WEST VIRGINIA UNIVERSITY

Department of Pathology and Laboratory Medicine

Graduate Medical Education Training Programs

CLINICAL CHEMISTRY AND IMMUNOLOGY

Resident Rotation Summary

Rotation Philosophy and General Purpose Statement:
The Clinical Chemistry and Immunology (Chem/Immuno) at West Virginia University is designed to instruct trainees in Chem/Immuno in a tertiary care, academic setting as well as a large, academic community hospital. Physicians in training are instructed in the methods used in automated chemistry, toxicology, and immunology laboratories. More importantly, they are expected to interpret laboratory findings and to troubleshoot unusual lab results. By providing residents with increasing responsibilities and duties, as their level of training increases, the teaching faculty hope to instill in the resident the skills and tools necessary to develop a life-long course of continued professional development.

Training Sites/ Institutional Site Directors: West Virginia University/ Peter Perrotta, M.D.
                                                                               CAMC/ Phyllis Sawyer, M.D.

Duration of Rotation:  3 months.

Post Graduate Level of Residents Involved in Rotation:  PGY levels 1-4.

Coordinating Teaching Faculty Member:    Peter Perrotta, M.D.
                                                                              CAMC/Phyllis Sawyer, M.D.

Teaching Faculty Members
            West Virginia University
                        Peter L. Perrotta, M.D.

            Charleston Area Medical Center
                        Phyllis Sawyer, M.D.

EDUCATIONAL GOALS AND OBJECTIVES:
The goals and objectives of the clinical chemistry and immunology experiences are to prepare and enable residents to:

• Understand the laboratory practices used to diagnose human disease in Chem/Immuno laboratories.
• Demonstrate a commitment to reviewing and improving Chem/Immuno laboratory practices within the laboratory quality assurance program.   
• Discuss the scientific basis of Chem/Immuno testing/interpretation, and have the ability to utilize the medical literature and other sources to enhance Chem/Immuno diagnostic testing. 
• Communicate effectively in verbal and written form with their clinical colleagues, administrative, technical, and clerical personnel.
• Explain the policies and regulations affecting health care (i.e., CAP accreditation, HIPAA, compliance to Medicare and billing regulations, etc.)
• Demonstrate professional behavior regarding patients, other physicians and all clinical laboratory personnel. 

REQUIRED COMPETENCIES:
PATIENT CARE

• Residents gather essential and accurate clinical information about the patients on whom they receive clinical consults including (All PGY levels):
  • Discuss patient history with clinical housestaff and/or attendings.
  • Review reports of previous laboratory results
  • Review of the online medical record when applicable.
  • Follow all patient confidentiality rules per WVUH HIPAA guidelines.
• Residents are able to be actively involved with Chem/Immuno consultations and are able to handle clinical questions with increasing degrees of independence including (all PGY Levels):
  • Researching and reviewing medical information from charts, laboratory information system (LIS) and hospital information system (HIS)
  • Interpreting Chem/Immuno testing including – but not limited to - cardiac markers, toxicology assays, serum protein electrophoreses (SEP), immunofixation electrophoresis (IFE), L/S ratios, and AFP testing during pregnancy.
  • Timely and effective communication with clinicians and laboratory staff.
• Residents demonstrate competence in the methodology and performance of procedures considered essential for Chem/Immuno practices as outlined in the sections below.
• Senior residents (PGY 3-4) are involved in developing and validating new assays in the chemistry and immunology laboratories.  Examples of these over the past year include revising our guidelines for glucose tolerance testing and evaluating alternatives to our FLM testing. 
• Senior residents (PGY 3-4) are more involved with the quality assurance program and have the opportunity to inspect our lab or other labs during CAP inspections.  During our last inspection at Geisinger Hospital, a resident was involved in inspecting the chemistry and toxicology labs at that institution.

Automated chemistry testing

• Understand the concepts of analytical and clinically reportable range

• Review the analytical procedure manuals in the Chemistry Lab for the two major automated instruments (LX20, Centaur)
• Describe how reference ranges are established and validated
• Interpret results of common laboratory tests

• Cardiac marker testing
• Describe current diagnostic criteria for myocardial infarction (MI), which includes an understanding of the role of diagnostic modalities (i.e. ECG, laboratory testing, imaging, ect.)
• Be familiar with the diagnostic & prognostic significance as well as the limitations of  current coronary artery disease biomarkers (Troponins I and T, creatinine kinase including isoforms, myoglobin, and cobalt-bound albumin)
• Understand relevant analytical issues regarding assays used to measure cardiac markers (e.g., preferred specimen, interferences such as RF and human anti-mouse monoclonal antibodies, analytical false positives, etc.)
• Understand the pathophysiology of congestive heart failure (CHF) and the role of laboratory testing in CHF (BNP and NT-proBNP), along with the limitations of these tests.

• Blood gas testing
  • Understand the principles of partial pressure of gases and the need for an O2 carrier. Be able to describe the alveolar-arterial O2 gradient
  • Understand the significance of P50, O2 content, O2 capacity, and O2 saturation, and be able to distinguish between O2 sat and PO2
  • Describe the hemoglobin-oxygen dissociation curve and factors that affect curve and P50
  • Be familiar with principle of integrated blood gas, electrolyte and CO-Oximetry systems

• Acid/Base Chemistry
  • Define the Henderson-Hasselbach equation.
  • Understand major clinical disorders of acid-base balance (e.g. metabolic & respiratory acidosis, metabolic & respiratory alkalosis, mixed disorders)

• Renal Physiology
  • Understand the physiology of normal renal function
  • Develop a broad appreciation of a wide range of renal diseases (e.g., pre-renal azotemia, obstructive azotemia, glomerulonephritis, acute vs chronic renal failure, uremic syndrome)
  • Become familiar with National Kidney Foundation  practice guidelines for these conditions, including the use of estimated glomerular filtration rate (eGFR) in diagnosing and monitoring renal diseases.
  • Describe laboratory analytical methods (e.g., Jaffe vs creatinase ) used to assess renal function (creatinine, BUN and GFR) and proteinuria
  • Define osmolality, list molecules in serum that contributes to osmolality, and calculate osmolal gap. Understand the principle of the osmometer.

• Liver Function Testing
  • Understand the dynamics and mechanisms of  liver enzyme release, including the clinical utility of liver enzyme testing (e.g., AST, ALT, GGT, NTP, ALP, GGT, LDH)
  • Understand the biochemical assessment of liver function through non-enzymatic analytes such as albumin, ammonia, bile acids, bilirubin, BUN, cholesterol, total protein, and triglycerides
  • Be familiar with bilirubin metabolism including:
    • Fractionation of bilirubin (conjugated, unconjugated, d-bilirubin, direct vs indirect)
    • Unique aspects of neonatal bilirubin
    • Conditions and  genetic defects that affect bilirubin metabolism, transport and clearance (e.g., Gilbert syndrome, Dubin- Johnson, Rotor’s syndrome, etc.)

• Thyroid Function Testing
  • Understand the structure, biosynthesis, secretion, and metabolism of major thyroid hormones (T4, T3, rT3)
  • Describe normal thyroid physiology and control of thyroid function, including hormones such as TRH and TSH.  
  • Recognize common causes of hypothyroidism and hyperthyroidism
  • Interpret laboratory tests of thyroid function  
  • Be familiar with current analytical methods used for thyroid testing (TSH methods, isotopic and nonisotopic methods, T4, free T3 methods, T uptake methods, antimicrosomal/antithyroid peroxidase antibodies assay, thyrotropin-receptor antibodies assay,  TSH suppression and stimulation tests, etc)

• Pituitary Function Testing
  • Understand the physiolog action, biochemistry and regulation of anterior pituitary hormones (ACTH, GH, PRL, LH, FSH) and of posterior pituitary hormones (ADH, Oxytocin)
  • Interpret endocrine tests of hypothalamic-pituitary function (cosyntropin test/rapid ACTH stimulation test, insulin hypoglycemia test, metyrapone test, levodopa test, arginine infusion test, glucose-growth hormone suppression test, TRH test, GnRH test, clomiphene test, CRH test, gonadotropin-releasing hormone test, water deprivation test, saline infusion test and water loading test)

• Adrenal Cortical Function Testing
  • Describe the physiological action, biochemistry, biosynthesis, chemical structure and metabolism of  glucocorticoids and mineralocorticoids.
  • Understand clinical conditions associated with excess and/or deficiency of adrenal cortical hormones. Be familiar with testing the functional status of the adrenal cortex (basal levels vs. stimulation tests & suppression tests, circadian rhythm of corticosteroids, morning ACTH, cortisol [urinary, random and free], rapid ACTH Cortisol stimulation test, multi-day ACTH stimulation, metyrapone stimulation, CRH stimulation)

• Gastric Pancreatic and Intestinal Function Testing
  • Be familiar with clinical manifestations of gastric, pancreatic & intestinal  disease and diagnostic methodologies such as breath tests for H. pylori, fecal occult blood, lipase amylase (fractionation of amylase; pancreatic versus salivary and amylase/creatinine clearance ratio)

• Glucose monitoring and diabetic testing

• Understand the metabolism of carbohydrates (insulin, C-peptide and other regulatory hormones)
• Be familiar with the American Diabetes Association (ADA) definitions of impaired fasting glucose and diabetes mellitus Type I & Type II
• Describe the laboratory assessment of diabetes and glucose metabolism (blood glucose, oral glucose tolerance test,  Hb A1c, fructoseamine and urinary microalbumin).

 

• Mineral and Bone Metabolism
  • Understand the biochemistry and physiology of calcium, phosphate, and magnesium
  • Recognize physiological states of  calcium, phosphate, and magnesium (free ionized, protein-bound, complexed and total) and factors that affect these states (pH, protein concentrations, etc)
  • Be familiar with hormones that regulate mineral metabolism (PTH, calcitonin, vitamin D, PTHrP, etc)
  • Understand various PTH assays including “bio-intact” PTH and intra-operative PTH testing
  • Interpret laboratory evaluations of metabolic bone diseases such as osteoporosis, osteomalacia and Paget’s disease

• Porphyrins and Disorders of Porphyrin Metabolism
  • Be familiar with the chemistry, biochemistry and biosynthesis of heme and porphyrins. This includes the enzymes involved in  heme and porphyrins biosynthesis
  • Be familiar with porphyrin disorders such as primary porphyrin disorders including neurological/psychiatric vs. cutaneous photosensitivity as well as secondary or acquired  porphyrin disorders
  • Recommend screening and diagnostic tests for disorders of porphyrin metabolism

• Tumor Markers
  • Be familiar with the definition, classification, biochemistry and distribution of tumor markers including: PSA, prostatic acid phosphatase, alkaline phosphatase, NSE, calcitonin, HCG, adrencorticotropic hormone, α-fetoprotein, CEA, tissue polypeptide antigen, CA 15-3, CA 27,29, CA 125, CA 19-9, CA-50, CA 72-4, CA 242, NWP22 and receptors (ER and PR)
  • Know the laboratory assessment of  various tumor markers and factors affecting the results
  • Understand the conceptual basis of assays used to screen for malignancy (limits of sensitivity and specificity using Bayes theorem)

• Fetal Lung Maturity
  • Understand the physiology of respiratory distress syndrome (RDS)
  • Be familiar with fetal lung maturity testing (lecithin/sphingomyelin (L/S) ratio, phosphatidyl glycerol (PG), foam stability index (FSI or shake test), DSPC, Fluorescence polarization, Counting of lamellar bodies).
  • Understand the biochemistry,  physiology and diagnostic performance of fetal fibronectin

• Trace Elements
  • Understand the biochemistry, physiology and metabolism of trace elements  (iron, magnesium, zinc, copper, manganese, molybdenum, selenium, cobalt and fluoride) as well as ultratrace elements (nickel, vanadium, boron and silicon)
  • Describe the biochemistry and clinical significance of metal binding proteins such as transferrin, ferritin and ceruloplasmin
  • Know the clinical assessments of trace elements (e.g., serum iron, iron binding capacity, transferrin, transferrin saturation, serum ferritin, zinc protoporphyrin, serum ceruloplasmin)
  • Recognize the specimen of choice (plasma, urine, hair, nail) and the analytical methods for determining trace element levels

• Vitamins
  • Define and classify major vitamins including fat soluble vitamins (A, D, E, K) and water soluble vitamins (B1, B2, B6, B12, C, niacin, nicotinamide, folic acid, biotin, panothenic acid)
  • Understand the clinical disorders associated with the deficiency as well as toxicity of these vitamins

• Cholesterol & Lipids Testing

• Be familiar with the chemical structures, biosynthesis, classification, functions and metabolism  of lipids and lipoproteins
• Be familiar with Fredrickson classification and ATP III classification of hyperlipidemia
• Understand the pathophysiology of lipid disorders
• Describe principles of analytical techniques used to assess lipids

• Proteins
  • Understand  the principles of protein analysis in body fluids (e.g., Kjeldahl and Biuret methods, refractometry, qualitative dipstick).
  • Be familiar with the principles of serum, urine, CSF and pleural fluid protein electrophoresis including:
    • Identifying various proteins and interpreting the significance of findings (e.g., monoclonal gammopathy, light-chain diseases, Bence-Jones proteinuria, Oligoclonal banding, proteinuria, etc.). 
    • Recognizing the significance of CSF/serum albumin index, CSF IgG index)
  • Transudates versus exudates in peritoneal fluid
  • Pleural/serum protein ratio,  pleural fluid LDH and protein, glucose, pH, and lipids of pericardial fluid

• Clinical Enzyme Kinetics
  • Understand the principles of enzyme kinetics (Michaelis-Menten equation, concepts of Km, Vmax. Zero-order and 1st-order kinetics)
  • Clinical enzymology including isoenzymes and isoforms
  • Be familiar with the principles of analytical enzymology and know the concepts of activity vs. mass assays (e.g. CK versus CK-MB assays)

• Therapeutic Drug Monitoring – General
  • Understand basic pharmacokinetic principles involving Vd, dose, peak and trough concentration of a drug, area under the curve (AUC), clearance, half-life, bioavailability and protein binding. 
  • Be familiar with one compartmental and two compartmental model of drug distribution, first and second order elimination kinetics and effect of disease on K, the elimination rate constant.
  • Recognize effects of disease such as uremia, hepatic disease on protein binding of drugs.
  • Understand common drug-drug interactions with particular emphasis on effect of one drug on clearance of another drug, for example increased clearance of phenytoin in the presence of carbamazepine, an inducer of cytochrome P 450 enzymes, digoxin-quinidine interactions, etc.
  • Understand which free/unbound drugs are frequently measured and why.
  • List common factors affecting free/unbound drug levels.

• Therapeutic Drug Monitoring of Specific Drugs
• Analgesics/Antipyretics: Toxic levels of acetaminophen and salicylate. Liver failure due to acetaminophen overdose and specific antidote for treatment.
• Antidepressants: (Tricyclic antidepressants, selective serotonin reuptake inhibitors). Limitation of immunoassays for tricyclic antidepressant for therapeutic drug monitoring due to cross-reactivity of active metabolites.
• Anticonvulsants: Familiar with therapeutic drug monitoring of classical antidepressants such as phenytoin, carbamazepine, Valproic acid, Phenobarbital, primidone and ethosuximide. Understand clinical utility of monitoring free phenytoin, free valproic acid and free carbamazepine concentrations in patients with uremia, hepatic disorder, AIDS hypoalbuminemia, and other conditions. Understand the need for therapeutic drug monitoring of newer anticonvulsant such as lamotrigine, gabapentene, oxcarbazepine and tiagabine.
• Cardiovascular drugs: Therapeutic drug monitoring of digoxin and effect of endogenous digoxin-like immunoreactive factors on various immunoassays used for monitoring serum digoxin concentrations. Understand therapeutic drug monitoring of lidocaine, tocainide, mexiletine, and quinidine.
• Antibiotics: Understand need for monitoring of both peak and trough concentrations of aminoglycosides and vancomycin.
• Immunosuppressants: Proficiency in therapeutic drug monitoring of cyclosporine and tacrolimus with understanding of C0, C2 and AUC monitoring for cyclosporine. Be familiar with therapeutic drug monitoring of newer immunosuppressants such as sirolimus and mycophenolic acid.

• Clinical and Forensic Toxicology
• Understand drug screenings and confirmation (Immunoassays v GC/MS).
• Be familiar with alcohol poisoning with ethanol, methanol, isopropanol, and ethylene glycol. Understand DWI laws and legal limit of blood alcohol concentration (0.08% plasma in certain states and whole blood in others)
• Be familiar with atomic absorption or mass spectrometric technique for determination of heavy metals in body fluids such as lead, mercury, arsenic, cadmium and others.
• Understand pathophysiology of cyanide and carbon monoxide poisoning.

MEDICAL KNOWLEDGE

• Residents demonstrate an investigatory and analytical thinking approach to clinical situations including:
  • Development of reasonable and complete differential diagnoses for Chem/Immuno cases based on the available clinical information, laboratory tests, and current published information (all PGY Levels).
  • As part of their workup of cases, they suggest appropriate additional testing (isoenzymes, immunofixation studies, and further clinical testing such as serology, etc.) if applicable (all PGY Levels).
  • Formulation in a comprehensive, cohesive, and coherent fashion the above differential diagnoses and discussion of pathologic findings in the final pathology report.
  • Are encouraged to participate in at least one research project, such as clinicopathologic studies, or case reports with literature review (all PGY Levels).
• Residents discuss the basic and clinically supportive sciences which are appropriate to the specialty of Chem/Immuno, including:
  • Discuss pathophysiology of various diseases, drugs metabolites, and metabolic disorders during discussion of Chem/Immuno cases, and use of such knowledge to provide useful consultation.
  • Discuss basic statistical principles in order to analyze quality control and quality assurance data, to calculate normal ranges for new assays, and correlate methodology and instrumentation (all PGY levels).
    • Understand the principles of sensitivity, specificity, positive and negative predictive value, and Bayes theorem in the interpretation of the clinical significance of laboratory testing
    • Understand the meaning and limitations of reference ranges and the factors affecting these ranges in populations
• Explain the clinical presentations and manifestations of various diseases during discussion and workup of Chem/Immuno cases, and use of such knowledge to formulate pathologic diagnoses and consultations (all PGY levels).
• Explain basic chemistry assays and instrumentation methodology, including biochemical and immunologic principles, methods, and applications (all PGY levels).
  • Understand the principles and operation of techniques such as photometric, electrochemical and electrophoretic methods. In addition, understand  the analytical aspects of immunoassays (including competitive & and noncompetitive immunoassay design, homogenous vs. heterogeneous assays) and various signal generation and detection systems such as chemiluminescence, direct fluorescence, and fluorescence polarization.
  • 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 immunoassays (EMIT, CEDIA, FPIA, MEIA II, electrochemiluminescence)
  • Understand the principles of performance for common point-of-care devices such as glucometer, urine drugs of abuse, and activated clotting time devices. Know the issues surrounding specimen preparation and transport.
• Discuss human anatomy and physiology during discussions with clinicians (all PGY levels).

• Understand "chain of custody" and other legal requirements for forensic chemical pathology (all PGY levels)

PRACTICE-BASED LEARNING

• Residents show the ability to analyze practice experience and perform practice-based improvement activities using a systematic methodology, including:
  • Evaluating their concordance with staff diagnoses and using these results to direct their studying and improve their diagnostic acumen (all PGY levels).
  • As senior residents 9PGY 3-4), actively participate in monthly Clinical Pathology Quality Assurance Committee meetings, learning how to identify and report on a variety of QA monitors (case turnaround time, mislabeled/unlabeled specimens, clotted specimens, etc.).
• Residents show ability to locate, appraise, and assimilate evidence from scientific studies related to patients’ health care problems, including: (all PGY levels)
  • Perform literature search and review to find relevant scientific references to aid in the workup of Chem/Immuno cases (computer-based searches).
  • Obtain and incorporate information about their patient population (via COPATH and Medsite computer searches and medical records chart review) for clinicopathologic study of selected diseases.
• Residents are able to explain study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness (PGY 3-4).
• Residents demonstrate competency in the performance information technology to manage information, access on-line medical information, and support their own education, including (all PGY levels):
  • Access of patient clinical information and previous pathology accessions via Medsite and Copath.
  • Perform computer searches of the medical literature.
  • Perform digital imaging technology.
  • Access web-sites pertaining to specific laboratory diagnoses

• Residents actively participate in the teaching of medical students and other health care professionals employed in the Chem/Immuno section, including (PGY 3-4):
  • Teaching medical students as lecturers (senior residents only), leaders in small groups and laboratory sections.
  • Teaching medical technologists, med tech students and other clinical residents during clinical path rotations.   
• Residents make informed decisions regarding diagnostic workup of clinical consults (all PGY levels):
  • They consider specialized testing, etc. based on patients’ clinical history, up-to-date scientific evidence gleaned from textbooks, journal articles, internet-based searches, and clinical judgment. 
  • They are expected to be able to handle more difficult cases and their approach and diagnosis should more closely correlate the final diagnosis as they progress through their residencies.
• Residents use available information technology (hospital and laboratory information systems, internet-based literature searches) (all PGY levels)
  • To support workup and diagnosis of Chem/Immuno consults.
  • To help educate clinicians by providing relevant literature references.
• Residents work with health care providers, in the generation of accurate and clinically useful Chem/Immuno reports and effective communication of results to clinicians (all PGY levels).
• Demonstrate competency in handling practical problems related to laboratory operations and management through involvement with basic issues of laboratory management, such as evaluation of analytical instrumentation, laboratory staffing, cost accounting of a new analytical method relative to an older one, and new method evaluation for technical performance (PGY 3-4).

• Residents demonstrate effective communication with other health care providers, patients, and patients’ families by all PGY levels):
  • Presenting cases at in-house tumor boards and conferences under direct faculty supervision.
  • Interacting with clinicians, patients, and patients’ families during performance of clinical consults and by providing support to clinicians and families during on-call assignments.  Residents obtain consents for sweat chloride tests performed in the labs from family members.

• Residents (all PGY levels) must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:
  • Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supercedes self-interest with prompt response to calls from the clinical Chemistry lab, faculty and clinicians during their Chem/Immuno and Clinical Pathology on-call rotations and accountability for this.
  • Exhibit a commitment to excellence and on-going professional development by utilizing the available study materials within the department.
  • Demonstrate a commitment to ethical principles pertaining to provision of pathology services, confidentiality of patient information, informed consent, and business practices
  • Demonstrate appropriate behavior with the faculty, clinicians, their peers, and the administrative, technical and clerical staff of the hospital.

SYSTEMS BASED PRACTICE

• Residents (all PGY levels) must demonstrate an awareness and responsiveness to the larger context and system of health care and the ability to call on system resources to provide pathology services that are of optimal value.
  • Residents are expected to be able to discuss clinical pathology diagnoses affect health care decisions for patients and the health care system.
  • Explain the types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
  • Practice cost-effective health care and resource allocation that does not compromise quality of care, understanding the need for and cost of special studies, extended testing, and other send-out testing.  
  • As senior residents PGY 3-4) attend the CP QA committee meetings to be able to explain how to partner with the administrative and technical staff to assess, coordinate, and improve health care and know how these activities can affect system performance
    • Understand the fundamental principles of TQM
    • Understand the functions of calibrators and controls
    • Understand common statistical concepts used in quality control programs such as precision and accuracy, Levey-Jennings control chart, Westgard rules and application, and delta checks and apply these to appropriate laboratory undertakings
    • Be familiar with external quality assessment and proficiency testing programs such as CAP statistics and Clinical Laboratory Improvement Act (CLIA) criteria governing laboratory testing

• Residents may also inspect the section of Chem/Immuno during a CAP inspection (PGY 3-4).

Supervisory Guidelines for Patient Care and Specimen Handling
Specimen handling in the laboratories is the direct responsibility of the laboratory technologists.  Resident decision making in the laboratory is under the direct supervision of the teaching faculty at their assigned site.  The on-service teaching faculty members are physically present during standard operating hours; faculty members not physically present are rapidly available by phone or pager.  No diagnosis is communicated to the clinicians before a faculty member has evaluated the case.

Daily Duties and Responsibilities: Clinical Chemistry and Immunology

• Research any chemical pathology questions that are posed to the laboratory and review with attending pathologist. This includes communicating with the Technical Supervisors of the Chemistry and Immunology labs on a daily basis (all PGY levels).

• Review all Protein Electrophoresis and Immunofixation scans in advance of their signout. Record your interpretation and then review findings with the pathologist responsible for the final interpretations (all PGY levels).

• For any medical renal biopsies, go on-site with the nephrologists to collect and evaluate adequacy of the specimen, perform the initial immunofluorescence microscopy evaluation, and review the light microscopy sections, when available, with the faculty pathologist assigned.  Serve as liaison between the pathology and nephrology services for renal biopsy evaluations (all PGY levels). 

Other expectations

• Read sections on Management, Clinical Chemistry, and related sections in Henry’s Laboratory Medicine Textbook

• Learn the names of the instruments in use at WVU for chemistry testing, and make a list of the tests performed on each. This is done be reviewing the procedure manuals for the chemistry laboratory.

• Review lectures on “Plasma Proteins and Protein Electrophoresis” and “Monoclonal Gammopathies” as self-study or with Dr. Stead,

• Participate in the evaluation of, any new chemistry test being introduced at West Virginia University Hospitals (WVUH). Provide short talks on such tests to staff pathologists, residents in clinical pathology, and to outreach labs.

• Identify cases suitable for use in an educational case presentation to staff pathologists and other residents in clinical pathology. These will also be used as continuing education topics for medical laboratory personnel. 

• Provide a lecture to staff pathologists and other residents in clinical pathology on a case or subject. Offer this same lecture as a continuing education topic to the laboratories where we provide medical director services through University Medical Laboratories.

• Conduct a mock CAP inspection of the WVUH Clinical Chemistry Laboratory using the most recent checklist available (PGY 3-4).

• Residents may also spend at least one of their months in Chem/Immuno at CAMC, and all residents will rotate through the CAMC toxicology laboratory.
  

Opportunities to Function as Consultant to Other Physicians

The resident is expected to integrate laboratory findings from Chem/Immuno testing with clinical status, surgical pathology results, bone marrows, and other clinical tests (for example correlating a monoclonal gammopathy on serum protein electrophoresis with multiple myeloma on bone marrow).  Residents have the responsibility, under faculty supervision, of discussing the interpretive consultative reports with appropriate members of the clinical/surgical teams. Through their discussions with the clinical team members, the residents have the opportunity to directly impact patient care.  The resident is expected to interact on a daily ongoing basis with the clinical services in gathering important clinical history, reviewing slide material with the clinical services, and making recommendations for further assessment of abnormal Chem/Immuno assays. Through their discussions with the clinical team members, the residents have the opportunity to directly impact patient care. Other departments on the WVUH campus, with ACGME approved post graduate training programs include, but are not limited to the following: Anesthesiology, Internal Medicine, Family Practice, Neurosurgery, Obstetrics & Gynecology, Ophthalmology, Otolaryngology, Orthopedic Surgery, Pediatrics, Radiology, Surgery, and Urology.

On Call Duties
During clinical pathology call the resident provides first call consultation and problem solving. During this period, the residents will on average have at least one out of every seven days free of hospital duties.  The resident is directly supervised by the CP faculty member on-call.  While on-call, residents are supervised by a Faculty Member, who is available at all times, either via their office phone, pager, or home phone. During the WVU rotation, all calls are reviewed at an on-call conference.  The resident is expected to be available to laboratory personnel, either in person or by pager, throughout the working day. No on call duties outside of regular laboratory working hours are assigned to the resident at CAMC.
Due to the at-home nature of call, the call duties are constructed in the following fashion consistent with the rest of the program.

Communication with On-duty Faculty

During general working hours, the on service teaching faculty is available in person; other faculty members are available by scheduled appointment, by phone, by pager, and most of the time residents may just feel free to walk into their offices. During the on call hours, the teaching faculty is continuously available either at home by phone or by pager.

Structured Education and Management of the Chemistry/Immunology Laboratory

The residents attend scheduled quality assurance, laboratory safety, and other appropriate staff meetings, as they relate to laboratory management. As opportunity provides, residents will be allowed to participate in CAP laboratory accreditation activities, including self-inspections and inspections of other institutions. Residents are urged to attend an Inspector Training Course provided by the CAP.

Rotation Evaluation:
Resident portfolio of cases of the month, presentations to medical technologist, and clinical consult cases. 
Review of resident portfolio yearly to assess improvement and discuss self-education
Chem/Immuno score for the in-service examination compared to national means
360o Global evaluation
Scores on portion of quarterly quizzes related to chemical/immunology.

Chemical Pathology Reference Materials:

• Henry JB (ed). Clinical Diagnosis and Management by Laboratory Methods (20th Edition), WB Saunders, 2001

• Tietz Textbook of Clinical Chemistry & Molecular Diagnostics (4th Edition), 2006

• American Association of Clinical Chemistry website, http://www.aacc.org/

• National association of clinical biochemists:  http://nacb.org/