Teaching of Clinical Pathology

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Teaching of Clinical Pathology, Current Exposure. NYU School of Medicine2nd year: 6-8 hours scattered throughout

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Teaching of Clinical Pathology

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1. Teaching of Clinical Pathology Robert Boorstein, MD,PhD Bellevue Hospital, NYU Medical School

2. Teaching of Clinical Pathology, Current Exposure NYU School of Medicine 2nd year: 6-8 hours scattered throughout “integrated” Host Defense Course and Organ Systems: Cancer Diagnostics, Cardiac Enzymes, Toxicology, Blood Bank, Hematopathology

3. The Bottom Line Most of what students learn about laboratory medicine is learned from point of view of internal medicine.

4. Positive student attitudes Students do have some understanding of the biological basis of disease. Students are well inculcated with the primacy of the doctor patient relationship

5. Deficiencies Despite courses of biostatistics and epidemiology, minimal functional understanding of specificity, sensitivity and predictive value. View clinical data as facts, not as data points with error. Very limited understanding of the time course and evolution of disease.

6. General Competencies Importance of accurate, clear communication to (and from) physicians. Focus on timeliness, appropriateness, and utility, of information The logic and utilization of clinical algorithms and practice guidelines (as compared with clinical judgment).

7. Specific clinical pathology issues Handling of large amounts of clinical information Comfort with quantitative results and with results expressed as risks Understanding the rapid pace of change in laboratory medicine

8. A case study A 35 year old male is admitted to the medicine service with pneumonia. There is vague suspicion of HIV. Stat testing for HIV is available only for pregant women and occupational exposures. TAT for routine HIV testing is 4 days. The hospitalist orders a viral load and CD4/CD8 count to rule out HIV.

9. Issues Misuse of prognostic tests for diagnostic purposes. Lack of understanding of proper use of prognostic markers. Lack of understanding of how to diagnose acute HIV infection. Failure to get appropriate informed consent or provide appropriate counselling.

10. When to teach: During Preclinical years? Students have already mislearned many concepts No time available in 2nd year Students have no clinical context until 3rd year.

11. When to teach Clinical Pathology: After 3rd year? Students have been exposed to many clinical settings. Developing a sense of natural history of disease Have some understanding of how much they don’t know. Looking for practical information Looking for intellectual underpinnings to unify concepts and facts

12. Utilization of Clinical Laboratories in Medical Practice. 2 week course Meets daily for two hours 24-36 students in two sections. Case based teaching. Students read primary literature and lead discussions presentations

13. UTILIZATION OF CLINICAL LABORATORIES IN RATIONAL MEDICAL DECISION MAKING Monday, June 20: 10 AM – 12 Noon Groups A and B, Coles Lab 303 Introduction (Boorstein) Tuesday, June 21: 10 AM – 12 Noon Group A, Coles Lab 303 Hemostasis (Karpatkin) Group B, Coles Lab 304 ‘ Tumor Markers (Boorstein) Wednesday, June 22 Group A, Seminar Rm 3; Noon – 2 PM Tumor Markers (Boorstein) Group B, Coles Lab 301; 1 PM – 3 PM Hemostasis (Green) Thursday, June 23: 10 AM – 12 Noon Group A, Coles Lab 303 HIV, HBV, HCV (Hanna) Group B, Coles Lab 304 Diabetes Monitoring (Chen) Friday, June 24: 10 AM – 12 Noon Group A, Coles Lab 303 Diabetes Monitoring (Chen) Group B, Coles Lab 304 HIV, HBV, HCV (Hanna) Monday, June 27: 10 AM – 12 Noon Group A, Coles Lab 303 Frozen Sections (Mittal) Group B, Coles Lab 304 Cancer Diagnostics (Yee) Tuesday, June 28: 10 AM – 12 Noon Group A, Coles Lab 303 Cervical Cancer (Simsir) Group B, Coles Lab 305 Frozen Sections (Mittal) Wednesday, June 29 Group A, Coles 109 – 10 AM – 12 Noon Clinical Algorithms (Donnelly) Group B, Alumni A – 9 AM – 11 AM Cervical Cancer (Cangiarella) Thursday, June 30: 10 AM – 12 Noon Group A, Coles 109 Cancer Diagnostics (Boorstein) Group B, Schwartz Lecture Hall C Clinical Algorithms (Donnelly) Friday, July 1: 10 AM – 12 Noon Groups A and B, Coles Lab 303 Summation (Boorstein)

14. From “Prostate Cancer Screening” …At the next clinic visit the physician repeats the digital exam and the PSA determination. The exam yields no new information and the PSA result is 6.0 ng/mL. The physician requests that the patient be seen in urology clinic. Two weeks later the patient has another digital rectal examination and the urologist feels a small induration. The patient is offered a biopsy and it is set up for 2 weeks. 6. What is the significance of a mildly elevated PSA (>4-10 ng/mL)? Of a PSA >10-20 ng/mL? Of >20 ng/mL? 7. Is screening recommended for the detection of prostate Ca? Why?

15. From “Diabetes monitoring” …The clinic nurse performed a point-of-care testing (POCT) glucose measurement right before the patient was sent to phlebotomy and obtained a result of 285 mg/dL. When the main laboratory result is seen the doctor is concerned and demands a repeat glucose meter test; the repeat POCT glucose is 300 mg/dL. The doctor questions the laboratory director, wanting to know “which is the accurate result?” 3. What is the value of POCT for patient care? 4. Does the POCT glucose have to be as accurate and precise as Central Lab’s glucose?

16. The bottom line: integration of laboratory data in patient management Algorithms The ordering physicians The laboratories Clarify difference between tests for screening, prognosis, and diagnosis. Results as risks (probability) Links to therapy Social, Economic, Political, and Operational issues that effect the availability and utilization of laboratory tests The physicians responsibility for information management

17. A case study Over a 16 month period, a large public hospital in New York fails to notify up to 19000 patients of the results of their Pap smears. After investigation, about 300 patients have not received appropriate management in a timely manner. What is the obligation to the patient of the physician? What are the obligations of the laboratory to report results? to follow up results? What are the consequences to the patients?

18. Medical Decision making Decisions made physicians on behalf of an individual patient vs. Decisions made by laboratories, hospitals, insurers, society that put obligations or constraints on physician behavior.

19. Patient safety The role of the physician in reducing medical errors, including Appropriate collection, handling, and transport of specimens. Appropriate labeling of specimens. Appropriate communication of results

20. Evaluation Evaluation of the class as a whole, rather than of individuals. In class “exam” using audience response system.

21. Is there benefit to ordering a CK-MB mass assay along with a troponin assay? Yes No

22. Would you do a sentinel node biopsy in a patient with breast carcinoma metastatic to lungs? Yes No

23. A positive sentinel node biopsy should be followed by axillary lymph node dissection. True False

24. Can many ovarian tumors be recognized as benign on gross examination alone? Yes No

25. A patient recently found to be HIV antibody positive has been referred to the Bellevue HIV virology clinic for follow-up. At the patients first visit to the virology clinic the following laboratory tests should be ordered. HIV viral load. HIV genotype test. HIV phenotype test. A and B. All of the above.

26. The INR is calculated by multiplying the prothrombin time ratio (PTR) by the ISI of the thromboplastin reagent. True? False?

27. A 45 year old women has a routine pap smear. Her gynecologic exam is normal. Her pap smear is diagnosed as “Atypical Squamous Cells”. What would be the reasonable next step in her management? Recommend HPV testing Recommend colposcopy Recommend repeat pap 12 months later Recommend clinical followup

28. Normal appearing Endometrial cells in a Pap smear are normal in a pap smear in a postmenopausal patient are reported in the “atypical squamous cell” category of The Bethesda system are normal in a pap smear during the first twelve days of the menstrual cycle require hysterectomy in most patients

29. Would you offer PSA testing to a 65 year old Caucasian male with no symptoms. yes no

32. Comments The clinical lab selective was excellent--a good balance between practical knowledge and the pathophysiology underlying lab tests. The cases used were good because we had a lot of exposure to these topics in the past and thus could appreciate the nuances that this course addressed. I have a better understanding of what can go right & wrong from when you take the patient sample to when the result is reported. I understand the system as a whole better and feel more comfortable calling the lab with a question now. I also better understand my role (i.e.when to order reflex testing or to cover the whole syringe of the ABG w/ice). Learning about the financial aspects & how what I order will make a difference was interesting.

33. More comments Mostly good with lots of student participation....a few of the days were more "power point" while I preferred the discussion and cases to getting lectured at. Overall very good. The seminars worked best when the preceptor let the students lead & just added info to correct, clarify or fill in missing info. This was a good time in our education to have this course because I would not have appreciated it w/o some clinical experience but I am glad that I can use what I learned while I am still a student.

34. More comments The strengths of this selective were the ample breadth of topics covered in the sessions and the student driven discussion sessions based on well written, thought-provoking case vignettes and discussion questions. While the subject matter was not the most exciting, it was extremely practical and I feel it will help me on the wards.

35. More comments The strengths of this selective were the ample breadth of topics covered in the sessions and the student driven discussion sessions based on well written, thought-provoking case vignettes and discussion questions. While the subject matter was not the most exciting, it was extremely practical and I feel it will help me on the wards.

36. Acknowledgements Adam Cabezas Joseph Leo

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