Teaching Pediatric Laboratory Medicine to Pathology Residents

Training in pediatric laboratory medicine is an essential component of residency training in clinical pathology. Infants, children, and adolescents comprise just less than one third of the population of the United States and account for nearly 150 million outpatient visits and more than 2 million hospitalisations annually.1 Pediatric ambulatory care is largely provided by primary care physicians or physician extenders,2 and much of the inpatient care, especially for newborns, and the emergency care of children is provided outside of children's hospitals.1 As a result, pediatric laboratory tests can be a significant component of the workload in general hospitals and integrated health care systems (Figure). These tests are essential to the correct diagnosis of diseases, many of which are unique to this age group or may first present in childhood, and to the monitoring of the response to therapy and prediction of prognosis. However, the small size of the youngest patients, the rapidity of physiologic changes in acute illnesses in infants and children, the effect of the maternalfetal relationship and of growth and development on the interpretation of results, and the broad spectrum of dis eases diagnosed in the pediatric period present challenges to the clinical laboratory. For these reasons, clinical pathologists should be trained to meet the laboratory medicine needs of pediatric patients and to assist the clinicians caring for children with the selection and interpretation of laboratory studies.

A proposal for curriculum reform in clinical pathology residency training, the Graylyn Report, was put forward in 1995 by the Conjoint Task Force on Clinical Pathology Residency Training, a collaborative effort of the Academy of Clinical Laboratory Physicians and Scientists, the American Society of Clinical Pathologists, the Association of Pathology Chairs, and the College of American Pathologists.4 Since that time, specific recommendations have been published for training in transfusion medicine,5 molecular pathology,6 management,7 and informatics,8 but there are no publications defining critical topics, listing key resources, or describing training experiences for the complex area of pediatric laboratory medicine. Therefore, the members of Children's Health Improvement through Laboratory Diagnostics (CHILDx), a group of pathologists and laboratory scientists with interest and expertise in pediatric laboratory medicine, convened a task force to develop a list of curriculum topics and to recommend training experiences in pediatric laboratory medicine for trainees in combined anatomic and clinical pathology or clinical pathology residency programs. It is hoped that this compilation will also be useful to directors of pediatric pathology fellowship programs.

CURRICULUM CONTENT AND DESIGN

Concepts integral to pediatric laboratory medicine that impact all laboratory medicine disciplines include (1) selection of methods that require minimal sample size, have a dynamic range that includes values seen in pediatric health and disease, and are free from interference by substances commonly present in pediatric specimens; (2) use of age, gender, and development appropriate reference ranges; and (3) identification of resources for reference and continuing education in pediatric aspects of each discipline. More specific topics unique or especially important to pediatric laboratory medicine in each of the major disciplines of laboratory medicine are listed in Table 1. Topics in maternal-fetal medicine are included in this list because the results of tests in this rapidly growing area of clinical and laboratory medicine are essential to the care of fetuses and newborn infants. Many of these topics can be covered in the context of more general lectures or discussions about the subject, and others can be grouped around clinical scenarios. For example, the transfusion needs of pediatric trauma patients might be covered in a general discussion of transfusion in trauma by inclusion of the relationship of patient size to the potential complications of incompatible plasma and massive transfusion, and a lecture on neonatal transfusion medicine could include discussions of the fetal and neonatal immune response, hemolytic disease of the newborn, neonatal alloimmune thrombocytopenia, exchange transfusion, use of dedicated units for chronic transfusion of neonates, and the controversies regarding the cytomegalovirus status and irradiation of cellular products for neonates.

Training in laboratory medicine necessarily uses a variety of teaching formats. A carefully erafted series of directed readings and/or didactic lectures is necessary to cover the breadth and complexity of the field, but for optimal learning, this must be supplemented by practical experiences such as direct observation or performance of certain procedures, case-focused rounds in the laboratory and/or the clinical unit, on-call responsibility for clinical laboratory problems and consultations, and participation in laboratory and interdepartmental quality improvement activities and conferences. Katzman et al9 have described an interdisciplinary approach to the teaching of perinatal anatomic and clinical pathology in which faculty members from pathology, pediatrics, and obstetrics-gynecology departments instruct pathology residents. Subspecialist clinicians or visiting lecturers may be used to teach specific topics in pediatric laboratory medicine, but the importance of role models-faculty actively engaged in the practice of laboratory medicine who interact with clinicians as well as laboratory professionals-cannot be overemphasized. Similarly, graded responsibility, beginning with lectures or discussions and progressing to consultations and frontline on-call responsibility, is essential to reinforce knowledge and develop professionalism. In this regard, the members of the task force drew a sharp distinction between "shadowing" a mentor or clinician, or acting as an observer on laboratory and clinical rounds, and actually being on the front line or "hot seat" for laboratory medicine consultations. Participating in a call rotation with responsibility for after-hours laboratory and clinical consultations reinforces didactic lessons, and this experience can be even more effective if the pathology residents who have been on call present interesting cases at a regular conference attended by other trainees and laboratory medicine faculty, if a teaching hospital that can offer these experiences in pediatric laboratory medicine is not immediately available, consideration should be given to allowing trainees to complete a rotation off-site.

Residents generally require 4 to 8 weeks of training to gain sufficient confidence to answer consultative questions.10 Transfusion medicine and coagulation testing are common topics for routine and after-hours consultations in pediatric as well as adult laboratory medicine,11 and exposure to these areas should occur early in the program and be reinforced by actual consultative experiences. Infectious diseases constitute a large proportion of the conditions seen in ambulatory and inpatient pediatrics. The topics listed under "Microbiology and Virology" in Table 1 can be incorporated into the microbiology rotation, but several task force members have found pediatric infectious disease specialists to be especially receptive to clinicopathologic correlative conferences or rounds, and program directors may want to explore this option. Resident presentations on other aspects of laboratory medicine can be integrated into pediatric ward rounds or existing surgical pathology or morbidity and mortality conferences with pediatric subspecialty groups. Residents should also be afforded the opportunity to reinforce learning through participation in research projects, which may be case reports or more extensive clinical correlative, method development, or translational studies. Some residents may develop a stronger interest in 1 aspect of pediatric laboratory medicine, such as cytogenetics or biochemical genetics. These trainees should be encouraged to pursue this interest through elective laboratory or clinical rotations and additional consultative, administrative, and research experiences. However, it is the opinion of the CHILDx task force that residents who wish to pursue a career as a director of a specialized laboratory should complete a formal fellowship in that discipline and receive appropriate board certification or other qualification.

COMPETENCY IN PEDIATRIC CLINICAL PATHOLOGY

The Accreditation Commission for Graduate Medical Education has recently mandated that educational programs for all medical specialties include detailed performance measures to assess the trainee's competency in 6 areas: patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (www.acgme.org/outcome). The CHILDx task force considered the process of graded responsibility described previously a means of achieving competency in these areas. Performance as a consultant in pediatric laboratory medicine will develop competency in the areas of patient care, interpersonal and communication skills, professionalism, and systems-based practice. In becoming an effective consultant, the trainee will necessarily develop skills in acquiring medical knowledge and in practice-based learning and improvement. Therefore, measurement of competency in pediatric laboratory medicine could include both documented exposure to the topics listed in Table 1 and formal assessment of the trainee's skill in providing laboratory and clinical consultation or teaching for 1 or more of the these topics in the context of his or her rotation through each of the disciplines of laboratory medicine. Specific pediatric laboratory medicine competencies in these areas could include the following:

Patient Care

1. Gather essential and accurate information about pediatric patients, including prenatal history, gestational age and size at birth, neonatal course, family and social history, growth and development, treatments and immunizations, and results of previous laboratory studies.

2. Make informed decisions about test selection and interpretation in pediatric patients based on patient information, age and development-appropriate reference ranges, relevant scientific evidence, and clinical judgment.

Medical Knowledge

1. Successfully complete a program of instruction in pediatric laboratory medicine as defined by the program director.

2. Identify and use key text and electronic resources for the selection and interpretation of laboratory tests in fetuses, infants, children, and adolescents.

Practice-Based Learning and Improvement

1. Use appropriate texts and information technology to support clinical consultations and diagnostic decision making in pediatric laboratory medicine.

2. Understand the use and limitations in pediatric laboratory medicine of clinical studies of test performance conducted on an adult population.

3. Identify clinical and laboratory medicine consultants who can provide assistance with questions in pediatric laboratory medicine.

Interpersonal and Communication Skills

1. Communicate effectively with pediatric clinical colleagues by demonstrating a knowledge of and sensitivity to pediatric laboratory testing needs to support patientfocused care.

2. Use listening skills to identify opportunities to improve laboratory medicine services to pediatric patients.

3. Communicate effectively with hospital and laboratory administrations to provide appropriate laboratory support for pediatric patients.

4. Participate in the teaching of pediatric laboratory medicine to laboratory personnel, physician and nursing staffs, and students and trainees.

Professionalism

1. Demonstrate respect, compassion, integrity, and responsiveness to the needs of pediatric patients, their parents and guardians, and their primary health care providers.

2. Demonstrate a knowledge of and commitment to the ethical principles pertaining to patient care and the conduct of clinical research in pediatric patients.

Systems-Based Practice

1. Partner with health care providers and managers to assess, coordinate, and improve pediatric health care.

2. Demonstrate a sensitivity to pediatric laboratory testing requirements in deliberations regarding central versus point of care testing, on site versus reference lab testing, determination of reference ranges and critical values, and the selection of laboratory methods and equipment.

COMMENT

Pediatric laboratory medicine is an essential component of the clinical pathology training of pathology residents and must be included in accredited pediatric pathology fellowship programs. As noted in the beginning of this article, a considerable proportion of pediatric and neonatal care is provided by primary care clinicians and/or takes place outside of specialized children's hospitals. Therefore, pathologists serving facilities that do not provide highly specialized pediatric care might be called on to provide pediatric laboratory medicine consultations, and pathologists in all hospitals caring for neonates and children need to consider the needs of these young patients not only when establishing reference ranges but also when selecting laboratory equipment and analytical methods and when determining which tests will be provided on an immediate basis, which will be offered as point-of-care tests, and which results will be defined as critical values. For example, rapid availability of results for hyperbilirubinemia and hypothyroidism are essential in determining the normal neurologic development of newborns, and rapid diagnostic tests for viral and bacterial infections can greatly facilitate the acute management of infants and children. Similarly, as Kost1- noted in the report of his survey of critical values for emergency clinician notification in 39 children's hospital laboratories in the United States, the critical limits for many anaIytes are different in children and, especially, neonates. The relative infrequency with which primary care physicians, emergency medicine physicians, and hospitalists who care principally for adult patients encounter pediatric diseases and the growing complexity of pediatric laboratory testing are likely explanations for the published observations that these physicians do not always know the best laboratory tests to diagnose or monitor pediatric diseases.3,13 Even though many laboratory tests on patients younger than 18 years are performed in regional or national reference laboratories (http://www.childx.org/survey_results.htm), the ordering physician may ask the local pathologist to assist with test selection and/or the interpretation of results.

The CHILDx group has previously identified current challenges and future opportunities in pediatric laboratory medicine14 and has convened symposia on several of these issues (http://www.childx.org). A critical concern, however, is that pathologists outside of the highly specialized pediatric centers in which we practice receive appropriate training and be aware of key resources in pediatric laboratory medicine. To this end, the CHILDx task force has prepared the list of topics in Table 1 and key resources in Table 2, and the CHILDx Web site containing preprogrammed literature searches and hot links to other sites that address specific areas of pediatric laboratory medicine.

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