THE MANPOWER CRISIS IN CLINICAL CHEMISTRY T t is not widely recognized by people outside the field t h a t clinical chemistry is faced with a m a n power crisis. This crisis will become apparent in fiscal year 1972 when the provisions of Title 20 of the Medicare Bill (Federal H e a l t h I n surance for the Aged) t a k e effect. If our medical laboratories are to cope effectively with their new and greatly increased service responsibilities, they must be staffed by highly-trained scientists. Unfortunately, there are not enough welltrained individuals in the discipline of bioanalytical chemistry to properly staff existing laboratories or provide the increased number of competent scientists whose efforts will be required in the next decade. Title 20 of the Medicare Bill {1) states "the specific requirements t h a t must be met by an independent laboratory in order for its services to qualify for reimbursement under the supplementary medical insurance p a r t of the Health Insurance for the Aged program." Appertaining to manpower, Title 20 sets forth the duties and qualifications of the laboratory director, laboratory supervisors, clinical laboratory technologists, and clinical laboratory technicians. Laboratory Director
T h e laboratory director administers the technical and scientific operation of the laboratory. He series on a full-time, or a regular part-time basis provided he does not individually serve as director of more t h a n three laboratories. D e pending upon the laboratory workload, the director must spend an adequate amount of time in the laboratory daily to direct and supervise 32 A .
t h e technical performance of the staff. H e is responsible for the employment of qualified laboratory personnel and for their in-service training. H e is also responsible for the proper performance of all tests. If, for any reason, the director is to be continuously absent from the laboratory for more t h a n one month, he must provide a qualified substitute director. Except for those qualifying under a "grandfather clause," the laboratory director holds a doctoral degree. H e may be a physician certified in anatomical a n d / o r clinical pathology by the American Board of Pathology or the American Osteopathic Board of Pathology, or possess qualifications equivalent to certification. A physician may also qualify by certification in a t least one laboratory specialty by the two above-mentioned boards of pathology, or the American Board of Microbiology, the American Board of Clinical Chemistry, "or other national accrediting board acceptable to the Secretary of Health, Education, and Welfare in one of the laboratory specialties," or through a minimum of four years of special training and experience subsequent to obtaining the medical degree. T h e important provision on this training and experience is t h a t " a t least two (years) were spent acquiring proficiency in one of the laboratory specialties in the clinical laboratory—with a director at the doctoral level—of a hospital, a health department, university, or medical research institution, or in the case of a State which regulates clinical laboratory personnel, in a clinical laboratory acceptable to that
State."
ANALYTICAL CHEMISTRY, VOL. 42, NO. 12, OCTOBER 1970
WILLIAM C. PURDY Department of Chemistry, University of M a r y l a n d , College P a r k , Md. 20742 ROBERT S. MELVILLE, Research Grants Branch, National Institute of General Medical Sciences, Bethesda, Md. 20014 An individual with a doctoral degree in a chemical, physical, or biological science m a y also qualify as a laboratory director, but he must be certified in at least one laboratory specialty by the American Board of Microbiology, the American Board of Clinical Chemistry, or other national accrediting board, or qualify by experience and training as does the physician. Laboratory Supervisors
Depending on size, the clinical laboratory has one or more supervisors. Under the general direction of the laboratory director, they supervise technical personnel and reports of findings, and perform tests requiring special scientific skills. In the absence of the director, supervisors are held responsible for the proper performance of all laboratory procedures. "A qualified supervisor is on the premises during all hours in which tests are being performed." To qualify as a supervisor, an individual " (Ï) is a physician or has earned a doctoral degree from an accredited institution with a chemical, physical, or biological science as his major subject, and (ii) subsequent to graduation has had at least two years' experience in one of the laboratory specialties in a clinical laboratory—with a director at the doctoral level—of a hospital, a health department, university, or medical research institution, or in the case of a State which regulates clinical laboratory personnel, in a clinical laboratory acceptable to t h a t State." A person with a M.A. or M.S. degree in one of the chemical, physical, or biological sciences may qualify after four years' ex-
REPORT FOR ANALYTICAL CHEMISTS
A Report to the Committee on Analytical Chemistry of the National Research Council, National A c a d e m y of Sciences perience of which not less than two years "has been spent working in the designated laboratory specialty in a clinical laboratory" restricted as above. The person who holds the B.A. or B.S. degree in one of the chemical, physical, or biological sciences requires a minimum of six years' experience of which not less than two years are restricted as above, plus successful completion of pertinent course work, "which, when combined with the foregoing experience, will provide technical and professional knowledge" comparable to that possessed by the person with the master's degree. A clinical laboratory technologist may qualify in the same manner as a person with a bachelor's degree. Clinical Laboratory Technologists The clinical laboratory technologists are employed to proficiently perform those clinical laboratory tests which require "the exercise of independent judgment." "Each clinical laboratory technologist possesses a current license as a clinical laboratory technologist issued by the State, if such licensing exists, and meets one of the following requirements : " (1) A bachelor's degree in medical technology from an accredited college or university. (2) Three academic years (at least 90 semester credits) at an accredited college or university which must meet the requirements for admission to a 12-month training program in a school of medical technology approved by the Council on Medical Education and Hospitals of the American Medical Association, and successful completion of that program. ANALYTICAL CHEMISTRY, VOL. 42, NO. 12, OCTOBER 1970 .
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(3) A bachelor's degree in one of the chemical, physical, or biological sciences and additional experience a n d / o r training covering several fields of medical laboratory work provided the combination is comparable to the requirements in (1) above. (4) Three academic years at an institution acceptable in (3) above with a distribution of courses involving both lecture and laboratory work plus experience a n d / o r training in medical technology as in (2) above provided the combination is comparable to the requirements in either (1) or (2) above. Clinical Laboratory Technicians
These technicians are employed in sufficient number to meet the workload demands of the laboratory and "function only under direct supervision of a clinical laboratory technologist." "Each clinical laboratory technician possesses a current license as a clinical laboratory technician issued by the State, if such licensing exists, and meets one of the following requirements:"
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(1) A high school graduate who, subsequent to graduation, has served two years as a technician trainee in a clinical laboratory with the director at the doctoral level or in an approved State clinical laboratory. (2) A high school graduate with at least one year of technician training in a program approved by the Council on Medical Education and Hospitals of the American Medical Association. (3) A high school graduate who, subsequent to graduation, has successfully completed an official milit a r y medical laboratory procedures course of at least 50 weeks duration, and has held, at the journeyman's level, the military enlisted occupational specialty of Medical Laboratory Specialist (Laboratory Technician) . The duties and qualifications for clinical laboratory personnel set forth in Title 20 of the Medicare Bill (1) are quite specific. Although programs in medical technology and technician training are presently inadequate to meet the
ANALYTICAL CHEMISTRY, VOL. 42, NO. 12, OCTOBER 1970
personnel needs of this bill, the real crisis exists in supplying the laboratory directors and supervisors. I t must be remembered t h a t the Medicare Bill states, "A qualified supervisor is on the premises during all hours in which tests are being performed." For this reason this report will focus on the problem of securing qualified personnel to fill the positions of laboratory director and supervisor. The Manpower Supply
Are we training sufficient m a n power with an adequate background to meet this challenge, a challenge with a deadline date of July 1, 1971? The answer must be in the negative. A recent report of the Committee on Education of the American Association of Clinical Chemists {2) listed those schools which provide training programs in clinical chemistry. Only Seattle University offers a program leading to a B.S. degree in clinical chemistry. At the M.S. level, the Chicago School of Medicine and the University of D a y t o n have programs. Completion of these programs plus the required six or four years' additional experience, respectively, qualify the individual as a laboratory supervisor. These individuals cannot qualify as laboratory directors under the provisions of the Medicare Bill. Doctoral programs in clinical chemistry are available at the State University of New York at Buffalo, the University of Florida, Georgetown University, Loyola University of Chicago, Ohio State University, the University of Oklahoma, and the University of Washington. Three of these programs, at SUNYBuffalo, Ohio State University, and the University of Washington, are supported by training grants from the National Institutes of Health. With two years of additional experience, individuals graduating from these programs can qualify as laboratory supervisors, and by passing the certification examination of the American Board of Clinical Chemists or with an additional two years' experience, they can qualify as laboratory directors. In addition to the seven universities with doctoral programs, postdoctoral training programs are
Report for Analytical Chemists
this new booklet "figures" help you
available at Buffalo General Hos pital, the University of Connecticut, Hartford Hospital, H a r v a r d Uni versity, the University of Iowa, Mount Sinai Hospital of New York, the University of Pennsylvania, and the University of California at San Francisco. I n these postdoctoral programs an individual with a doc toral degree can receive the two years of required training and ex perience needed for qualification as a laboratory supervisor and for the certification examination as a lab oratory director. The Challenge
I n its 1968 "Guide Issue," the American Hospital Association (3) listed a total of 6783 registered hos pitals within the United States. Of this total, 58.2% or 3950 hospitals operated their own clinical labora tories. T h e remaining hospitals em ployed private clinical laboratories.
These data, compiled in August 1968, were the 1967 statistics on hospital laboratories. Although the "Guide Issue" is published an nually, the questionnaire used in this survey does not always ask identical questions ; the 1969 survey did not include the clinical labo ratory in its coverage. To be ac credited by the AHA, a hospital must have laboratory facilities available. The Washington office of the AHA reported in March of this year t h a t they now have nearly 8000 hospitals accredited by them. This does not represent the total number of private clinical labora tories in the country. Educated guesses by several clinical chemists as to the number of private clinical laboratories range from three to six times the number of accredited hos pitals. However, even 8000 can make the manpower crisis painfully obvious. As a supervisor must be
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William C. Purdy is head of the Analytical Division, Department of Chemistry, University of Maryland. He earned his B.A. (cum laude in chemistry) from Amherst College in 1951 and his Ph.D. at MIT in 1955. After serving as an instructor at the University of Connecticut, he joined the University of Maryland as an assistant professor; he became a full professor in 1964, and was ap pointed head of the Analytical Chemistry Division in 1968.
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ANALYTICAL CHEMISTRY, VOL. 4 2 , NO. 12, OCTOBER 1970
Robert S. Melville has been a Sci entist Administrator with the Re search Grants Branch of the Na tional Institute of General Medical Sciences, National Institutes of Health since November, 1965. Dr. Melville received an A.B. degree from Clark University, Worcester, Mass. in 1937; he earned his Ph.D. degree in biochemistry at the State University of Iowa in 1950.
Report for Analytical Chemists
on the premises whenever tests are being performed, and assuming an 8-hour workday per supervisor, 8000 hospitals would require a minimum of 24,000 laboratory supervisors. Pathology training programs cannot begin to meet the manpower needs from the point of view of numbers or chemical education. The National Registry of Clinical Chemists, an examining body, has requirements for registration that parallel the qualifications of the laboratory supervisors. In February 1970 there were 696 registered clinical chemists in the United States with another 203 applications in various stages of preparation (4) · Beginning with a doctoral degree, a minimum of two years is required to qualify as a laboratory supervisor. The Federal deadline is July 1, 1971. Can the Analytical Chemist Help?
A growing concern for public health exists at all levels. The Federal government has sponsored many new programs designed to
improve the quality of medical and hospital care. Many state legislatures have established new regulations concerning the operation of clinical laboratories. These activities indicate not only the opening up of new employment opportunities, but also, an increasing concern for the quality of the analytical work done. In the past, laboratory directors and supervisors generally have come from the ranks of biochemistry, pathology, or medicine, and have been woefully undertrained in analytical chemical techniques. Few, if any, individuals entered this field from the discipline of analytical chemistry, and yet, future developments in clinical laboratory science will depend in very large measure on the discovery and development of new and better analytical methods and instrumentation. Clinical laboratories, therefore, will require individuals primarily devoted to basic and applied research and development in analytical chemistry.
Until recently many analytical chemists have looked upon the clinical laboratory as foreign territory. This situation resulted from the types of samples examined and the unfamiliar medical terminology. Too few undergraduates receive any exposure to the possibilities of research and development in clinical laboratories. This is particularly true of students in analytical chemistry. By long-standing tradition, courses at the undergraduate level in analytical chemistry have revolved about conventional inorganic analysis with very little opportunity to explore the analysis of biologically interesting materials. Few, if any, undergraduate students ever have the opportunity to quantitatively pipet blood. The analysis for iron is quite different when performed on a biological matrix than in an aqueous solution. Experts generally agree that it is easier to obtain an orientation to disease and to the fundamental principles of biology and medicine later in training as contrasted to the need for an early acquisition of a solid working knowledge of physics, mathematics, and chemistry. However, the appetite for clinical investigation could be wetted by introduction to biological concepts and materials during this early educational period. Analytical chemistry lends itself to this process as well as any other discipline usually studied by undergraduate students. Many of the larger metropolitan medical centers now have what are virtually basic research departments. Even in small hospitals (250 beds), it is no longer unusual to have competent chemists serving in one capacity or another. After July 1, 1971, the Medicare Bill will require a qualified laboratory director and supervisor for 100-bed hospitals that wish to receive Medicare payments for their laboratory work. Additionally, new regional laboratory programs are being established which will require staffs of many specialists, analytical chemists, engineers, electronics specialists, systems analysts, etc. As the fruits of these programs begin to affect the smaller hospitals in a given region, increased sophistication will become apparent even at the small county hospital level.
ANALYTICAL CHEMISTRY, VOL. 42, NO. 12, OCTOBER 1970
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Report for Analytical Chemists
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Where shall we find the profes sionally trained individuals to carry on this important work? Many biochemists do not have adequate training in analytical chemistry and many analytical chemists do not have adequate biochemical training. What we really need is a symbiosis between these two areas. Investigation of normal and ab normal human biochemistry or clin ical chemistry is not performed in the same intellectual context as that of general biochemistry. The latter is rapidly changing into molecular biology which approaches its prob lems concerning its materials from a much more general point of view. The trend in biochemistry today is toward study of microorganisms rather than of higher forms. The study of clinical biochemistry is not widely recognized as a specific academic discipline, but is left to the few clinicians and biochemists whose primary interest compels them to become involved. Fre quently, they are forced to deal with analytical methods and prob lems which they do not completely understand. This is the vital pres sure point to which the impact of modern instrumentation and analy sis might be applied. While many of the newer pro cedures represent considerable ad vances in clinical chemistry, not all the users of these techniques have the proper theoretical understand ing of them. Many biologists could also benefit from such analytical ex pertise as the definition of suitable standards, reference methodology, data evaluation, and modern data analysis. Conversely, many ana lytical chemists need to learn more of biological systems, of enzyme and protein chemistry, and of sequen tial metabolic reactions. Through increased awareness of each other's processes, techniques, and goals, the symbiosis between analytical and clinical chemists might be hastened with mutual ad vantage.
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ANALYTICAL CHEMISTRY, VOL. 42, NO. 12, OCTOBER 1970
(1) Fed. Reg., 31, 243 (1966). (2) American Association of Clinical Chemists' Report. (3) J. Amer. Hosp. Assoc. 42, 3 (1968). (4) Roethel, D.A.H., Clin. Chem., 16, 151 (1970).
