Insufficient Teaching of Laboratory Medicine in US Medical Schools

Abstract

For most of us who attended medical school more than 10 years ago, there was a course called ‘‘pathology’’ in the curriculum. The focus of the pathology course in most schools was almost exclusively anatomic pathology. The anatomic pathology of the myocardial infarction and the scar that evolves from it was shown to us with little information on troponin testing, despite the increasing difficulties in the interpretation of troponin test results. The change in the microscopic appearance of the myocardium showed the pathogenesis of myocardial infarction and, on that basis, was certainly important to discuss. The laboratory medicine/clinical pathology that was taught was very ‘‘anatomic pathology like.’’ Clinical pathology that was largely associated with the microscope was commonly included, such as peripheral blood smears, Gram stains and stains for other microorganisms, and the antinuclear antibody test. There were also other tests described with visual rather than numerical results, such as the gels from serum protein electrophoresis, and the aggregation of blood cells in the determination of blood type and Rh status. However, this approach to medical student teaching of laboratory medicine completely omitted the teaching of tests that generated only numbers and no visual pattern. Major areas of the clinical laboratory test menu including coagulation, endocrinology, and toxicology, which have limited gross and microscopic descriptions, were minimally considered in the pathology course and in the pathology textbooks. Over the past 10 to 15 years, a new approach to teaching basic science, including pathology, has appeared in many medical school curricula. The organor system-based approach includes pathology, but even in these basic science courses not called ‘‘pathology,’’ the pathology topics still remain dominantly anatomic. These are referred to as ‘‘student-centered curriculum,’’ in the form of problem-based learning and/or case-based learning. In these curricula, pathology/laboratory medicine learning objectives are woven into the first 2 years of medical school, and learning objectives are developed from cases that have pathology and laboratory data. An increasing percentage of medical schools are all student centered, partly student centered, or currently going through curricular revision to become more student centered. Education of medical students in the United States by experts on the selection of clinical laboratory tests and interpretation of the test results remains at risk for being very limited in the student-centered curriculum as well. Changes in the medical school curriculum have been occurring at a time when the test menu has been dramatically increasing in size, complexity, and cost. Highly complex genetic testing began to emerge in the clinical laboratory shortly after the year 2000, and medical students are poorly taught when to order such complex testing and how to interpret the genetic test results. Unfortunately, today medical students graduate and enjoy support by anatomic pathologists and radiologists to interpret test results, but they are faced with the impossible challenge of ordering the correct tests, and only the correct tests, from the thousands of expensive assays on the clinical laboratory test menu, with little or no education on the topic prior to graduation. In most institutions, no one is available to ‘‘automatically’’ help the treating physician with clinical laboratory tests as they are assisted in anatomic pathology and radiology, where cases are reviewed as a matter of course, without a special request. It is clear to me after 30 years in the field that less than 1% of the laboratory-related questions