Rotation Goals and Objectives
Length of Rotation: 3 months (consecutive)
Introduction
The Clinical Chemistry and Coagulation rotation is a three-month rotation offered to CP and AP/CP residents. The rotation is designed to give residents exposure to the wide array of testing modalities used in a modern clinical chemistry laboratory and consulting experience in the area of clinical chemistry. This experience includes the specialized areas of endocrinology, laboratory toxicology, therapeutic drug monitoring as well as the laboratory evaluation of coagulation disorders.
Residents will acquire the knowledge and skill essential to serving as medical director of a clinical chemistry laboratory in a low-moderate complexity laboratory. The goals and objectives can be divided into the 6 basic ACGME core competencies:
I. Patient Care: Residents are involved in various clinical activities including participation in interpretative reporting for protein electrophoresis and clinical consultation under the supervision of faculty members responsible for the operation of the various laboratories within the division. By the end of this rotation, residents should be proficient in:
- The analysis and interpretation of serum and urine protein electrophoresis
- The analysis and interpretation of urinalysis specimens, including crystal identification
- The application of laboratory testing to:
- Routine therapeutic drug monitoring;
- Evaluation of unknown intoxications;
- Drugs of Abuse screening in the hospital and the workplace.
- The evaluation of patients with coagulation disorders including:
- Prolonged PTT and/or PT
- Bleeding disorders
- Thrombotic disorders
- Heparin-induced thrombocytopenia
- Communication skills necessary to provide useful consultative services to clinical colleagues to promote the understanding and effective use of the chemistry, toxicology and coagulation laboratory.
II. Medical Knowledge: During the course of the rotation, residents will receive didactic sessions with faculty and laboratory staff in the Clinical Chemistry, Toxicology and Special Coagulation laboratory. Lecture topics include:
General Chemistry and Endocrinology |
Cardiac tests Renal Function Testing Tumor Markers Adrenal function testing Thyroid Function testing Automation in the lab Electrolytes & Blood Gases Carbohydrates, Glucose, & Insulin General principles of laboratory measurements GI Testing Chromatography Point of Care Testing Analytical methods Mass Spectrometry in the Clinical Lab |
Toxicology and Therapeutic Drug Monitoring |
Overview of TDM and Basic Pharmacokinetics Introduction to Pharmacogenomics Pharmacogenetics Testing MPA monitoring Trace metal analysis Drugs of Abuse Testing |
Coagulation
|
Overview of Coag Testing & the Lab Current View of Coagulation Part 1 Current View of Coagulation Part 2 Hemophilia A and B Von Willebrand Disease Heparin-Induced Thrombocytopenia APLA Gene Therapy in Coagulation TTP and ADAMTS-13 Anticoagulant Therapy in the pediatric patient |
Laboratory in-lab demonstrations include:
General Chemistry and Endocrinology |
Serum and Urine Protein Electrophoresis Basic Point of Care Device Usage |
Toxicology and Therapeutic Drug Monitoring |
Immunoassays (Drugs of abuse) HPLC (Cyclosporine and/or mycophenolate) Alcohol testing Atomic Absorption Spectroscopy (Lithium) Liquid Chromatography-Mass Spectrometry |
Coagulation
|
ELISA MDA/Optical Clot Detection Serotonin Release Assay Prolonged PTT evaluations Platelet aggregation testing |
III. Practice Based Learning and Improvement: Critical evaluation of individual and systematic diagnostic practices is encouraged. Every day, residents have the opportunity to review serum and protein electrophoresis cases and formulate a preliminary diagnosis and report; these cases are discussed with an assigned faculty member and feedback is given on pertinent cases at this time. Similar review of cases being evaluated in the special coagulation laboratory are peformed semi-weekly where residents integrate the laboratory testing with clinical history to provide a consultative report to the ordering physician. Continual feedback and self-assessment is provided which allows the resident to improve his/her diagnostic practice for future cases. Feedback from the faculty after resident presentations at multidisciplinary conferences also provides the opportunity for self-assessment and continual improvement in resident performance in this area. Participation in a quality assurance and improvement projects focused in clinical chemistry and coagulation is a required part of the rotation with the aid of faculty. Residents are also encouraged to utilize library and web-based information sources when evaluating consultative cases in preparation for providing a recommendation. Each resident also participates in the development and validation of a clinical chemistry or coagulation assay if an assay is under development at the time of the rotation. Otherwise, they participate in a “virtual” assay development and validation using prior material in order for them to become proficient in this important aspect of operating a clinical laboratory.
IV. Interpersonal and Communication Skills: Residents are expected to have strong communication skills in order to interact appropriately with clinical colleagues, faculty and laboratory staff. Residents routinely provide consultations to clinicians and laboratory staff, as they carry pagers that allow clinicians and staff to contact them for clinical chemistry, toxicology and coagulation-related cases. Residents advise clinicians (with input from the clinical faculty and laboratory technical managers) on appropriate test selection, specimen and sample collection requirements; they also discuss test results, methods, diagnostic and prognostic implications. In conjunction with laboratory staff, they help trouble shoot technical problems, help track down clinical history when necessary and serve generally as liaisons between the laboratory and clinicians outside of the laboratory. Positive, constructive interactions with laboratory and technical support staff (laboratory technicians, medical technologists) are necessary and will be monitored by means of regular discussions between the faculty and laboratory staff.
In addition, residents will develop communication skills in the course of their participation in a weekly laboratory toxicology conference and monthly journal club that occasionally involves participants from other departments.
V. Professionalism: A professional demeanor must be maintained at all times when dealing with support staff, colleagues and clinical staff. As mentioned above, residents are critical participants in patient care, in their role as liaisons between the laboratory and clinicians, offering advice on the use and interpretation of tests, recommending additional or follow-up tests; in this role, residents should interact in a professional manner with their clinical colleagues and all laboratory staff during any consultation. Bioethical and patient confidentiality (HIPAA) issues should be discussed with appropriate faculty members when they arise. Feedback on any issues pertaining to professionalism will be immediately provided should problematic issues arise; at the halfway point of the rotation (6 weeks) feedback on each resident’s professionalism will be provided to all individuals.
VI. Systems-Based Practice: Issues of laboratory management within the clinical chemistry and coagulation section are addressed as part of the core didactic series. Residents also must attend the departmental laboratory management lecture series and CAP virtual management conference when their schedule permits. During the course of the rotation, the resident will be trained as to the critical role of the clinical chemistry and coagulation laboratories in the diagnosis and management of patients. The resident’s participation in test development and validation which encompasses issues of QA/QC, methodology, potential clinical utility, etc. as a summative evaluation of clinical chemistry and coagulation knowledge, will address issues of the laboratory’s role in the larger health care system; each resident’s performance in the completion of this project will be evaluated and feedback provided.
Resident duties and responsibilities while on the rotation
- Daily review and sign-out of SPEP/UPEP results
- Particpation in weekly coagulation laboratory sign-out
- Review urinalysis cases (including crystal identification) weekly as scheduled
- Act as the primary consultant to clinical services for testing inquiries related to the general chemistry, toxicology, endocrinology and coagulation laboratories with oversight of the appopriate service faculty
- Assist automated/core laboratory director with oversight duties within the laboratory
- Review send-out test approvals daily with designated service attending
- Attend all scheduled didactics.
- Participate in all scheduled laboratory demonstrations and exercises.
- Lead the weekly case-based conference with faculty guidance and support for discussion.
- Perform a useful quality assurance or quality improvement project in conjunction with and under the guidance of a faculty member, and present the results of this project to the faculty and staff.
- Give one brief coagulation-oriented presentation to the coagulation laboratory technicians
- Present an article at the monthly coagulation journal club
- Present an article at the monthly clinical chemistry & toxicology journal club
- Perform a QA/QI project including a final summary report under the supervision of one of the division faculty members.
Residents assume increasing responsibility during the three-month rotation in the following manner:
- In the week before the rotation, they shadow the seasoned clinical chemistry and coagulation residents who immediately precede them and learn how to use the lab computer, format the reports and who/what can help them with which types of issues.
- Residents work closely with the faculty, lab managers and technologists early on. As they become more comfortable with the methods and the tests, they become more independent. All consultations are initially discussed with senior residents (such as the chief resident) or attendings on service. As time progresses, residents generally are capable of providing routine consultation without discussion with the attending(s) on service. Consultations are still reviewed regularly with residents. It is expected that the resident will also assume increasing responsibility for oversight of the automated laboratory fielding questions and addressing problems in a more independent fashion as they progress through the rotation; however, they will always have close supervision and backup from the laboratory directors.
Supervision and evaluation of resident competency
Residents will be under the direct supervision of the faculty at all times during the rotation. Resident competency will be evaluated according to the ACGME general categories in a 360o evaluation that includes input from the sources defined in the table below.
evaluating party |
patient care |
medical |
practice based learning |
comm. skills |
profess- |
systems based practice |
Faculty- Clinical Chemistry |
X |
X |
X |
X |
X |
X |
Faculty - Coagulation |
X |
X |
X |
X |
X |
X |
Lab staff in Coagulation and Toxicology laboratories |
|
|
X |
X |
X |
|
Test Development and Validation Project |
|
X |
X |
X |
|
X |
Feedback will be given orally to the residents throughout the rotation. Feedback will also be provided to the residents in written form via the online Oasis system at the end of the rotation.