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Location: OHSU and Kaiser Permanente Duration: 3 months Organization: Chemical pathology is comprised of a 12-week rotation. Six weeks of the rotation are performed at the OHSU Hospital and clinical laboratories. The remaining six weeks are spent at the Kaiser Clinical Laboratory. The first two weeks of the rotation at OHSU are focused on laboratory instrumentation and test methodology, general laboratory operations and procedures including quality control and quality assurance, regulatory requirements (CAP/CLIA), and safety (OSHA). The remaining four weeks of the OHSU rotation are comprised of correlation of laboratory test results with pathophysiology. This includes a review of the basic biochemistry and physiology of the human body and biochemical and morphological manifestations of disease states. Following the six weeks at OHSU, residents complete six additional weeks of training at the Kaiser Regional Clinical Laboratory. During this time, residents gain addition experience in therapeutic drug monitoring and toxicology, endocrine function testing, and other esoteric testing not offered in the OHSU clinical laboratory. Goals of the rotation: The overall goal of the Clinical Chemistry rotation is to provide the resident with a set of tools that will enable the resident to develop and maintain a level of expertise in clinical chemistry that is appropriate to the professional responsibilities undertaken as a practicing pathologist. This includes understanding the role of analytical and quality principles that underlie laboratory techniques employed in the clinical chemistry laboratory. These tools will include basic principles of medical microscopy and urinalysis, analytical chemistry, quality control, quality assurance and laboratory management, correlation of laboratory test data with pathophysiology, development of effective personal reference tools (textbooks, journals, handouts, files), and development of a set of personal educational objectives for the rotation and the residency. Opportunities will be provided so that the resident can become proficient in these areas by the application of these tools in the laboratory setting.
Objectives: Core competencies that the resident will have learned following completion of this rotation are summarized below: Patient Care The resident will demonstrate the ability to provide effective clinical consultation by showing proficiency in the following: • • • • • • • • Gather appropriate and accurate clinical information. Interpret laboratory test results within the clinical context. Develop a diagnosis or differential diagnosis, based on laboratory results and clinical information. Use of information technology to support patient care decisions and educate practitioner. Use evidence-based medicine and clinical decision-making concepts to interpret results and make informed decisions. Advise clinicians on the use of clinically appropriate and cost-effective tests. Advise clinicians on appropriate follow-up for unexpected test results. Understand the limitations of point-of-care testing, and how to interpret these results in the appropriate context.
Medical Knowledge The resident will demonstrate the following: • • • • • • • • • • • • • Show knowledge of common clinical chemistry tests and their medical application and correlation to pathophysiologic processes. Show knowledge of the effects of disease, and preanalytical, analytical, and postanalytical variables on clinical laboratory test results. Show general knowledge in the basic and clinical sciences necessary for effective consultation in laboratory medicine. Ability to collect and evaluate medical evidence regarding the utility of laboratory tests. Show an analytical approach to laboratory and clinical questions. Show an understanding of laboratory work-flow and how this impacts the selection of laboratory instrumentation and personnel needs. Show an understanding of how to effectively meet regulatory guidelines governing clinical laboratory operations. Show an understanding of point-of-care testing and how it relates to testing performed within the main clinical laboratory setting. Development of a personal strategy to maintain and update medical knowledge required for understanding the clinical chemistry laboratory. 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.
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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. o Distinguish between urate and calcium pyrophosphate crystals, using polarized light.
Practice-Based Learning and Improvement The resident will demonstrate: • • • • • • • Ability to find and evaluate evidence from scientific studies. Application of appropriate statistical and study design principles in the evaluation of scientific evidence. Ongoing identification of deficiencies in personal medical knowledge and attempts at remediation. An understanding of, and the ability to, apply principles of quality assurance and quality control. Ability to evaluate current and proposed testing methods for analytical performance, clinical utility, and cost effectiveness. Use and evaluation of proficiency testing results to improve laboratory practice. Ability to use laboratory problems and clinical inquiries to identify process improvements that lead to increases in patient safety and outcome, and minimize opportunities for medical errors.
Interpersonal and Communication Skills The resident will demonstrate: • • • • • • Ability to effectively work with others as part of the health care team. Ability to communicate clearly and effectively with clinicians, laboratory technologists, and other medical personnel. Ability to use appropriate modes of communication in a timely manner. Ability to choose and use appropriate mechanisms for communication (telephone, face-to-face, email). Ability to express ideas and positions clearly and effectively, both verbally and in written form. Ability to prepare and deliver effective presentations.
Professionalism The resident will demonstrate: • • • Compassion, respect, and integrity. Responsiveness to the needs of the patient and society the supersedes self-interest. Knowledge and understanding of ethical and privacy issues affecting the clinical laboratory.
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Maintenance of confidentiality of patient information. Consistent performance of all duties in a timely, dependable, and responsible manner. Prompt and courteous response to all pager and telephone calls. Regular, punctual attendance and participation in rounds, conferences, meetings and rotation responsibilities. Commitment to excellence and ongoing professional development.
Systems-based Practice The resident will demonstrate: • • • • • An understanding of the role of the clinical laboratory in the health care system, and the importance of reliable, cost effective and timely laboratory results in the clinical decision-making process. Understand the role of laboratories in preparedness for biological and chemical terrorism. An ability to work with clinicians, administrators and others to determine the role of the laboratory in specific situations to optimize patient care. An understanding of CLIA, CAP, and JCAHO guidelines for clinical laboratories. An understanding of point-of-care testing and its role in patient care .
Specific competencies: In addition to the general competencies outlined above, residents should be able to do the following by the end of the Chemistry rotation: Consultation: Residents should be able to perform on clinical chemistry issues. Residents should be able to clearly define the issue or question to be addressed and be able to obtain the relevant clinical information. The resident should be able to determine what knowledge is necessary to address the issue, and remedy any gaps in personal knowledge that may exist. Finally, the resident should be able to reach an appropriate conclusion based on the information that is available, communicate this information to the appropriate personnel, and followup in a timely manner. Clinical Laboratory Method Validation Residents should understand and be able to discuss requirements necessary for validating methods in accordance with CLIA and CAP requirements, including: • • • • • • • Accuracy and precision Analytical sensitivity and specificity Analytical measurement range Clinically reportable range Reference range validation Comparison with reference method or other established method Test cost analysis
Duties and Responsibilities: I Orientation to Laboratories The resident should arrange with the appropriate director or supervisor at OHSU or Kaiser Permanente to receive an initial orientation to key areas and personnel. The trainee meets with the faculty and other laboratory staff on a regular basis to review specific cases needing consultation or further follow-up, discuss assigned reading material, and learn the operation of laboratory instrumentation and the performance of laboratory methods. Residents are given a project to complete during the rotation (see below).
II Laboratory Project A laboratory project will be selected for each resident. These projects will be performed under the guidance of a faculty advisor. The project will provide pertinent experience related to the operation of the clinical laboratory. Projects may involve method development, method validation, review of laboratory data and clinical applications. Residents will need to learn the use of statistical methods appropriate to the project being performed. Resources: Residents are given selected readings, handouts, procedures and note covering each of the topics covered. A set of case studies is available for teaching purposes. Representative cases of various hemoglobinopathies and serum protein abnormalities are available at the Kaiser Laboratory for residents. Primary texts used in this rotation are as follows: Henry JB. Clinical Diagnosis and Management by Laboratory Methods,20th Ed. WB Saunders, Philadelphia 2001 CA Burtis and EA Ashwood. Tietz Textbook of Clinical Chemistry, 3rd Ed. WB Saunders, Philadelphia 1999 Evaluation: Residents in chemical pathology are evaluated at the beginning and end of each rotation by assessing their performance on a multiple-choice examination. Resident performance on the examination taken at the beginning of the rotation is used to assess areas of strength and weakness in chemical pathology, so that the rotation may be tailored to an individual resident. The examination taken at the end of the rotation is used to quantitatively assess overall resident knowledge in chemical pathology and to assess progress made during the rotation by comparison to performance on the previous examination.