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Laboratory Medicine Learning Objectives for Medical Students

Appropriate selection of clinical laboratory testing is increasingly being recognized as an important facet of optimal patient care, patient safety and healthcare costs. A major roadblock to improving laboratory test utilization is the lack of formal education in laboratory medicine during medical school. To address this issue, a national committee of pathology and laboratory medicine practitioners and experts in medical education has devised a set of comprehensive learning objectives for pathology and laboratory medicine for medical students. The complete set was published in Academic Pathology (Magid MS, Shah DT, Cambor CL, et al. Consensus Guidelines for Practical Competencies in Anatomic Pathology and Laboratory Medicine for?the Undifferentiated Graduating Medical Student. Academic Pathology, October-December 2015; 1-17).

Being a clinical pathologist, I found the objectives for laboratory medicine to be particularly enlightening. Today’s blog contains a summary of the laboratory medicine learning objectives for medical students.

A. Laboratory medicine: basic principles of laboratory testing: students should be able to:

1. Demonstrate knowledge of the impact that gender, race, age and physiological state, eg, pregnancy, may have on reference ranges.
2. Interpret laboratory test results from several of their patients that fall outside the reference range.
3. Compare and contrast reference ranges and therapeutic ranges.
4. Describe variables in specimen collection, preparation and processing that may affect the clinical interpretation of a test result.
5. Correctly collect and submit laboratory specimens on their patients, including correct pairing of the patient identification of a specimen with the accompanying requisition form.
6. Provide examples of common reasons for specimen rejection and/or invalid test results.
7. Define the terms ‘‘test sensitivity and specificity’’ and illustrate their impact on test selection and results interpretation.
8. Define the terms ‘‘test precision and accuracy’’ and illustrate their impact on test selection and results interpretation.
9. Define the terms ‘‘negative and positive predictive value’’ and illustrate their impact on test selection and results interpretation.
10. Compare and contrast the attributes of a ‘‘screening test’’ and a ‘‘confirmatory test’’.
11. Differentiate between STAT (Latin statim [immediately]) and routine testing.
12. Define ‘‘critical value’’ and give examples of test results that represent critical values. Describe the importance of receiving critical values from the laboratory and acting on the information.
13. Define ‘‘point of care’’ (POC) testing and appraise its indications and limitations.
14. Assess appropriateness of ordering laboratory tests, taking into account: ordering a test only if the result will influence diagnosis, prognosis and/or treatment; selecting the appropriate test for the clinical evaluation desired; avoiding excessive repetition of a test; and indications for and disadvantages of multitest panels.
15. Evaluate the consequences of unnecessary testing on the care of an individual patient.
16. Evaluate the consequences of unnecessary testing on community healthcare costs.
17. Illustrate how consultations with pathologists/clinical laboratory scientists may assist in devising the most efficient and cost effective path to laboratory diagnosis in specific patients or clinical situations

B. Selected subspecialty competencies: transfusion medicine: students should be able to:

1. Describe the importance of appropriately drawing and labeling a blood bank specimen.
2. Interpret information generated from a ‘‘type and screen’’ order on one of their patients.
3. Compare and contrast blood components available for clinical use and their indications.
4. Discuss infectious and noninfectious risks of blood transfusion.
5. Describe various clinical presentations of transfusion reactions.
6. Discuss the causes, workup, and immediate management of transfusion reactions.
7. Describe therapeutic apheresis and explain its role in treatment of sickle cell disease, leukemia, thrombotic thrombocytopenic purpura (TTP), neurologic disorders, and solid organ transplant rejection.
8. Describe stem cell therapy and list its common indications.
9. Explain the HLA system and its role in transfusion and transplantation.

C. Selected specialty competencies: clinical chemistry and immunology: students should be able to:

1. Describe appropriate test selection for evaluation of: cardiovascular function, respiratory function, hepatic function, gastrointestinal function, and renal function.
2. Discuss the efficient use of laboratory tests to diagnose and manage thyroid disease.
3. Discuss the efficient use of laboratory tests to screen, diagnose and manage diabetes in nonpregnant and pregnant individuals.
4. Describe the urine and plasma tests needed to investigate suspected adrenal disorders.
5. Explain the role of laboratory tests used to confirm and manage normal and abnormal pregnancies.
6. Illustrate the use of laboratory tests in therapeutic drug monitoring of their patients.
7. Discuss the clinical indications and limitations of toxicology testing, especially testing for drugs of abuse.
8. Discuss the appropriate use of laboratory tumor marker tests, eg, prostate-specific antigen (PSA), carcinoembryonic antigen (CEA), and monoclonal antibodies.
9. Describe the clinical indications for ordering the basic metabolic panel, comprehensive metabolic panel, and urinalysis.
10. Interpret the results of an abnormal basic metabolic panel, comprehensive metabolic panel, and urinalysis.
11. Identify markers of inflammation and explain their clinical uses and limitations
12. Select and interpret appropriate tests for workup and interpretation of autoimmune disease, immunodeficiencies, and allergy testing.

D. Selected specialty competencies: hematology: students should be able to:

1. Outline the principles for analysis of complete blood count (CBC) and leukocyte (WBC) differential analysis.
2. Use the Complete Blood Count (CBC) with red and white blood cell morphology on a peripheral smear to develop a differential diagnosis for a patient with anemia.
3. Identify the likely deficiency of clotting factor(s) using the prothrombin time and the partial thromboplastin time coagulation tests.
4. Discuss the differential diagnosis and laboratory evaluation for anemia, erythrocytosis, leukopenia, leukocytosis, thrombocytopenia, and thrombocytosis.
5. Interpret body fluid test results of one of their patients.
6. Interpret the results of a basic coagulation workup of patients with bleeding disorders.
7. Describe the laboratory tests used to diagnose disseminated intravascular coagulation (DIC).
8. Identify the molecular and coagulation tests used to diagnosis hereditary and acquired risk factors for thrombosis.
9. Select appropriate tests for monitoring commonly used anticoagulants including warfarin, heparin, and new oral direct inhibitors of thrombin and of factor Xa.
10. Explain platelet function testing and select appropriate tests for monitoring common platelet function inhibitor drugs.
11. Understand the clinical indications and limitations of D-Dimer testing in the workup of suspected deep vein thrombosis or pulmonary embolism.

E. Selected specialty competencies: microbiology: students should be able to:

1. Describe the preanalytic variables that affect the diagnostic accuracy of microbiologic testing, including: presence of normal flora; presence of contaminants; collection timing and techniques, transport media, and sample storage conditions; and prior patient treatment with antibiotics.
2. Discuss factors affecting turnaround time in microbiologic workups.
3. Compare and contrast the interpretation of a Gram stain for rapid diagnosis of causative agents in normally sterile versus other body sites.
4. Discuss the appropriate use of aerobic an anaerobic blood cultures in the diagnosis of sepsis.
5. Explain the clinical laboratory algorithm for testing for urinary tract infection.
6. Discuss, with examples, the application of serological testing in infectious diseases to diagnose the cause of an infection.
7. Discuss the application of serology in infectious diseases to establish immune status.
8. Compare and contrast indications for different techniques of diagnostic microbiology workup, including culture, molecular testing and immunologic testing.
9. Demonstrate the use of culture and sensitivities in the selection of an appropriate antibiotic therapy.
10. Explain how rapid identification of an infectious organism, antibiotic susceptibility testing and rapid reporting of results to a clinical pharmacologist enhances antibiotic stewardship.
11. Describe clinical indications and test selection for the workup of human immunodeficiency virus (HIV) infection.
12. Describe the clinical indications and test selection for the workup of suspected viral hepatitis.
13. Explain the role of stool cultures, ova and parasite examinations, rapid antigen tests, and molecular tests in the differential diagnosis of diarrheal diseases.

F. Selected specialty competencies: molecular diagnostics: students should be able to:

1. Explain the application of molecular testing in infectious diseases, genetic diseases, oncologic diseases and fetal risk assessment.
2. Explain the use of genetic testing to predict patient response to therapeutic medications, e, g, anticoagulants and antineoplastic agents.
3. Debate issues associated with genetic testing, such as legal, ethical and social considerations.
4. Describe commonly used molecular genetic testing methods, such as amplification (polymerase chain reaction [PCR]), sequencing and cytogenetics and explain their clinical applications.