Merle A. Evenson Department of Medicine, University of Wisconsin, Madison, Wis. 53706
Analytical The Need for Chemistry
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Clinical Chemistry Training Programs T^T ATIONAL AWARENESS of the
rising
-*-^ cost of health care is a factor focusing attention on the field of clinical chemistry. T h e use of com puters and mechanization in medi cal laboratories, justified by pre dicted decrease in unit cost of the tests, has interested the Federal government, industry, and some academic departments in the field. T h e kind and extent of the contri butions from each of these resources is not yet apparent. A significant effort by analytical chemists would certainly result in major contribu tions in the clinical laboratory field. While this report is written for chemists, it should be k e p t in mind t h a t a clinical chemist must have training beyond t h a t of analytical chemistry. Previously, a clinical chemist's duties called for him to develop and supervise chemical test ing of end products of metabolism. Only recently have the measure ments on the r a t e of enzymatic transformation of intermediates been undertaken. As mechanized equipment becomes more available, a clinical chemist's d u t y will involve the study of biochemical parameters in man. These studies will be di rected toward diagnosis and assess ment of abnormalities. T h e clinical chemistry laboratory of the future will most likely serve a more diag nostic function. T h e clinical chem ist on one hand will be expected to draw more on the biochemistry of disease and on the other h a n d to introduce new physical chemistry measurements previously used only in research. T h e critical shortage of clinical
chemists adequately trained in ana lytical chemistry soon will result in a manpower crisis. Federal H e a l t h Insurance for the Aged (Medicare) will enforce minimum qualifications for the chemists under Title 20 of the Medicare Bill, effective in fiscal year 1972. T h e classification and requirements for each personnel category in the Medicare Bill are given in the P u r d y and Melville re port (1). Several training pro grams have been initiated to meet the challenge, but recent tightening of Federal funds for training grants has dampened much of the enthusi asm for additional new programs. W h a t role analytical chemistry plays in the training of personnel a t all levels depends upon their will ingness to recognize clinical chem istry as a worthy field and to work with h u m a n biological specimens. T h e magnitude of health care costs at the national level is inter esting. Cost for health care in creased from 26 to 60 billion dollars between 1962 and 1969 owing prin cipally to increased salaries for health care personnel. T h e gross national product (G.N.P.) went from 4 to 8 % in t h a t seven-year period. B y comparison, in Sweden, 2 . 5 % of the G.N.P. was spent in 1955 for health care and 5.8% of the G.N.P. was spent in 1968. I n contrast to the increasing percent age of the G.N.P. spent for health care, the percentage spent for sci ence in the U.S. decreased from 2 . 5 % in 1965 to 2 % in 1969, ac cording to Weinberg (β). These statistics lead to the conclusion t h a t the priorities of increased support
for health care and decreased sci ence support are not a recent trend. I n 1969 it was estimated t h a t there were more t h a n 8000 operating hospitals in the United States and more t h a n 5 0 % of those operated their own clinical chemistry labora tories. T o d a y in the U.S., only 1600 people have more t h a n a bachelor's degree in chemistry, and are mem bers of the American Association of Clinical Chemists ( A A C C ) , T h e r e is a national need for qualified clini cal chemists t o d a y . I t was estimated t h a t more t h a n one billion laboratory tests were performed in clinical laboratories in 1967 and more t h a n 300 million chemistry procedures were per formed in hospital laboratories in 1968. T h e 20 most common clinical chemistry tests are glucose, blood urea nitrogen, sodium, potassium, chloride, bicarbonate, total biliru bin, uric acid, calcium, albumin, p H , P002 a n < i Po 2 serum, glutamicoxalacetic transaminase, total pro tein, lactic dehydrogenase, alkaline phosphatase, creatinine, cholesterol, phosphorous, creatine phosphokinase, and protein-bound iodine. These tests usually provide 9 0 % of the work volume in the chemistry laboratory. I n addition, commer cial clinical laboratories perform a substantial percentage of the test volume done in the United States. T h e clinical laboratory business is very large and growing rapidly. Currently each clinical chemistry laboratory doubles its own size every five years. C a n analytical chemistry m a k e contributions to this field now and in t h e future?
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Before looking to the future, let's look at the history of clinical chemistry. In 1526, Paracelsus stated that "chemistry should not be concerned with transmutation of elements but should serve as the foundation for medicine" (3). Von Helmont, Pregl, Priestley, and Lavoisier all worked on biological and medically related problems during the 17th, 18th, and early 19th centuries. In the early 1800's organic chemistry included human chemistry, chemistry of other living systems, and carbon chemistry. Later, organic chemistry was redefined as the study of only carbon chemistry. Early in the 1900's biochemistry divided into human chemistry as taught in medical schools and what has now become known as classical biochemistry, often taught outside of and independent of medical schools. In 1906, a group of chemists studying living organisms formed the Biochemical Society and began publishing Biochemical Journal. The Journal of Biological Chemistry was first published six years later and contained several clinical chemistry studies. Nutritional biochemistry departments began working with microorganisms such as yeasts, molds, and E. coli in the 1930's. In 1948 the Society for Clinical Chemists was formed. It principally attracted people trained in medicine and/or biochemistry. In 1955 clinical chemists published their own journal, and in the 1960's clinical chemistry began to draw more classically trained chemists into the field. A few analytical chemists such as Folin, Peters, Van Slyke, and Somogyi actively published some of their work in the previously mentioned journals in the 1920's. Several clinical chemistry tests and some equipment are named in their honor. The Folin-Wu and Somogyi-Nelson glucose methods and the Van Slyke gasometer illustrate their contributions. Johns Hopkins University was one of the first medical schools in the early 1900's to use chemists in the training of physicians. Many other medical schools have now followed in this practice. With the departure of biochemists from the medical school, a phy54 A .
sician-pathologist frequently was pressured into administratively becoming responsible for clinical chemistry. The chemistry procedures were usually manual (cookbook) , few in number, and not very accurate or precise. (Gravimetric sodium and potassium are examples of the laborious, nonspecific, and manual clinical chemistry procedures formerly used.) The pathologist had the unpleasant task of being responsible for a laboratory that was the justified target of many complaints. With the advent of commercially available instrumentation (the photoelectric colorimeter and the flame photometer in the 1930's), the quality of the performance improved and the workload of the hospital laboratory increased rapidly. When mechanization of manual procedures occurred with the introduction of the Technicon AutoAnalyzer in 1957, a quantum jump occurred in the laboratory's work volume. In 1965, still another quantum jump occurred when multichannel AutoAnalyzers were introduced into clinical chemistry laboratories. Conditions within the hospital laboratory began to improve. The heavy work load and service commitment were still present but instrumentation had elevated the laboratory stature. Financially, in 1965, the laboratory was very attractive and nonphysicians were entering the field at an increasing rate. As a result, new analytical techniques were introduced to the routine laboratory by the nonphysicians. The problem of the lack of adequate training in analytical chemistry again is evident when one observes how some of the new tools frequently are misused. The diversity of analytical techniques used in a routine clinical chemistry laboratory is vast. Sodium, potassium, and lithium tests are usually accomplished by flame emission methods. Calcium, magnesium, copper, zinc, and lead are frequently done by atomic absorption. Glucose, blood urea nitrogen, and phosphorous are usually carried out by visible absorption spectrophotometry. Total barbiturates are done by uv absorption. Kidney and gall stone analyses utilize infrared spectrophotometry while blood Cor-
ANALYTICAL CHEMISTRY, VOL. 42, NO. 14, DECEMBER 1970
tisol uses fluorescence. Drug and steroid fractionations are often done by gas-liquid chromatography. The enzyme tests CPK, SGOT, and LDH are completed by kinetic methods. Serum protein fractionation is done by electrophoresis and lipid fractionation by thin layer chromatography. Chloride analysis may utilize coulometry and pH, potentiometry. Spinal fluid protein analysis frequently is accomplished by ultrafiltration dialysis and/or gel permeation. This is but a sampling of the techniques used every day in the production line of the routine clinical chemistry laboratory. Can anyone say that this is not analytical chemistry? Let's look next at the administrative and academic arrangements usually encountered by clinical chemists. In an organizational structure, the clinical chemist is usually responsible to a physiciandirector of clinical laboratories. The physician will most often be a pathologist. The pathologist-director may not have financial freedom from the hospital administrator, so the clinical chemist may not have direct access to the financial control of the laboratory. In general, the clinical chemist may have significant responsibility without adequate authority. A clinical chemist may have an academic appointment in pathology or some other medical department. Alternatively, he may have a total or joint appointment in another science-related department such as biochemistry or physiology. Generally, however, the clinical chemist does not have the same type of formal training as the majority of the members of his department. This situation may not be very desirable for professional growth. In addition, one occasionally hears from the chemist, "I don't want some physician telling me how to do a chemical analysis," and the physician may in turn reply, "I won't tolerate some chemist telling me about medicine." It can be an unfortunate encounter for all concerned. A very large portion of a clinical chemist's job responsibility is spent with service. A real danger exists when the clinical chemist becomes a supertechnician at the expense of research and teaching. For the well
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being of the individual this should not occur. Still another problem exists between the clinical chemist and the academic analytical chem ist. The analytical chemist fre quently criticizes the clinical chem ist's work as "an old application of an analytical principle and lacking in originality and sophistication." The work of the analytical chemist is frequently criticized by the clini cal chemist as "too expensive or not relevant to today's problems. It is lacking in recovery experiments, in interference studies, and in com parison of results to the existing method on fresh human specimens." With skyrocketing health costs, it is logical to direct more attention to the biochemistry of human dis ease. If more fundamental human biochemistry is elucidated (4) us ing solid analytical chemistry, then steps toward disease prevention and earlier detection should alleviate some of the financial pressure now on health care. The blending of analytical chemistry and human biochemistry can make an increas ingly important contribution to health care. Analytical chemistry must con tinue to distinguish itself by main taining high quality. Excellent analytical chemistry needs to be practiced daily in clinical chemistry laboratories. Frequently, however, high analytical quality in the mea surements are lacking throughout the laboratory. Solid analytical chemistry training for all clinical chemists can help improve the qual ity in the field of clinical chemistry. In summary, one strongly agrees with Mcinkc (S) that "analytical chemistry is not a fading discipline" and with Siggia (β) that "when we as analytical chemists take pride in the quality of our work, we as indi viduals or we as a field cannot be demeaned."
A Compact FID is Available From C O W - M A C
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