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February 17, 2003
Volume 81, Number 7
CENEAR 81 7 p. 79
ISSN 0009-2347


ACS COMMENT
Chemistry In Evidence-Based Health Care

KENNETH E. BLICK, CHAIR, ACS BOARD COMMITTEE ON CLINICAL CHEMISTRY

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With all the recent flap regarding product liability and corporate integrity, it is no surprise that hospitals in the U.S. can be dangerous places for patients. Indeed, the January 2003 issue of Consumer Reports features the possible risk for injury due to incompetence and inattention in many hospitals with an alert for "buyers to beware." Unfortunately, mistakes of commission and omission abound. And treatment and diagnostic misadventures are identified in some of our most prestigious medical centers.

Who's to blame? Some would say bad government policy, including the government's prospective payment system for medical services and the inadequate funds available for government-supported programs, particularly Medicare and Medicaid. Others might fault managed-care initiatives, which may focus more on profits than on patient safety. In addition, many Americans arrive at hospital emergency rooms with neither health insurance nor any intention of paying for medical services rendered. Regardless of the cause, the health care system is broken and a critical overhaul is urgently required. There are simply too many patients to manage effectively and safely.

Are improvements on the way? Perhaps, but real improvements will require completely rethinking health care delivery and the way we train individuals to work in this new, high-tech medical business. First, hospitals must recognize that they are really in the information business. Diagnosis, treatments, and follow-up evaluation must be based on objective and supportive information.

Nearly 70% of the objective information on a patient's chart is laboratory data derived from chemical analytical testing. The patient's diagnosis, treatment, ongoing evaluation, and prognosis are based primarily on chemical information from laboratory tests that involve traditional technologies and chemical techniques such as spectrophotometry, immunoassay, potentiometry, and chromatography. This is "evidenced-based medicine," in which all medical decisions are essentially data driven (or based on unique data events).

These days, automation and computerization play a critical and unique role in medical laboratory testing by fusing biochemistry, robotics, and information technology. At the same time, computerized quality-control and management systems are designed based on statistical tools to ensure that these highly automated analytical testing systems perform in a controlled fashion. Of course, errors will occur in such a system, but design must include expert systems to ensure that such errors are corrected so they do not recur.

The urgent need for clinical chemists and medical technologists to oversee the implementation and operation of highly automated and computerized medical laboratories and hospitals is increasingly apparent from a patient safety standpoint. However, the training of these individuals has diminished dramatically in recent years, with program closures in medical technology/clinical chemistry leaving patients at increased risk of being treated or diagnosed based on laboratory data generated by inadequately trained analysts.

In addition to insufficient training programs for medical laboratory professionals, existing programs still train medical laboratory professionals using a "generalist" curriculum that emphasizes courses in biology, genetics, immunology, and the like, when, in fact, the practice of modern laboratory medicine in highly automated core laboratories involves application of robotics, analytical chemistry, biochemistry, immunochemistry, biosensors, computers, and statistics. Perhaps the current crisis in attracting highly trained and talented individuals to work in clinical laboratories can draw attention to the need for change in the current curriculum and certification requirements for medical laboratory professionals. Indeed, the ACS Committee on Clinical Chemistry has proposed the need for new courses for medical personnel that integrate current traditional chemistry courses in general, organic, and biochemistry into a new chemistry course called "clinical chemistry."

The ACS Committee on Clinical Chemistry will endeavor to raise awareness of these concerns through the following:

  • Stressing to chemistry departments the importance of clinical chemistry as an essential course unifying general chemistry, organic chemistry, and biological chemistry and recommending that all chemistry departments develop and offer such a course.
  • Emphasizing that clinical chemistry serves as the essential course that bridges students from the basic sciences to the clinical sciences. Involving chemistry departments in the training of laboratory medicine professionals through closer cooperation with other departments and disciplines such as biology and through collaborative efforts with hospitals and regional clinical reference laboratories.
  • Establishing clinical chemistry as a career path not only in the medical laboratory field but also in other areas, including, for example, nursing, medicine, dentistry, forensic science, pharmaceuticals, and research.

While there are many barriers to establishing a clinical focus in so-called traditional chemistry departments, we must recognize that the expanding employment opportunities for our chemistry graduates are not in the classic chemical industry but rather in the biotechnology and clinical fields. In addition, a clinical focus in chemistry training is now required to produce medical professionals with the skills necessary to effectively and safely manage patients in an evidence-based medicine approach.

Our medical technology and understanding of disease have developed beyond the current ineffective approach to training medical professionals. ACS Immediate Past-President Eli Pearce has suggested that it is time for "Reinventing Chemical Education" (C&EN, Dec. 9, 2002, page 33). In our view, a new course called "clinical chemistry" is the interdisciplinary course now required for medical training.



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