Graduate Medical Education Training Programs

CLINICAL CHEMISTRY AND IMMUNOLOGY

Resident Rotation Summary

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. As they evaluate patient specimen, physicians in training are instructed in methods and interpretation of automated chemistry and toxicology testing, serum protein electrophoreses, interpretation and clinical consultation in clinical chemistry and immunology such as L/S ratios for determination of fetal maturity, and screening tests such as AFP in pregnancy. 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.

Teaching Faculty Members

West Virginia University

Patricia A. Canfield, M.D.

Linda L. Cook, M.D.

Charleston Area Medical Center

Mary B. Taylor, M.D.

EDUCATIONAL GOALS AND OBJECTIVES:

• The goals and objectives of the clinical chemistry and immunology experiences are to prepare and enable residents to:
• Perform the laboratory procedures involved in the work-up and diagnosis of laboratory cases in order to practice Chem/Immuno independently.
• Demonstrate professional behavior regarding patients, other physicians and all clinical laboratory personnel.
• Demonstrate a commitment to reviewing and improving Chem/Immuno practice patterns and to life-long learning.
• Discuss the scientific basis of Chem/Immuno and the ability to utilize the medical literature and modern techniques to provide accurate Chem/Immuno diagnoses.
• 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.)

REQUIRED COMPETENCIES:

PATIENT CARE

Residents gather essential and accurate clinical information about the patients on whom they receive clinical consults, including:

• Discussion of history with clinical housestaff and/or attendings,
• Preview of laboratory reports of previous pathologic specimens
• Review of the online medical record when applicable.
• Residents are able to be actively involved with Chem/Immuno consultations and are able to handle clinical questions with increasing degrees of independence including:
• Researching and reviewing medical information.
• Preparation and interpretation of Chem/Immuno testing including cardiac markers, toxicology assays, serum protein electrophoreses, L/S ratios, and AFP testing during pregnancy.
• Timely and effective communication with clinicians.

Residents demonstrate competence in the methodology and performance of procedures considered essential for Chem/Immuno practices, including:

• Automated chemistry testing.
• Interpretation of Chem/Immuno tests.
• Toxicology assays and drug testing.
• Cardiac markers.
• Screening tests such as AFP screening during pregnancy and lipid profiles.

Residents make informed decisions regarding diagnostic workup of clinical consults:

• 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)

• 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.

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.

Evaluation:

Rotation evaluation

Resident portfolio of cases of the month, presentations to medical technologist, and clinical consult cases.

360o Global evaluation

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.
• 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.
• 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.

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.
• 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.
• Explain basic chemistry assays and instrumentation methodology, including biochemical and immunologic principles, methods, and applications.
• Discuss human anatomy and physiology during discussions with clinicians.

Evaluation:

Rotation evaluation

Chem/Immuno score for the in-service examination compared to national mean

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.
• As senior residents, 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:

• 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.

Residents demonstrate competency in the performance information technology to manage information, access on-line medical information, and support their own education, including:

• 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 pathologic diagnoses (grading systems for tumors, etc.).

Residents actively participate in the teaching of medical students and other health care professionals employed in the Chem/Immuno section, including:

• Teaching medical students as lecturers (senior residents only), leaders in small groups and laboratory sections.
• Teaching medical technologists and other clinical residents during clinical path rotations

Evaluation:

Rotation evaluation

Review of resident portfolio yearly to assess improvement and discuss self-education

INTERPERSONAL AND COMMUNICATION SKILLS
Residents demonstrate effective communication with other health care providers, patients, and patients’ families by:

Presenting cases at in-house tumor boards and conferences under direct faculty supervision.
nteracting with clinicians, patients, and patients’ families during performance of clinical consults and by providing support to clinicians and families during on-call assignments.
Evaluation:

Rotation evaluation

360o Global evaluation

PROFESSIONALISM
Residents 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 on-call rotations and accountability for this.
  Exhibit a commitment to excellence and on-going professional development by utilizing the study materials within the department including the slide file, the image data base, and books and journals for their own professional advancement.
  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.

Evaluation:

Rotation evaluation

360o Global evaluation

SYSTEMS BASED PRACTICE

Residents 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 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
Residents may also inspect the section of Chem/Immuno during a CAP inspection.

Evaluation:

360o Global evaluation

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

• Month 1
  Read the chapter entitled “Principles of Instrumentation” in Clinical Diagnosis and Management by Laboratory Methods, 20th edition, by John Bernard Henry.
• Learn the names of the instruments in use at WVU for chemistry testing, and make a list of the tests performed on each.
• Review lectures on “Plasma Proteins and Protein Electrophoresis” and “Monoclonal Gammopathies” as self-study or with Dr. Stead,
• Review all Protein Electrophoresis and Immunofixation plates in advance of their signout, and record your evaluations on forms provided for this. Review findings with the pathologist responsible for the final interpretations.
• 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.
• Visit each facility for which University Medical Laboratories provides laboratory medical director with the responsible pathologist at least once. State the names of the chemistry instruments at each, and identify them as “general” chemistry analyzers, “immunochemistry” analyzers, or “special purpose” (dedicated, single test) analyzers.
• Participate in the evaluation of, any new chemistry test being introduced at West Virginia University Hospitals (WVUH).
• Identify a patient or subject suitable for use in an educational case presentation to staff pathologists and other residents in clinical pathology and as a continuing education topic to medical laboratory personnel.
• In conjunction with Dr. Stead, participate in researching any chemical pathology question that is asked by one of the clinicians.

Month 2:

• Review the lecture entitled “Cardiac Markers and Related Tests” with Dr. Stead.
• Review all Protein Electrophoresis and Immunofixation plates in advance of their signout, and record your evaluations on forms provided for this. Review findings with the pathologist responsible for the final interpretations. Visit each facility for which University Medical Laboratories provides laboratory medical director with the responsible pathologist at least once.
• 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.
• Provide a lecture to staff pathologists and other residents in clinical pathology on a patient or subject identified the previous month. Offer this same lecture as a continuing education topic to the laboratories where we provide medical director services through University Medical Laboratories.
• Participate in the evaluation of, any new chemistry test being introduced at WVUH. Provide a short talk on one such new test (if there are any) to staff pathologists and other residents in clinical pathology and to outreach laboratories.
• Perform the initial research on any chemical pathology question that is asked by one of the clinicians, and review the results with Dr. Stead.
• Month 3
  Review all Protein Electrophoresis and Immunofixation plates in advance of their signout, and record your evaluations on forms provided for this. Review findings with the pathologist responsible for the final interpretations.
• Visit each facility for which University Medical Laboratories provides laboratory medical directorship with the responsible pathologist at least once.
• Provide a lecture to staff pathologists and other residents in clinical pathology on a patient or subject identified in the clinical laboratories and relating to chemical pathology. 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. Identify all new questions to Mr. Robinson and Dr. Stead.
• 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 Patient Cares in gathering important clinical history, reviewing slide material with the Patient Cares, 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. The residents are on at-home/pager call every other week. The on-call periods last from 7:00 a.m. on Monday morning through the following weekend, ending at 7:00 a.m. on the subsequent Monday.

Communication with On-duty FacultyDuring 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.