LABORATORY MEDICINE SPECIALIZATION
TEACHING AND TRAINING IN ITALY WITH A GLANCE TO SOME EUROPEAN AND
NON-EUROPEAN COUNTRIES
Gian Cesare Guidi
Correspondence
Gian Cesare Guidi
Department of Life and Reproduction Sciences, Laboratory of
Clinical Chemistry Policlinico "G. Rossi" University of Verona -
Italy
37134 Verona - Italy
email: giancesare.guidi@univr.it
Tel. +390458124308
Fax: +390458027484
Abstract
The Italian Ministry of Education, University and
Research has recently reformed the medical schools of
specialization in accordance with a series of EC Directives. Four
different curricula have been defined into the class of
"Diagnostics and Laboratory Medicine", respectively: Anatomic
Pathology, Clinical Biochemistry, Clinical Pathology, and
Microbiology & Virology. Each curriculum is based on a scheme
of 300 credits, that includes formal educational activities) and
practical activities distributed on a five years' period. The four
curricula share a common course of either formal or practical
activities. Main training and professional objectives are in favour
of: a) the principles of appropriateness and of evidence based
medicine, b) the acquisition of either on-the-bench experience and
practice, or skills in organizing and managing the laboratory
activities and personnel c) the understanding of data and phenomena
relevant to the patients in a clinically oriented vision, d) the
ability to translate research results into diagnostic advantages,
e) the values of humanism and ethics.
When comparing the Italian curriculum with some European and
non-European curricula in Laboratory Medicine, many similarities
are apparent: above all, the medical pertinence of the profession
is increasingly affirmed in favour of a consultancy role to be
played by the specialist in Laboratory Medicine at the clinical
level. Main conclusions: a) the education, skill and expertise
required for laboratory specialists regard now a broad variety of
issues, b) these embrace not only technical, scientific and
organizational aspects, but even the ability to develop
consultative capacities in different diagnostic areas, c) moreover
the implicit translational aspects in the profession require the
adoption of innovative and multifaceted curricula.
Introduction
In the early seventies no specialization and/or post-graduation
were needed for obtaining a position in the Italian hospital
laboratories. Such a condition of no-needed specialization lasted
until the early nineties, when European Community started to issue
directives (1,2) to the state members to adopt a system on a
uniform basis of graduation and of post-graduation/specialization
for all medical graduates. To be specialized became, over a few
years, a pre-requisite for practising the medical activity in a
specific professional field. As a consequence the Italian National
Health System was encouraged to demand applicants the ad
hoc specialization, as a pre-requisite for a position. In
hospital laboratories, where not only medical doctors but even
biology and chemistry graduates (so called scientists) are
employed, this fact caused for some years a diversity of positions.
On one side specialized MDs, on the other side non-specialized,
non-MD graduates, a condition able to generate some serious issues.
In the following years this was mended by some laws by decree
(3).
Curricula in "Diagnostics and Laboratory Medicine" in
Italy
In 2005 a reform of the Italian Medical Schools of
Specialization (4) has defined four different types of curricula
into the class "Diagnostic and laboratory medicine",
respectively:
- Anatomic Pathology, with admission open only to candidates with
medical graduation;
- Clinical Biochemistry, with admission open to candidates with
medical graduation or alternatively in: Biology, Veterinary
Medicine, Medical Biotechnology, Veterinary Biotechnology,
Pharmaceutical Biotechnology, Pharmacy, Chemistry;
- Clinical Pathology, with admission open to candidates as in
point 2;
- Microbiology and Virology, with admission open to candidates as
in point 2.
The two curricula showing more similarity are Clinical
Biochemistry and Clinical Pathology, and are to be dealt with in
the following discussion.
All the curricula are based on a common scheme of 300 credits,
which includes formal educational activities (up to 30% of credits)
and practical activities (at least 70% of credits) distributed over
a five years' period.
Both formal and practical activities are specifically and precisely
defined for each curriculum in terms of:
- disciplines contributing to the education of the trainees
- skills to be achieved by the trainees.
A. The common course
All the four curricula share a common course (s.c. "common
trunk") of either formal or practical activities, in order to
fulfil the basic requirements needed for an education in Laboratory
Medicine (LM). The common course (81 credits on the whole) is
distributed all over the curricula five years, with the main
dedication in the first three years.
Consequently each of the individual schools provides the common
basis of educational and professional skills within the field of
LM, which is therefore deemed to be a wider professional domain in
the clinical-diagnostic area. This aspect appears substantially in
accordance with parallel curricula in Laboratory Medicine of USA
and some other European countries.
Main disciplines of the common course are: Clinical Biochemistry
and Molecular Biology, General and Clinical Pathology, Anatomic
Pathology, Surgical Pathology, General and Clinical Microbiology,
Internal Medicine.
The common course appears able to do a liaison role throughout the
curricula for:
- promoting multi-disciplinary learning;
- focusing on a comprehensive, clinically oriented view of the
profession;
- allowing the trainee to acquire theoretical and practical
knowledge more extensively than traditionally achieved in
individual sectors.
In this way, every specialist in progress increases/improves
her/his professional competences:
- by sharing the wider fields of knowledge that characterize the
range of Laboratory Medicine disciplines;
- by being allowed to boost her/his skills to levels not more and
not just limited to technical and analytical issues;
- by being entitled to do on a par with clinicians when
interviewing and/or advising
B. General objectives of education in LM
Both educational training and professional educa tion are
addressed at:
- developing special aptitudes to work in accordance with
the principles of appropriateness and of evidence based
medicine;
- stimulating the overall ability of the trainee towards a
critical approach to knowledge, through either the acquisition of
the on-the-bench experience, or the ability to translate innovative
research results;
- understanding data and phenomena, by critical review of
findings based on real or simulated cases;
- paying attention to the values of humanism and ethics of the
profession in Laboratory Medicine;
- favouring patient's treatment issues related to a holistic view
of healthcare;
- enhancing professional interactions;
- paying attention to her/his own territorial and social
context.
C. Specific objectives of education in LM
a) Curriculum in Clinical Biochemistry
Both educational training and professional education are
addressed at:
- acquiring theoretical scientific and professional knowledge of
the biological and biochemical parameters, and relevant alterations
observed/measured in samples, ex vivo and in
vivo, in relation to either normal or patho-physiological
states;
- becoming familiar with the clinical biochemistry and pathology
of nutrition and of physical activities at different levels of body
organization, from single molecules to cells, tissues, organs, and
the whole body both in man (and in animals);
- gaining skills in the study of markers of changes that are at
the basis of inherited and acquired genetic diseases;
- gaining skills in organizing and managing the laboratory
activities and personnel, from single sections to more complex
units, in a certification/accreditation context;
- acquiring knowledge and skills in laboratory processes and
methods, particularly as regards:
-
- methods of molecular biology/pathology applied to clinical
needs, molecular diagnostics and recombinant biotechnology for the
diagnosis and evaluation of both disease susceptibility and
prevention,
- use of innovative technologies for quantitative and qualitative
analysis of the above parameters to levels of high sensitivity and
specificity,
- use of methods and technologies for the evaluation of
environmental pollutants and of xenobiotics, including additives
and residues in food;
- becoming able to apply and report the prescribed quality
control procedures.
b) Curriculum in Clinical Pathology
Both educational training and professional education are addressed
at:
- acquiring theoretical scientific and professional knowledge in
the field of diagnostic pathology and clinical laboratory methods
in cytology; cytopathology, immunohematology, genetics and in the
diagnostic application of molecular methodologies in human
samples;
- acquiring the necessary competence in diagnostic and clinical
aspects of reproductive medicine and in laboratory medicine of the
sea and of sports activities;
- gaining skills in the study of cellular pathology in oncology,
immunology and in immunopathology, and in genetic pathology, at
ultrastructural and molecular levels;
- acquiring knowledge and skills in laboratory processes and
methods, particularly as regards:
-
- diagnostics on human samples, related to issues of hygiene and
preventive medicine,
- diagnostics, control and prevention of human health in
environmental, occupational medicine, community medicine, forensic
medicine, thermal medicine and space medicine.
Relevant LM curricula in some European and non-European
countries
A summary comparison with curricula from some other countries,
either European or non-European, seems now appropriate.
- At first the "Summary of Graylyn Conference recommendations for
Clinical Pathology (CP) training" in USA (5) is considered, that
among others states:
"After completing CP residency training, the resident should
be capable of directing and managing clinical laboratory services
and be able to:
- serve as a consultant to physicians on cost-effective test
strategies and interpretation of results;
- select, evaluate, and apply laboratory instruments and
procedures appropriate to the screening, diagnostic, and monitoring
needs of clinical decision making;
- plan, organize, staff, and direct laboratory
resources;
- use the techniques of medical informatics to acquire and
manage data, translate data to clinically useful information, and
communicate that information in support of patient care and
educational programs;
- play an influential role in medical staff and healthcare
delivery activities that reach beyond the confines of the
laboratory."
- In Canada, Medical Biochemistry and Clinical Biochemistry are
based on two post-graduation training curricula:
- Medical Biochemistswhose training is regulated by
the Royal College of Physicians and Surgeons of Canada (6). The
requisites are: a) graduation from medical school, b) completion of
the required internship (4/5 years).
- Clinical Biochemists whose training is regulated
by the more recently created Canadian Academy of Clinical
Biochemistry (CACB), and is performed in several medical schools
with courses of 2/3 years duration (7). The requisites are: a) PhD,
b) some post-graduate research experience.
Details of both medical and clinical biochemist training
programs reveal a difference in emphasis and duration rather than
in course content, with medical trainees required to spend at least
1 of their 4 training years in clinical disciplines relevant to the
practice of biochemistry.
- Chemical Pathology (also known as Clinical Biochemistry) in UK
(8)
Doctors in the speciality, obtained through an examination, have
dual direct responsibilities:
- the provision of a reliable analytical service;
- the management of the (analytical) process (and the
staff);
Moreover they have to manage and supervise:
- assurance of quality and provision of guidance on the selection
of tests and
- assessment of the significance of the results (particularly
with some of the less generally familiar tests);
in that both are considered the province of the chemical
pathologist.
Not last:
- the clinical role, not only by advising on the management of
patients with metabolic disturbances but by increasingly having
direct responsibility for such patients in out-patient clinics and
on the wards.
- Final look at Biologie médicale in France that has been very
recently reformed, with a decree deemed able to significantly
modify the professional scenery in either public or private sectors
(9). The access to the profession is open to both medical doctors
and pharmacists.
Cardinal points of the reform are:
- the profession is medically oriented;
- the medical biologist has a full medical role in patient's
care, with the right of checking appropriateness in test
prescription.
At the completion of the studies, the specialist should:
- be competent in the analytical and methodological fields, with
knowledge in human metabolism, physiology and pathology;
- be able to discuss with clinicians, with a scientific based
approach, as for the appropriateness of prescriptions and
interpretation of results;
- take into account the medico-legal aspects of the profession
and the framework of ethical standards needed to support
patients.
Interestingly some common key words/phrases appear throughout
the curricula from the different countries above considered, Italy
included:
- trainees are either Medical graduates or "Scientists"
graduates;
- professional perspective is clinically/medically oriented,
holistic, with attention to humanism and ethics;
- educational propensity is oriented towards multidisciplinary
learning
- abilities and competences to be developed encompass, among
others, consultancy, appropriateness, translational issues;
skills should be gained in technical, analytical and staff
management; together with the ability to play influential role in
medical staff and healthcare.
Organizational aspects of Italy's main LM
specialization courses: articulation of training activities, time
duration, tutoring and final examination
For each trainee the School Council (i.e. the governing body)
shall establish:
- the standard location(s), with reference to the specific
activities to be performed, either formal instruction or practical
training
- specific training programs, generally based on a semester
term
- the pace of knowledge acquisition, training and competence by
gradually increasing the complexity, criticality, technological
sophistication and responsibility to be attributed to the trainee:
the latter identifies the increasing levels of autonomy the trainee
is entitled to assume in laboratory activities
- the criteria for evaluating either the progress of
learning/training or the levels of achievement with respect to the
objectives
- appropriate means for the registration and reporting of
individual progression.
The School Council annually appoints tutors (staff structure),
who are each assigned a set number of trainees, usually two but not
more than three, and are charged to:
- play the vocational training activity in the field,
- participate in educational activities seminars, discussion of
clinical cases, staff meetings, journal clubs, inter-disciplinary
meeting, etc.
- provide a detailed assessment on the activities carried out by
the trainee during the vocational training.
For obtaining the diploma of specialization, the trainee must
complete 300 credits on the whole, articulated in a full 5 years'
course.
During each year (about 60 credits) formal activities account for
about 30% of the credits; training (on the bench) activities for
the 70% of the remaining credits.
The final examination consists in the discussion of a thesis of
specialization and takes into account the results of all
evaluations resulting from the in itinere trials and
judgments of the teachers-tutors.
Number of Specialization schools, network organization
and trainee positions in Italy
Presently there are:
- 8 Schools of specialization in Clinical Biochemistry
- 18 Schools of specialization in Clinical Pathology
- 19 Schools of specialization in Anatomic Pathology
- 9 Schools of specialization in Microbiology and Virology
Each school is part of a network of university hospital
laboratories (possibly on a regional basis) and of major Health
Service Hospitals that distinctly provide either formal or training
activities.
Each trainee is selected on the basis of an entrance examination
consisting of a series of multiple choice questions; after
admission he/she signs an agreement for the whole course of
specialization and is waged for during the whole course
duration.
As for 2009, the following agreements have been drawn up:
- Clinical Biochemistry: 26
- Clinical Pathology: 55
- Anatomic Pathology: 59
Microbiology and Virology: 29.
Conclusions
The education, skill and expertise required for laboratory
professionals embrace now a variety of technical, scientific and
organizational issues. Laboratory Medicine trainees are expected to
learn and attain either technical or, more and more, consultative
capacities in rather different diagnostic areas. Translating into
practice some innovative findings coming from scientific research
implies new and multifaceted curricula for medical laboratory
specialists. All the above can be achieved from the beginning by
planning the most appropriate means of instruction and training
provided by the university courses, and through the continuous
education by the scientific associations later on.
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