St. Louis, MO.
8 Weill Cornell School of Medicine, New York, NY.
9 Columbia University, New York, NY.
10 University of Utah, Salt Lake City, UT.
11 University of Washington, Seattle, WA.
aAddress correspondence to this author at: Department of Laboratory Medicine, Yale University School of Medicine, 333 Cedar St., PO Box 208035, New Haven, CT 06520-8035.
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Abstract
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Ten years have passed since the Graylyn Conference Report on Laboratory Medicine/Clinical Pathology training was issued. Over that time period, the Accreditation Council for Graduate Medical Education (ACGME) substantially revised the requirements for training programs, the American Board of Pathology (ABP) amended both the requirements and the time periods needed for certification, and the discipline itself, along with the broader discipline of pathology, evolved significantly. Recently, a curriculum proposal in anatomic pathology was published as a potential template to be used by training programs to help meet these new and evolving needs. Toward the same end, the Academy of Clinical Laboratory Physicians and Scientists has now developed a template for a curriculum in clinical pathology (laboratory medicine), taking into account newly designated and revised areas of residency core competency, the alterations in training requirements promulgated by the ACGME and ABP, and the rapidly developing nature of the discipline itself. The proposed clinical pathology curriculum defines goals and objectives for training, provides guidelines for instructional methods, and gives examples of how outcomes can be assessed. This curriculum is presented as a potentially helpful outline for use by pathology residency training programs.
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Introduction
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Clinical pathology (CP),
1
also referred to as laboratory medicine, is an expansive discipline that is anchored in the clinical laboratory and encompasses a fund of knowledge, reasoning, and skills in pathophysiology, diagnostics, and therapeutics. The appropriate constituents of training in this field and the best means for evaluating adequacy of that training are topics of continuous evolution, as they are in all fields of medical practice. In the case of CP, several different training traditions exist. In the United States, a highly academic venue with a focus on translating research laboratory technologies into clinical practice ("Laboratory Medicine") has combined with a community practice–based tradition emphasizing clinical consultation and resource management ("Clinical Pathology") to produce training programs that integrate all the diverse subdisciplines of CP and which are centered under the broader aegis of pathology. This cohesive training, research, and service environment distinguishes the discipline in the United States; in contrast, in much of the rest of the world training in the subdisciplines more frequently remains discrete and/or embedded within other medical specialties. As such, training in the United States, and in those other countries which share this approach, must not only convey subdiscipline-specific information but also enshrine the common approaches, competencies, and world view shared by these pathology subdisciplines.
Ten years ago, 4 major pathology organizations [Association of Pathology Chairs, College of American Pathologists (CAP), Academy of Clinical Laboratory Physicians and Scientists (ACLPS), and American Society for Clinical Pathology] formed a conjoint committee to examine issues related to optimal CP training, which culminated in publication of the Graylyn Conference Report (1). The major conclusions from that conference are summarized in Table 1
. Since then, however, several major shifts in clinical practice and in the philosophy behind residency education and evaluation have occurred. In particular, the Accreditation Council for Graduate Medical Education (ACGME) has mandated the development of a defined educational program (i.e., curriculum) for trainees in all medical specialties, focused on 6 main areas of competency: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice(2). A second major change was the reduction in the total time period required by the American Board of Pathology for pathology training by 12 months, from 5 years to 4 years in the case of combined anatomic pathology (AP)/CP certification qualification and from 4 years to 3 years for qualification in AP alone or CP alone. In response to these changes, the Association of Directors of Anatomic and Surgical Pathology recently published a proposal for an "idealized" curriculum for AP training(3)(4)(5). In a parallel fashion, ACLPS has now formulated a similar document for CP training, which forms the basis of this report. To accomplish this goal, the ad hoc committee of ACLPS (a) reviewed subdiscipline CP curricula that were previously published, especially in the areas of transfusion medicine(6), molecular diagnostics(7), laboratory management(8), and informatics(9), as well as broader curriculum documents in the field(10)(11); (b) reviewed the CP curriculum in use at 11 institutions that volunteered to supply their programmatic documentation (Stony Brook University Hospital, University of Alabama at Birmingham, University of Minnesota, University of Southern California, University of Texas at San Antonio, University of Utah, University of Vermont, University of Virginia, Weill Medical College of Cornell University, William Beaumont Hospital, and Yale University); and (c) produced a draft proposal that was subsequently reviewed by an additional coterie of members and nonmembers drawn from academic, community, and commercial practice as well as by current residents in 4 programs and by the full membership of ACLPS at the 2005 annual meeting.
The Residency Review Committee for Pathology has had the opportunity to independently review this curriculum. The Committee found the document to be comprehensive and "of great value to anyone who is responsible for the design, evaluation, and improvement of CP education at any level. As such, the Committee encourages its dissemination to program directors, faculty and others who are involved in the education of pathology residents and/or fellows." In particular, the Residency Review Committee for Pathology believes that this curriculum "should be especially valuable to residency directors as they respond to the ACGME’s General Competency initiatives" (Steven P. Nestler, PhD, Executive Director, Residency Review Committee for Pathology, August 2005).
It is important to recognize the diversity of pathology training programs themselves as well as the fundamental need to train individuals for potentially diverse career paths in CP, the latter including pathways that emphasize full-time clinical practice as well as those that concentrate on investigative work in addition to clinical practice. Moreover, careers in CP, as for all of medicine, may take place in a variety of settings that themselves emphasize different aspects of the discipline, including academic, community, public health, and industry environments. Thus, this proposed curriculum is viewed as a document that can and should be appropriately modified by individual programs to best meet their own unique programmatic goals, in keeping with both their available resources and their ability to provide appropriate levels of training for all, or for a subset, of these career paths in CP. The current document is deliberately phrased in broad terms in many areas. The hope of the ad hoc committee is that this publication will represent the first step in an evolutionary process, which will be followed by the articulation and publication of more detailed subspecialty curricula, created with input from subspecialty organizations as well as from the general pathology associations and community.
The outline below is designed to meet the didactic criteria articulated by the ACGME, specifically: "Education in clinical pathology must include microbiology (including bacteriology, mycology, parasitology and virology), immunopathology, blood banking/transfusion medicine, chemical pathology, cytogenetics, hematology, coagulation, toxicology, medical microscopy (including urinalysis), molecular biologic techniques, aspiration techniques, and other advanced diagnostic techniques as they become available" (12). It is also designed to presage and incorporate the emerging fields of complex multiparameter diagnostic systems, new biological approaches to diagnostics, including proteomics, cellular therapeutics, and pathology informatics, that are now becoming more routinely incorporated into medical delivery systems and will play an increasingly important role for the clinical pathologist of the future. Finally, the areas of overlap between AP and CP training are taken into account, and hence there are some portions of this CP curriculum that are appropriately also included in an AP curriculum, such as that proposed by Association of Directors of Anatomic and Surgical Pathology(3)(4). The goal of the current document is to be as reasonably comprehensive and inclusive as possible while simultaneously recognizing the need for creative exploration of new educational strategies by diverse programs.
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Overall Goals of the Laboratory Medicine Curriculum
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The overall goals of a training program in CP should be to develop a pathologist with the following characteristics (Table 2
): - A pathologist capable of communicating as a medical consultant to other clinicians and to patients, as well as being capable of optimally directing the management of the clinical laboratory enterprise. The pathologist understands the science and technology of the clinical laboratory and assures the quality, clinical appropriateness, and usefulness of the data produced by that laboratory. The pathologist is a clinician first and foremost.
- A pathologist who understands and consults on methods of diagnostic test development, test utilization in the context of both generally applicable and patient-specific clinical settings, and assay interpretation in the acute and chronic clinical management of patients. These activities include the pathologist’s role in the development and implementation of integrated medical informatics that optimize patient care. The specific level of technical expertise attained in training will vary with career goals/roles and with the emphasis of the training program itself.
- A pathologist who understands methods and implementation of clinical laboratory–based therapeutics, including minimally manipulated and engineered cellular therapy. The specific level of technical expertise attained in training will vary with career goals/roles of the trainee and with the emphasis of the training program.
- A pathologist who has the skills to consult in these areas at the broader systems level, and in the various extant healthcare delivery models.
- A pathologist who understands the role of research, in its broadest definition, in clinical decision-making, test development, knowledge generation, and continuing education.
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Competencies Common to All Rotations
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Competencies that are common to all rotations are outlined here. Competencies that are specific to individual rotations are included with each subdiscipline. Means of assessing competency in laboratory medicine are discussed in a separate section toward the end of the document.
Patient Care
- Gather essential and accurate information about patients using all relevant available modalities.
- Act as a skilled consultant to other clinicians to develop a diagnostic plan based on specific clinical questions and relevant clinical and pathologic information. This should be accomplished both in the patient-specific setting and the broader context of developing appropriate clinical pathway algorithms for diagnosis.
- Consult as part of a multidisciplinary healthcare team in developing a therapeutic plan that includes laboratory monitoring of efficacy and toxicity. Where clinically appropriate, consult on the use of laboratory-based therapeutics such as blood transfusion and other forms of cellular therapy.
- Provide expert consultation on the interpretation and follow-up of unusual or unexpected test results.
- Consult as a clinical expert in laboratory medicine at multidisciplinary conferences.
Medical Knowledge
- Be able to use all relevant information resources to acquire and evaluate evidence-based information. Demonstrate proficiency in evaluating and presenting findings from appropriate peer-reviewed journals.
- Develop and maintain a knowledge base in the basic and clinical sciences necessary for effective consultation in laboratory medicine.
- Demonstrate sufficient knowledge to determine clinically optimal yet cost-effective testing and laboratory-based therapeutic strategies, including issues of turnaround time, test menu construction, and in-house vs referral diagnostic testing.
- Employ mathematics and statistics as appropriate to laboratory testing; understand and implement quality control (QC) and quality assurance procedures as required.
- Recognize the unique aspects of laboratory medicine practice as modified by patient age and other patient population characteristics, especially aspects of pediatric and geriatric practice.
- Demonstrate awareness and understanding of general and test-specific standards for method development and evaluation, such as those promulgated by the Clinical Laboratory Standards Institute (CLSI; formerly NCCLS), CAP, and similar organizations.
- Demonstrate awareness and understanding of proficiency programs, such as those provided by CAP and similar organizations.
- Demonstrate knowledge of the principles of clinical research design, implementation, and interpretation. Understand the various levels of evidence in medicine and their translation into evidence-based practice.
- Be able to design a study that can be used to validate methodologies and parameters of clinical utility for the implementation and continuing use of new evidence-based analytes in the local setting.
Practice-Based Learning and Improvement
- Demonstrate the ability to critically assess the scientific literature.
- Demonstrate knowledge of evidence-based medicine and apply its principles in practice.
- Use multiple sources, including information technology, to optimize lifelong learning and support patient care decisions.
- Develop personally effective strategies for the identification and remediation of gaps in medical knowledge needed for effective practice.
- Use laboratory problems and clinical inquiries to identify process improvements to increase patient safety.
- Demonstrate knowledge of how to establish continuing competency assessment for pathologists as well as for laboratory personnel.
- Use proficiency programs to improve laboratory practices.
Interpersonal and Communication Skills
- Demonstrate the ability to write an articulate, legible, and comprehensive yet concise consultation note. Provide a clear and informative report, including a precise diagnosis whenever possible, a differential diagnosis when appropriate, and recommended follow-up or additional studies as appropriate.
- Demonstrate the ability to provide direct communication to the referring physician or appropriate clinical personnel when interpretation of a laboratory assay reveals an urgent, critical, or unexpected finding and document this communication in an appropriate fashion.
- Conduct both individual consultations and presentations at multidisciplinary conferences that are focused, clear, and concise.
- Demonstrate the ability to communicate the vision of the CP service role to other clinicians as well as to other healthcare personnel and administrators to develop clinically advantageous and cost-effective strategies.
- Choose effective modes of communication (listening, nonverbal, explanatory, questioning) and mechanisms of communication (face-to-face, telephone, e-mail, written), as appropriate.
- Demonstrate skills in obtaining informed consent, including effective communication to patients about procedures, alternative approaches, and possible complications of laboratory-based patient care diagnostic and therapeutic activities, such as those related to transfusion medicine.
- Demonstrate skills in educating colleagues and other healthcare professionals: (1) demonstrate the ability to help other residents obtain proficiency in laboratory medicine; (2) demonstrate the ability to work well with medical technologists and to present laboratory medicine concepts to them effectively in continuing education settings and in the day-to-day laboratory environment; (3) demonstrate the ability to educate nonpathology clinicians and other healthcare workers, including pharmacists, nurses, residents, medical students, and others, about topics such as the fundamental principles of pathophysiology underlying test design/interpretation and the approach to choosing and interpreting laboratory tests; (4) demonstrate an understanding of the principles one must follow when educating other practicing pathologists through publications or seminars on new testing and therapeutic strategies, research discoveries, and other cutting-edge professional knowledge.
Professionalism
- Demonstrate compassion: be understanding and respectful of patients, their families, and the staff and physicians caring for them.
- Interact with others without discriminating on the basis of religious, ethnic, sexual, or educational differences.
- Demonstrate positive work habits, including punctuality, dependability, and professional appearance.
- Demonstrate a responsiveness to the needs of patients and society that supersedes self-interest.
- Demonstrate principles of confidentiality with all information transmitted both during and outside of a patient encounter.
- Demonstrate knowledge of regulatory issues pertaining to the use of human subjects in research.
- Demonstrate a commitment to excellence and ongoing professional development.
- Demonstrate interpersonal skills in functioning as a member of a multidisciplinary healthcare team.
Systems-Based Practice
- Demonstrate understanding of the role of the clinical laboratory in the healthcare system.
- Demonstrate the ability to design resource-effective diagnostic plans based on knowledge of best practices in collaboration with other clinicians.
- Demonstrate knowledge of basic healthcare reimbursement methods.
- Demonstrate knowledge of the laboratory regulatory environment, including licensing authorities; federal, state, and local public health rules and regulations; regulatory agencies such as the Centers for Medicare and Medicaid Services and the US Food and Drug Administration; and accrediting agencies such as the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), CAP, and the ACGME.
- Understand and implement policies to continually improve patient safety as they relate to clinical laboratory testing at all levels.
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Didactic Methodologies
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The curriculum should emphasize knowledge-based and skills-based activities. Rotations in specific laboratories should emphasize graduated responsibility for clinical consultation and interpretation of unusual results, allowing the use of a case-oriented learning format. The resident should be included as a junior practitioner in the daily clinical workload of the laboratories. "Sign-out" responsibilities are usually accompanied by workstation-oriented teaching of pathophysiology and analytical issues, which in turn may be accompanied, as appropriate, by hands-on experience. Alternatively, a resident could generate a case portfolio including cases involving each of the major areas of laboratory testing. Case discussions should include a sufficient amount of detail demonstrating the resident’s analytical and consultative skills. The information created should demonstrate the ability of the resident to recognize problems in testing and interpretation, make recommendations for additional testing, and understand the clinical utility of test results. Rotations should also generally include active involvement in daily rounds and weekly supervisory meetings in which residents participate in discussions and decisions concerning quality assurance, proficiency testing, personnel management, budgeting, and instrument and procedure evaluations. Didactic sessions, case presentations in a grand-rounds format, research seminars, journal clubs, subspecialty conferences, and participation in multidisciplinary conferences are all useful exercises. Exit examinations held at the end of rotations are helpful in providing feedback to trainees. Principles of training common to all residency programs, such as stress management and maintenance of a nurturing educational environment, are also important parts of the didactic approach.
On-call responsibilities with comprehensive attending pathologist backup and feedback are critical to CP training. Indeed, we believe that all laboratory medicine training programs should have a 24/7 call system. In many programs, a single resident will take calls for all issues and consults at night and on weekends; other programs may want to delegate some areas, for example, blood bank, to a separate resident. The resident is the front-line recipient of calls, and a system of logging cases is essential. There should be an appropriate on-call orientation and training process, appropriate 24/7 backup by faculty members, and appropriate documentation and evaluation on a periodic basis. Although different formats are possible, discussion of these consultations with the entire resident staff in a morning-report format (even if only weekly) has been found to be useful in some programs.
Because project management in the development and implementation of laboratory assays is an integral part of the clinical activities of a laboratory medicine physician, it is recommended that each trainee be actively involved in these activities during his/her CP rotations. The experience should be meaningful and substantive and involve the trainee in all aspects of project management and research, including conception, design, execution, analysis, and communication. The process per se is a more important aspect of the training than the exact target of inquiry. As such, fewer, more involved experiences are preferred over a series of short projects in each rotation. The nature of the project or research should be tailored to the trainee’s career goals/roles and thus can range from assay validation or concordance studies, to utilization guideline construction, to a long-term basic research program. Some of these aspects of training are best incorporated as integral parts of each subdiscipline, whereas other aspects should be approached as free-standing electives. This committee does not recommend a specific structure for this training but emphasizes its central inclusion in the overall training program.
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Basic Schedule of Rotations
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It is important for residents to undertake graduated responsibilities during their training because the educational process is, of course, not just one of knowledge acquisition but, as importantly, one of attaining progressively more "attending-like" professional skills and mature judgment. In the schema used below, reaching skill levels I and II corresponds to those achievements that are required for minimal competency as a generalist in CP—these skills would normally be acquired in 18–24 months of training. We have used skill levels for pedagogical reasons, so as to suggest a sequence of teaching activities that builds on earlier knowledge and achievement. Individual programs may choose to alter this learning sequence to better fit their local environment. Serving as a guide for curriculum construction, skill level I corresponds roughly to the types of activities and responsibilities that a first- and/or second-year AP/CP resident (or a first-year CP-only resident) would be engaged in, that is, the level of achievement to be attained during the resident’s first exposure to the subdiscipline as a postgraduate. Skill level II corresponds to the achievements expected of a third- and/or fourth-year AP/CP resident (or second-year CP-only resident), that is, the higher level of responsibility and expertise that one would acquire and consolidate during repeat exposure to a subdiscipline. This 18–24 months of training (skill levels I and II) is used to acquire the minimal general skills in all areas sufficient to meet the competency levels required by the American Board of Pathology for eventual certification in CP. Because of the relative brevity of an 18-month course of training in CP, some programs may choose to have no elective time during that period, especially if the overall course of study for a particular AP/CP resident’s career goals will include a predominant AP emphasis; it is then possible to focus on "crossover" aspects of training during months 19–24 (for example, molecular pathology, informatics, management, and morphometric hematopathology). It is expected that for a program that includes 24 months of CP level I and II training, the last 6 months will usually include elective time and offer a degree of flexible emphasis in 1 or 2 areas for months 19–24.
Skill level III refers to the higher level of competency, responsibility, and breadth of knowledge required for those whose career path involves a major or exclusive emphasis on CP in their practice. This would usually correspond to a third year of training (total training of 36 months), such as that required for individuals training in CP without concomitant AP training or certification. In some cases, it might correspond to the last 6–12 months of CP training for an AP/CP resident whose 4-year program involves an emphasis on CP. Because this higher level of training is best individualized depending on career path and because only a subset of pathology programs have the resources to provide such training, suggestions for skill level III training are included as a separate portion of the curriculum in a later section of this document and not as part of the subdiscipline-oriented portion outlined below.
It is recognized that basic residency training in CP, like that in AP, is designed to produce a generalist pathologist. In an era of ever-increasing medical complexity, the role for subspecialization by at least a subset of pathologists is therefore increasing, and fellowship-trained subspecialists are likely to become increasingly important in medical care delivery systems.
In keeping with the prior recommendations of the Graylyn Conference and based on accepted educational practices, it is generally recommended that the core rotations be structured as subdiscipline-specific, concentrated, and protected rotations (for example, a rotation in chemical pathology rather than a joint rotation in chemical pathology and microbiology). Some rotations at higher levels and in more advanced years of training, when the trainee has acquired basic skills, may be productively cross-disciplinary within the broad field of pathology. As noted earlier, the sound principle of graduated responsibility makes a system of at least 2 distinct rotations in each major subdiscipline a generally preferable approach to education.
The general outline for rotations is conceived as follows:
- Chemical pathology (includes toxicology/xenobiotic management): level I (3–5 months); level II (1–2 months)
- Hematology (includes flow cytometry, coagulation, and medical microscopy): level I (3–5 months); level II (1–2 months)
- Microbiology (includes bacteriology, mycology, parasitology, and virology): level I (3–5 months); level II (1–2 months)
- Transfusion medicine (includes apheresis and cellular therapeutics): level I (3–5 months); level II (1–2 months)
- Immunopathology (includes tissue typing): level I (1 month); level II, sometimes combined with other rotations, especially chemical pathology or microbiology
- Molecular diagnostics (includes cytogenetics): level I/II (1–2 months)
- Management and informatics: level I/II (1–2 months equivalent; level I and II may both be incorporated as an integral part of other rotations)
It is recognized that there are areas of overlap between disciplines and that, therefore, some institutions may choose to include portions of the curriculum in different rotations compared with those in which they are subcategorized in this document. In addition, some aspects of the CP knowledge base and skill set are common across disciplines; hence programs may choose to emphasize some of these common areas in different rotations from those in which they are arbitrarily categorized here ("principles of laboratory medicine", management, quality assurance procedures, instrumentation, technical methodologies, and method development are such examples). Where possible, cross-references are indicated in the text. Similarly, there are areas of overlap between traditional AP and CP disciplines that may provide opportunities for programs to alter traditional rotation schedules, especially following minimal core training in AP and CP. Moreover, there are some rotations in the current curriculum of most institutions, and reiterated here, that are based to some extent on technology rather than on clinical field—molecular diagnostics to some extent fits this description—and programs may have different approaches as to how best to include education in these areas within their particular structures. Finally, there are aspects of laboratory medicine that are significantly influenced by characteristics of the patient populations, for example, pediatric and geriatric practice, and some programs may choose to utilize specialized rotations in different clinical settings to provide optimal training in these areas (for example, a pediatric hospital rotation). In summary, curriculum is in constant evolution, and, within the somewhat broad confines of the principles elucidated here, final determination of a training curriculum is best left in the hands of individual programs, which may choose to experiment with innovative organizational structures. Because of these considerations, a web page has been designed as an accompaniment to the current document (www.aclps.org). It is the expectation of ACLPS as sponsor of this web page that it will provide a mechanism for dynamic changes in curriculum recommendations as laboratory medicine evolves, as well as creating a mechanism for discussion on the frontiers of curriculum development and for including additional material that may be of use to training programs.
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Curriculum for Subdiscipline-Specific Rotations
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The curriculum outlined below attempts to identify most of the major areas needed for CP training in each classic subdiscipline. It is not designed to assess the relative weight to be given to each topic mentioned nor, for the sake of conciseness, is it completely comprehensive. As mentioned earlier, it is hoped that this can form the basis for discussion and for an evolutionary improvement in delineation of curriculum over time and for further work by both general and subspecialty groups of pathologists. In addition, there are some topics that apply to all subdisciplines but which may receive different emphasis in each section or be included predominantly as one of the general competencies outlined earlier. The importance of understanding the unique aspects of pediatric CP would be such an example. Each section ends with a listing of competencies specific to a subdiscipline and with a few possible reference materials. Again, there are many fine reference books available, and the list is by no means comprehensive. Several general texts in laboratory medicine are listed below and not reiterated in each section.
General Reference Materials:
Henry JB, ed. Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Philadelphia: WB Saunders, 2001.
Laposata M, ed. Laboratory Medicine: Clinical Pathology in the Practice of Medicine. Chicago: ASCP Press, 2002.
Mcclatchey KD, ed. Clinical Laboratory Medicine. Philadelphia: Lippincott Williams & Wilkins, 2002.
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Chemistry
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I. Analytical Techniques and Instrumentation
Skill Level I
- Understand the principles and operational characteristics of analytical chemistry techniques, including photometric, electrochemical, enzymatic, electrophoretic, radiometric, chromatographic, mass spectrometric, and immunologic methods (see also the Immunology and Immunogenetics section).
- Understand different types of random-access automated analyzers and the measurement principles employed in these systems, including spectrophotometric, ion-selective electrode, and electrochemical methods, as well as immunologic methods, including enzyme multiplied immunoassay technique, cloned enzyme donor immunoassay, fluorescence polarization immunoassay, microparticle enzyme immunoassay, electrochemiluminescence, ELISA, turbidimetry, and nephelometry.
- Understand the basic biology of, and analytical methods for, determination of qualitative and quantitative changes in blood and fluid proteins and amino acids (enzymes, biomarkers, hormones, and cytokines), carbohydrates, lipids and lipoproteins, and clinically relevant small molecules (including metals, trace elements, and vitamins).
Skill Level II
- Understand the principles of laboratory robotics and automation strategies.
- Understand the general principles of assay calibration, QC, and the need for calibration verification.
- Understand the causes of both positive and negative interferences as well as how to detect and avoid them.
- Understand the techniques employed for specific extraction of analytes from biological fluids.
- Identify factors influencing separation and resolution in electrophoresis and chromatography, including mechanism of separation and mobile/stationary phases.
- For chromatography, understand the importance of internal standards, the relative retention time, carryover, and matrix effects.
- For mass spectrometry, understand the pitfalls of ion suppression and the need for defining characteristic ion ratios for reliable compound identification.
II. Organ-Based Biochemical Pathophysiology
1. assessment of pulmonary function: blood gases and oxygen saturation
Skill Level I
- Understand the principles of partial pressure of gases and the need for an O2 carrier. Be able to describe the alveolar-arterial O2 gradient and anion gap.
- Know the pathophysiology of ketoacidosis and lactic acidosis.
- Understand the significance of P50, O2 content, O2 capacity, and O2 saturation and be able to distinguish between O2 saturation and PO2.
- Be able to describe the hemoglobin-oxygen dissociation curve and factors that affect the curve and P50.
- Understand the principles of integrated blood gas, electrolyte, and CO-oximetry systems.
2. acid-base chemistry, electrolytes, and relevant disorders
Skill Level I
- Define the Henderson–Hasselbach equation. Be familiar with physiologic buffer systems and the role of respiratory and renal compensation. Understand categories of clinical disorders of acid–base balance (metabolic and respiratory acidosis, metabolic and respiratory alkalosis, mixed disorders).
- Know the differential diagnosis of common electrolyte disorders.
3. assessment of renal function
Skill Level I
- Know the basic physiology of renal function. Understand the basic categories of renal diseases (e.g., pre-renal azotemia, obstructive azotemia, glomerulonephritis, acute vs chronic renal failure, uremic syndrome) and be familiar with the National Kidney Foundation practice guidelines for these conditions. Know the laboratory analytical methods (e.g., Jaffe vs creatinase) for the assessment of renal function (creatinine, urea nitrogen, glomerular filtration rate) and proteinuria. Understand the concept of creatinine clearance, how it can be used to estimate glomerular filtration rate, and the various methods employed to measure it. Understand renal handling of electrolytes and key metabolites and the interpretation of urinary electrolyte measurements.
- Understand the definition of osmolality, molecules in serum that contribute to osmolality, and calculation of osmolal gap as well as the principle of the osmometer. Understand the common pitfalls and sources of error during estimation of the osmolal gap (e.g., hyperproteinemia, hyperlipidemia, hypermagnesemia). Understand the differential diagnosis of an unexplained, increased osmolal gap, including alcohol or glycol ingestion, alcoholic or diabetic ketosis or ketoacidosis, and osmotherapy (e.g., mannitol or glycerol administration), among others. Understand the principles of fluid balance.
4. cardiac biomarkers for the assessment of coronary artery diseases
Skill Level I
- Know the current definition of myocardial infarction by the European Society of Cardiology/American College of Cardiology guidelines and the New York Heart Association classifications and understand the interaction of diagnostic modalities in its definition (electrocardiogram, laboratory testing, and imaging).
- Know the diagnostic and prognostic significance as well as the limitations of current coronary artery disease biomarkers [troponins I and T, creatinine kinase (CK-MB index and isoforms), and myoglobin].
- Know the pathophysiology and evaluation of congestive heart failure. Understand the markers of congestive heart failure [B-type natriuretic peptide (BNP) and N-terminal fragment of the BNP prohormone (NT-proBNP)] and their biological and technical limitations.
- Understand the utility of markers of inflammation in the evaluation of cardiac risk (e.g., homocysteine and C-reactive protein).
5. assessment of liver and biliary tract status
Skill Level I
- Understand the dynamics and mechanisms of liver enzyme release and the clinical utility of measuring hepatic enzymes (e.g., aspartate aminotransferase, alanine aminotransferase,
-glutamyltransferase, alkaline phosphatase, and lactate dehydrogenase).
- Know the biochemical assessment of liver function by nonenzyme analytes such as albumin, ammonia, bile acids, bilirubin, urea nitrogen, cholesterol, total protein, and triglycerides.
- Understand bilirubin metabolism, fractionation of bilirubin (conjugated, unconjugated,
-bilirubin, direct vs indirect) and unique aspects of neonatal bilirubin. Understand the conditions and genetic defects that affect bilirubin metabolism, transport and clearance (e.g., Gilbert disease and Dubin–Johnson syndrome).
6. assessment of thyroid function
Skill Level I
- Understand the structure, biosynthesis, secretion, and metabolism of thyroid hormones [thyroxine (T4), triiodothyronine (T3), and reverse T3 (rT3)]. Know thyroid physiology and control of thyroid function [thyrotropin-releasing hormone (TRH) and thyrotropin (TSH)].
- Know the common causes of hypothyroidism and hyperthyroidism.
- Know the laboratory tests for evaluation of thyroid disorders and be able to interpret these analytes in their clinical context with an appreciation for the euthyroid sick state.
- Be familiar with current analytical methodologies for thyroid testing (TSH methods: 1st-, 2nd-, and 3rd-generation assays; isotopic and nonisotopic methods; T4; free T3 methods; T-uptake methods; TSH suppression and stimulation tests).
7. assessment of pituitary function
Skill Level II
- Understand the physiological action, biochemistry, and regulation of anterior pituitary hormones [adrenocorticotropic hormone (ACTH), growth hormone (GH), prolactin (PRL), luteinizing hormone (LH), follicle-stimulating hormone (FSH)] and of posterior pituitary hormones [antidiuretic hormone (ADH) and oxytocin].
- Understand endocrine tests of hypothalamic-pituitary function (cosyntropin test/rapid ACTH stimulation test, insulin hypoglycemia test, metyrapone test, levodopa test, arginine infusion test, glucose-GH suppression test, TRH test, gonadotropin-releasing hormone (GnRH) test, clomiphene test, corticotropin-releasing hormone (CRH) test, gonadotropin-releasing hormone test, water deprivation test, saline infusion test, and water loading test). Understand the pathophysiology of disorders of the pituitary.
8. assessment of adrenal function
Skill Level I
- Understand the physiological action, biochemistry, biosynthesis, chemical structure, and metabolism of glucocorticoids and mineralocorticoids.
- Understand the physiological regulation of the renin-angiotensin-aldosterone system.
- Understand clinical conditions associated with excess and deficiency of adrenal cortex hormones. Understand testing of the functional status of the adrenal cortex [basal values vs stimulation tests and suppression tests, circadian rhythm of corticosteroids, morning ACTH, cortisol (urinary, random, and free), rapid ACTH cortisol stimulation test, multiday ACTH stimulation, metyrapone stimulation, CRH stimulation, and quantitative serum and urinary steroid hormone panels].
- Understand the synthesis and metabolism of biogenic amines, including catecholamines and serotonin.
- Be familiar with the strengths and weaknesses of tests available for evaluation of disorders of the adrenal medulla, such as pheochromocytoma or neuroblastoma.
9. assessment of reproductive function, pregnancy, and prenatal testing
Skill Level II
- Understand the role of sex hormones in reproduction and the evaluation of pregnancy and reproductive dysfunction, such as menstrual disorders and infertility.
- Understand the importance of demographic data and biochemical assessment in prenatal testing for fetal defects.
10. assessment of gastric, pancreatic, and intestinal function
Skill Level I
- Understand the clinical manifestations of gastric, pancreatic, and intestinal disease and diagnostic methodologies such as the breath tests for Helicobacter pylori, fecal occult blood, lipase, and amylase (e.g., fractionation of amylase; pancreatic vs salivary and amylase/creatinine clearance ratio).
- Appreciate the role of gastrointestinal hormones and enzymes in digestion and the evaluation of malabsorption and diarrheal syndromes.
11. assessment of glucose and evaluation of diabetes mellitus
Skill Level I
- Understand the metabolism of carbohydrates (insulin, C-peptide, and other regulatory hormones) and be familiar with the American Diabetes Association (ADA) definitions of impaired fasting glucose, impaired glucose tolerance, type 1 and type 2 diabetes mellitus, criteria for diabetic ketoacidosis and hyperosmolar hyperglycemic state, as well as gestational diabetes. Understand the underlying pathophysiology of different forms of diabetes.
- Understand the diagnosis and laboratory assessment of diabetes (blood glucose, oral glucose tolerance test, hemoglobin A1c, fructosamine, and urinary microalbumin) and its complications.
- Understand the diagnosis and evaluation of hypoglycemia.
12. assessment of mineral and bone metabolism
Skill Level I
- Understand the biochemistry and physiology of calcium, phosphate, and magnesium.
- Know the hormones that regulate mineral metabolism [parathyroid hormone (PTH), calcitonin, and vitamin D] as well as parathyroid hormone-related protein (PTHrP). Understand various PTH assays, including biointact PTH and intraoperative PTH.
- Know the pathophysiology of metabolic bone diseases such as osteoporosis, osteomalacia, and Paget disease.
13. assessment of porphyrins and disorders of porphyrin metabolism
Skill Level II
- Understand the biochemistry of heme and porphyrins.
- Understand the porphyrias and be able to consult on the selection and interpretation of both screening and diagnostic tests for each disorder.
14. tumor biomarkers
Skill Level I
- Be familiar with the definition, classification, biochemistry, and distribution of tumor markers, both protein and carbohydrate, including, but not limited to, prostate-specific antigen, calcitonin, human chorionic gonadotropin,
-fetoprotein, carcinoembryonic antigen, CA 15-3, CA 125, and CA 19-9.
- Know the limitations of laboratory assessment of various tumor markers and the factors affecting the results of different analytical procedures.
- Understand the conceptual basis of assays used to screen for malignancy, including Bayes theorem.
Skill Level II
- Be familiar with ongoing efforts to identify proteomic patterns for cancer detection.
15. assessment of fetal lung maturity
Skill Level I
- Understand the physiology of respiratory distress syndrome.
- Understand fetal lung maturity testing [lecithin/sphingomyelin (L/S) ratio, phosphatidyl glycerol (PG), foam stability index (FSI or shake test), fluorescence polarization, and counting of lamellar bodies]. Understand the biochemistry, physiology, and diagnostic performance of fetal fibronectin.
16. trace element assessment
Skill Level II
- Understand the biochemistry, physiology, and metabolism of trace elements (iron, magnesium, zinc, copper, selenium, cobalt, and fluoride). Know the biochemistry and clinical significance of metal-binding proteins such as transferrin, ferritin, and ceruloplasmin.
- Know the clinical assessments of trace elements (serum iron, iron-binding capacity, transferrin, transferrin saturation, serum ferritin, zinc protoporphyrin, and serum ceruloplasmin).
17. vitamin assessment
Skill Level I
- Know the definition and classification of vitamins: fat-soluble vitamins (A, D, E, and K) and water-soluble vitamins [B1, B2, B6, B12 (cobalamin), C, niacin, nicotinamide, folic acid, biotin, and pantothenic acid].
- Understand the clinical disorders associated with the deficiency as well as toxicity of vitamins.
18. cholesterol and lipid assessment
Skill Level I
- Understand the chemical structures, biosynthesis, classification, function, and metabolism of lipids and lipoproteins.
- Understand the Fredrickson classification and the National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (ATP III) classification of hyperlipidemia.
- Understand the pathophysiology of lipid disorders.
- Know the principles of analytical techniques for laboratory assessment of lipids.
19. serum and fluid protein and amino acid assessment
Skill Level I
- Understand the principles of protein analysis in body fluids (e.g., Kjeldahl and Biuret methods, refractometry, and qualitative dipstick).
- Know the principles of serum, urine, and cerebrospinal fluid (CSF) protein electrophoresis. Recognize key patterns of dysproteinemias and monoclonal gammopathies (see also the Immunology and Immunogenetics section).
- Understand approaches for distinguishing transudates vs exudates in fluids.
- Know the analytical methods involved in genetic and acquired aminoacidurias and the current guidelines for screening neonates for these disorders.
Skill Level II
- Understand the emerging technology of proteomics and its potential applications in clinical diagnostics.
20. clinical enzyme kinetics
Skill Level II
- Understand the principles of enzyme kinetics (e.g., Michaelis–Menten equation, concepts of Km, Vmax, and zero-order and first-order kinetics) and clinical enzymology, including isoenzymes, isoforms, and tissue distribution.
- Be familiar with the principles of analytical enzymology and know the concepts of activity vs mass assays (e.g., CK vs CK-MB assays).
21. pediatric biochemistry
Skill Level II
- Understand the differences and unique aspects of pediatric and neonatal chemistry, including reference ranges.
III. Therapeutic Drug Monitoring and Toxicology
1. pharmacokinetics
Skill Level I
- Understand the concepts of drug absorption, bioavailability, volume of distribution, and distribution phases (multicompartment models) and be able to predict peak drug levels.
- Understand the differences between first- and zero-order kinetics of drug metabolism/elimination.
- Understand the concepts of drug clearance, half-life, and the exponential rate constant. Be able to calculate steady-state drug levels and estimate peak and trough drug levels throughout a dosing cycle.
- Understand the origin and consequences of nonlinear or zero-order pharmacokinetics on drug pharmacokinetics.
- Understand the differences between measurement of total, free, and protein-bound drug levels and be able to assess the consequences of altered protein binding on pharmacokinetics and therapeutic drug monitoring.
2. drug metabolism
Skill Level I
- Understand the differences between phase I and phase II drug metabolism reactions.
- Appreciate the various consequences of competing metabolic pathways to modulate both the efficacy and toxicity of administered medications.
- Appreciate the frequent interindividual variability of drug-metabolizing enzymes and its impact on the variability of drug response.
3. pharmacodynamics
Skill Level I
- Understand the general mechanisms of drug action, including drug–receptor interactions, modulation of metabolic pathways, and nucleic acid biochemistry.
- Understand how reference ranges for therapeutic drug monitoring are established and understand the varying utility of trough, peak, or steady-state drug levels for monitoring both drug efficacy and toxicity. Understand the therapeutic index.
4. therapeutic drug monitoring of specific drug classes
Skill Level I
- Understand the principles and practice of therapeutic drug monitoring of antidepressants, mood stabilizers, and antipsychotics; anticonvulsants; cardioactive drugs; bronchodilators; antibiotics; and immunosuppressants.
- Understand the relative significance of peak and trough levels for monitoring of these drug classes.
5. toxicologic syndromes
Skill Level II
- Understand the pathophysiological basis and be able to recognize the five major toxicologic syndromes (cholinergic, anticholinergic, sympathomimetic, opiate, and sedative-hypnotic).
- Be able to formulate a toxicologic differential diagnosis and be able to design a clinical laboratory testing protocol for each of the syndromes.
- Understand the basic therapeutic approach to each syndrome.
6. laboratory evaluation and management of overdosed or poisoned patients
Skill Level I
- Be familiar with the National Academy of Clinical Biochemistry guidelines for Emergency Toxicology.
- Understand the important differences between urine and blood (including serum and plasma) for monitoring and detection of drugs/xenobiotics.
- Understand how to design and implement standardized STAT panels of laboratory tests for evaluation of overdosed/poisoned patients.
- Understand the limitations of drug "screening" protocols and be able to consult on the design of more extensive drug-testing protocols to supplement the standard STAT panels.
Skill Level II
- Understand the toxicologic profiles of specific agents, including acetaminophen, salicylates, alcohols and glycols, barbiturates, tricyclic antidepressants, carbon monoxide, organophosphates and carbamate, digoxin, lead, iron, and cyanide.
- Understand the general supportive measures, the role of alkalinization, the importance of specific antidotes, and the variable efficacy of exchange transfusion, hemodialysis, plasmapheresis, and charcoal hemoperfusion of blood in the management of specific agents.
7. laboratory evaluation of drugs of abuse
Skill Level I
- Understand the generic methodology of the routine immunoassays for drugs-of-abuse testing.
- Be familiar with the major drugs of abuse and their clinical manifestations.
- Know the common methods for adulteration of urine and the techniques available in the laboratory to detect them.
Skill Level II
- Know the specific reactivities of each immunoassay, the standard cutoffs for detection, and whether the assay is capable of detecting the parent drug, its metabolites, or both. Know which members of a drug class are poorly or well detected by a generic immunoassay (e.g., oxycodone detection by the opiate immunoassay) and know the common causes of false positives due to cross-reactivities.
8. pharmacogenomics
Skill Level II
See the Molecular Pathology section.
additional competencies specific to chemistry
Patient Care
- Understand "chain of custody" and other legal requirements for forensic chemical pathology.
Professionalism
- Demonstrate understanding of the social consequences of testing for drugs of abuse.
Chemistry Reference Materials:
See also the General Reference Materials.
American College of Cardiology. Myocardial Infarction Redefined—A Consensus Document of The Joint European Society of Cardiology/American College of Cardiology Committee for the Redefinition of Myocardial Infarction. http://www.acc.org/clinical/consensus/mi_redefined/.
American Diabetes Association Clinical Practice Guidelines. http://www.diabetes.org/for-health-professionals-and-scientists/cpr.jsp.
American Society for Clinical Oncology. 2000 Update of Recommendations for the Use of Tumor Markers in Breast and Colorectal Cancer. http://www.asco.org/ac/1,1003,_12-002130,00.asp.
Burtis CA, Ashwood EA, Bruns DE, eds. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics, 4th ed. St. Louis, MO: Saunders, 2006.
Kaplan LA, Pesce A, Kazmierczak S, eds. Clinical Chemistry: Theory, Analysis, Correlation, 4th ed. St. Louis, MO: CV Mosby, 2003.
National Academy of Clinical Biochemistry. NACB Laboratory Practice Guidelines. http://www.nacb.org/lmpg/main.stm.
National Heart, Lung, and Blood Institute, National Institutes of Health. Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). http://www.nhlbi.nih.gov/guidelines/cholesterol/.
Point-of-Care Testing
Point-of-care testing (POCT) occurs across all disciplines, but because there are important common issues in its clinical use, it has been made a separate, distinct part of the curriculum in this document. The POCT curriculum may be taught in a concentrated fashion in any of the subdisciplines, depending on what is most appropriate to the institution.
Skill Level I
- Understand definitions of POC and waived testing.
- Understand the range of analytes available in devices used at the point of care.
- Understand the impact of POCT on clinical care, in terms of volume of tests performed, turnaround time, and the utilization of common POC tests (e.g., bedside glucose, rapid strep, and activated clotting time).
- Understand the differences in reference ranges and test performance characteristics between POCT and central laboratory assays.
- Appreciate the difference between POCT and near-patient testing and the personnel resources that best accomplish quality testing in these distinct situations.
Skill Level II
- Understand the principles of performance for common POC tests such as glucose, urine drugs of abuse, rapid microbial antigen, and activated clotting time. Understand the performance characteristics of the common POC devices used for these tests. Know the issues surrounding specimen collection and preparation and the limitations and interpretation of results.
- Understand the quality principles of POCT, including QC of unit-use testing devices, and proficiency/competency assessment of testing with multiple sites and operators and diverse testing personnel.
- Understand the regulatory, administrative, and operational context of POC, waived, and home testing.
- Be able to assess economic, workflow, human resources, and clinical factors driving the decision to perform testing at the point of care vs the central laboratory.
- Know the most common test systems used in POCT.
- Develop an appreciation of emerging POCT technologies, including microelectrical mechanical systems (MEMS) and other biosensor techniques, and their potential clinical applicability.
additional competencies specific to poct
Systems-Based Practice
- Demonstrate the ability to design and communicate effective quality plans for nonlaboratorians performing POCT.
POCT Reference Materials:
See also the General Reference Materials.
Joint Commission on Accreditation of Healthcare Organizations. Quality Point of Care Testing: A Joint Commission Handbook. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 1999.
Price CP, St John A. Point of care testing. In: Burtis CA, Ashwood EA, Bruns DE, eds. Tietz Textbook of Clinical Chemistry and Molecular Diagnostics, 4th ed. St. Louis, MO: Saunders, 2006:299–320.
Price CP, St John A, Hicks JM. Point of Care Testing, 2nd ed. Washington: AACC Press, 2004.
Threatte GA. Physician office laboratories. In: Henry JB, ed. Clinical Diagnosis and Management by Laboratory Methods, 20th ed. Philadelphia: WB Saunders, 2001.
Hematology
I. Hematology/Body Fluids/Urinalysis
1. automated hematology
Skill Level I
- Understand clinical indications for peripheral blood cell enumeration and differential analysis.
- Know the components of a complete blood count and understand the information provided by each.
- Understand the principles of automated cell counting, including red blood cell (RBC) indices and their derivation.
- Understand how "absolute values" are determined and how they differ from "relative percent".
- Identify spurious white blood cell (WBC), RBC, hemoglobin, and platelet determinations and be able to propose a course of action to be followed for reporting results.
- Understand appropriate WBC correction for the presence of nucleated RBCs.
- Understand automated differential analysis and manual review criteria.
- Understand the absolute neutrophil count and its clinical utility, as well as problems associated with band counts.
- Understand QC procedures specific to cell counters, such as Rumke limits on differential cell counts and Bull analysis of indices.
- Understand principles of automated and manual reticulocyte enumeration and their respective technical limitations.
Skill Level II
- Interpret results of automated and manual cell counts and understand the relevant technical limitations.
- Recommend appropriate steps for abnormal sample processing, analysis, and result reporting.
- Review abnormal results and correlate results with peripheral blood smear findings and clinical history.
2. peripheral blood smear analysis
Skill Level I
- Know proper preparation and handling of peripheral blood smears, including standard stains and special stains used to identify cellular structures and inclusions.
- Understand normal RBC, WBC, and platelet morphology.
- Be able to estimate WBC and platelet counts.
Skill Level II
- Recognize abnormal RBC, WBC, and platelet morphology; formulate a differential diagnosis; and suggest appropriate laboratory testing for follow-up.
- Recognize technical artifacts in WBC, RBC, and platelet morphology.
- Recognize infectious disorders that can be diagnosed by blood smear.
- Recognize storage disorders and congenital disorders that have morphologic manifestations in the peripheral blood smear.
- Correlate peripheral blood smear findings with bone marrow morphology.
3. body fluid analysis: csf, ascitic/pleural fluid, joint fluid
Skill Level I
- Understand clinical indications for body fluid analysis.
- Understand manual hemocytometer cell counting.
- Understand cytocentrifuge sample preparation and slide staining.
- Identify blood and body fluid cell morphology.
Skill Level II
- Interpret results of body fluid analyses in the appropriate clinical context.
- Recognize malignant cells and recommend appropriate confirmatory tests.
- Correlate abnormal body fluid cell morphology with cytology, flow cytometry, and other relevant diagnostic test results.
- Identify body fluid crystals. Distinguish between urate and calcium pyrophosphate crystals, using polarized light.
4. manual hematology methods
Skill Level I
- Understand principles of microhematocrit determination and its technical limitations.
- Understand the principles of erythrocyte sedimentation rate.
- Understand the principle and utility of supravital stains, including reticulocyte stain, hemoglobin H preparation, and Heinz body preparation.
5. urinalysis
Skill Level I
- Understand the clinical indications for and utility of urinalysis.
- Understand the principles of methods involved in urine chemistry and urine sediment analysis.
- Understand the limitations of manual and automated urine chemistry and sediment analysis.
Skill Level II
- Interpret routine urine chemistry results and identify abnormal cells and organisms. Provide clinical follow-up as appropriate.
II. Special Laboratory Tests in Hematology
1. wbc disorders
See Section IV (Flow Cytometry) and Section V (Hematopathology) below.
2. rbc disorders
Skill Level I
- Learn the clinical indications for laboratory tests involved in the assessment of intrinsic and extrinsic RBC defects/disorders.
- Know the pathophysiology and characteristic laboratory findings of the major disorders causing normocytic, microcytic, and macrocytic anemia.
- Describe iron metabolism and laboratory tests for iron depletion.
- Understand hemoglobin synthesis and degradation.
- Understand the principles of hemoglobin screening by HPLC and electrophoresis at acid and alkaline pH.
- Understand the principle and clinical utility of screening tests for the presence of hemoglobin S.
- Know the pathophysiology and laboratory features of intrav
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Abstract
Introduction
