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A Pathologist's Perspective The Doctorate in Clinical Laboratory Sciences: The Time Has Come by Larry H. Bernstein, MD

At the March 1 Stakeholder meeting, the purpose was to present a draft proposal for a Doctorate in Clinical Laboratory Sciences (DCLS). Key issues needing full discussion, although not necessarily resolved in the meeting were: 1) the broad scope of the responsibilities of such a graduate; 2) clear differentiation from the narrow scope of the traditional PhD candidate, and 3) financial support for the professional (clinical) services position outlined. The scope of activities envisioned might vary in postdoctoral settings depending on specific requirements for the individual and the fit to organizations need. Despite the fact that PhD professionals in clinical chemistry or in microbiology may be fully engaged with problems in technical troubleshooting and in a busy consultation schedule, there is little question of how a DCLS would fit into the scheme of things. Organizations have actually been phasing out the positions for some time, and postdoctoral programs in both chemistry and microbiology have traditionally included a clinical orientation that is not part of a traditional PhD programs. This perhaps raises questions about the amount of time needed to complete the DCLS when combined with a PhD degree. However, the main purpose of NAACLS would be to define standards for a clinical profession. I am not interested in dwelling on these concerns here, but observe that the DCLS candidate would be able to integrate clinical and laboratory information much in the way a graduate of a medical institution is expected to perform in postgraduate practice, which distinguishes purely research-based from purely clinical skill-building. The DCLS will create a unique professional who will blend special integrative and research skills who will be qualified to guide the laboratory as a potential OUTCOMES-ENGINE for the organization. The discussion of activities tied to this position is related to how the activities are reimbursed, the topic on which I focus here. There is a potential for misunderstanding that is based on a perception of erosion of the contribution of the pathologist. That role is defined as the Director of the Laboratory under CLIA'88. Payments for clinical pathology services rendered by pathologists are for services in general and not related to a specific patient specimen. This is based on the CLIA defined oversight of laboratory, supervising laboratory personnel, reviewing abnormal results, discussing with clinicians which is paid to hospitals by Medicare. Hospitals are supposed to pay "reasonable compensation" to pathologists. The professional component assumes billing a component of patient costs in prospective payment for each clinical pathology test/procedure performed based on the pathologist's oversight of the laboratory (regardless of whether the pathologist performs or reviews the test). If we examine this further, the current reality identifies new opportunities and a synergistic relationship between the DCLS and the pathologist. Medicare policies and hospital choice increasingly restrict the scope of pathologist services that are payable under the rules applicable to physician services. One could ask whether the Medicare provision would continue to compensate the Part A Clinical Pathology as a professional component if it could be identified that a declining portion of a pathologist's time is engaged in Part A Medicare activities. This would also have an effect on other third-parties. Recent changes applying relative value scales has provided an opportunity for national standard-ization of pathology codes, and has permitted the introduction of clinical pathology interpretations as compensable physician services. However, the pressure to support the practice through a basic level of surgical pathology practice has eroded the availability of the pathologist for other activities, including Part A Clinical Pathology and Part B billable Clinical Pathology interpretations. Hospital administrations have responded to external pressures by trying to shorten hospital days and increasing admission rates under prospective reimbursement. They have had to meet operating budgets by working with tighter staffing provisions, and even by bundling of middle managers (radiology or pharmacy and laboratory), and by going to a core laboratory concept. This has had a direct impact on availability of positions for PhD clinical microbiologists and clinical chemists, as well as for supervisors. The solution is a new model for laboratory leadership that incorporates the DCLS. The DCLS is well positioned to be the either the Associate Director of Laboratories for Clinical Pathology under the Pathology Chair (just as there might be an Associate Director of AP). The DCLS would oversee the CP quality plan, and would integrate the system and information technology plan for the laboratory. The reimbursement would flow through the Part A payments for services not involving direct patient services. The DCLS would also do the reports for Part B Clinical Pathology that require interpretation, and the reports would be billable under the Chairman of Pathology. The model is workable, and it will lead to high performance and best outcomes. In the current environment the Part A responsibilities may be substantially neglected because there is no incentive for the pathologist's role. The Part B billable portion may likewise be neglected, which leads to no professional reimbursement - the work is most likely sent out. The DCLS could forge strong ties to the Medical Staff, and increase the opportunity for outside laboratory work. Pathology has three faces. The traditional department of pathology is a lineal descendent of an experimental tradition traced to John Hunter, Carl Freiherr von Rokitansky, Rudolph Virchow, and George H. Whipple. Surgical pathology and billable services have accompanied the success and support for modern surgery. Clinical pathology has emerged with improvements in clinical laboratory sciences and expanding use of diagnostic tests. This has changed the landscape of clinical laboratory science. The science has been divided over time and must be reintegrated in order to serve the primary goals of the health-care organization. The DCLS model being proposed makes everyone a winner.

Top of the News
			A Clinical Doctorate for the Laboratory
			Process and Outcomes of the NAACLS Graduate Task Force
			The Concept of the Clinical Doctorate in Clinical Laboratory Science: Role, Responsibilities and Education
Features
			A Pathologist's Perspective The Doctorate in Clinical Laboratory Sciences: The Time Has Come by Larry H. Bernstein, MD
			A Pathologist's Perspective The Clinical Doctorate: A Boon to Pathologists by Linda B. Piller, MD, MPH
			Evaluation of Participant Reactions to Stakeholder Meeting
Other News
			Background to Development of the Clinical Doctorate Initiative
			FAQs
			Next Steps in Development of Standards
			Planning for the March 1, 2006 Stakeholder Meeting
			Process Employed at the March 1, 2006 Stakeholder Meeting

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