Scand. J. din. Lab. Invest. 35, 1-3, 1975
EDITORIAL
Scand J Clin Lab Invest Downloaded from informahealthcare.com by Osaka University on 12/01/14 For personal use only.
Clinical Chemistry - Quo Vadis? A first golden age for the introduction of chemical methods in the medical field occurred in the first part of the 19th century at various European universities and hospitals. It was recognized that disease was a result of abnormal physiological, biochemical, and anatomical processes and that chemical determinations of various kinds might be of great importance diagnostically. Chemical methods were used first of all on urine, and many new tests, now bearing the names of their discoverers, were proved to be useful in clinical work. Names like Gmelin, Schlesinger, and Gunzburg are still familiar to clinical chemists of today, many having performed their tests frequently on urine, gastric fluid, and so forth. A second golden age for the application of chemical methods in medicine occurred about 1910, with the introduction of venous puncture for obtaining blood for chemical analyses. During the first decades of this century, methods were published for determining urea, creatininium, protein, uric acid, cholesterol, glucose, oxygen, carbon dioxide, and so forth in blood and plasma, and methods named after Folin, Ciocalteau, Liebermann and Burchard, and van den Bergh are still in daily use in clinical laboratories. Many of the methods were based on the principle of colorimetry, which had come into general use in chemistry after Duboscq’s introduction of the visual colorimeter in 1854. The variable quality of the chemical methods inherited from the previous century and the fruitful growth from the beginning of this century were evaluated in the twenties by the man whom clinical chemistry today looks on as its founder, Donald D. Van Slyke, whose book Quantitative Clinical Chemistry was published in 1932 with Peters as co-editor. This book accelerated the introduction of chemical methods in hospitals, which again led to the establishment of clinical chemistry as a special field to take care of the theoretical, technical and organizing aspects, which were related to the economical expediency and quality guarantee of having a centralized laboratory service within each hospital. The new departments improved considerably the clinical laboratory service through practical reforms of various kinds, by improving the quality of analytical results, and by increasing the variety of analyses offered. This resulted in a continuous and steep increase in the number of specimens received, which necessitated strengthening of the internal organization of the laboratories, simplification and standardization of analytical procedures, and use of computers. Today the clinical chemists might seem to be at the height of their importance, ruling over well-manned castles with enormous gun power in the form of a great variety of chemical methods and an abundance of modern equipment of numerous kinds. Out1
- Scand. J. d i n . Lab.
Invest
Scand J Clin Lab Invest Downloaded from informahealthcare.com by Osaka University on 12/01/14 For personal use only.
2
Editorial
side observers might therefore come to the conclusion that a third golden age of the application of chemical methods in medicine is occurring right now. This is obviously true in the sense that never before have so many chemical tests been available and performed for diagnosing diseases and controlling treatment. But is it true also for clinical chemistry as a clinical specialty and an academic discipline? The departments of clinical chemistry have borne the stamp of increasing complexity of equipment during the last one or two decades, mainly to cope with increasing amounts of specimens, demands for fast delivery of results, and a relative shortage of medical technologists. This increased complexity might open the way for technocracy, which may be unfortunate in itself. It might also, as a consequence of the inflexibility of a large internal organization due to the huge amount and variety of specimens, create a tendency t o methodological conservatism, characterized by hesitation in changing chemical procedures and analytical programs, changes that may be necessary t o guarantee the proper production and distribution of the results of the day. The clinicians’ well-known marked preference for old tests rather than new ones will generally add to a tendency towards methodological conservatism. To this has to be added that the use of automation and computers has not generally renewed the chemical methods; actually some disimprovements have even had to be accepted here and there. Therefore, despite methodological progress in some areas, it is questionable to talk about a new golden age for the departments of clinical chemistry in the sense that they have achieved new fundamental biological and medical knowledge to an essential degree, at least in comparison t o the golden ages during the 19th and early 20th centuries. Another feature has occurred in many places: medically trained people seem to be less interested in choosing clinical chemistry as a career discipline, at least in Scandinavia, proibably due to the increasing technical complexity of the machinery and their own decreasing participation in the clinical interpretation of results; this again is partly caused by the heavy workload in the laboratories, which leaves too little time for proper communication with the clinicians. Chemists, electronic engineers, and other nonmedically trained people now take more responsibility for the daily production of results, and for many of the hospital personnel the discipline has become synonymous with centralized laboratory service. Today the medically trained staff in the departments feels hesitant t o take time from their research work to learn to master adequately the complexity of the routine techniques, It has to be emphasized that in medical research chemical methods are used in many departments other than those of clinical chemistry, and the young physician motivated for research chooses his department more for its reputation for ideas and results than for the quality of the research tools themselves. Were the latter the case, physicians would crowd to departments of clinical chemistry, since they are the laboratories with indisputable expertise concerning chemical methods.
Scand J Clin Lab Invest Downloaded from informahealthcare.com by Osaka University on 12/01/14 For personal use only.
Editorial
3
The existence of some clinical chemical departments with a good reputation for professional skill and medical research should not moderate the endeavors of the discipline for new creativity. The ingenuity demonstrated by many clinical chemists in mastering the overwhelming routine workload should now be aimed more at the application in laboratory medicine of new discoveries in the basic sciences, leading to new biological and medical approaches of clinical significance. And to make the profession more attractive to medically trained people, the relation of the clinical chemical departments to patients should not be restricted just to the specimens. An open-minded cooperation between the laboratories and the clinical departments for studying, diagnosing, and treating diseases should be encouraged, and it should not be unfamiliar to the laboratories themselves to participate more in the therapeutic process and the control of patients with diseases inside fields in which the laboratory has the ability to advise owing to professional experience or special research activities. Also outside the hospitals should collaboration be encouraged between clinical chemistry and fields where interpretation is needed - for example, general practice and industrial toxicology. It is the responsibility of the present heads of clinical chemistry departments to make them attractive to the gifted chemist as well as the gifted physician devoted to research and professional skill. Without this attractiveness the future development and flourishing of the discipline cannot be assured.
Poul Astrup Dept. of Clinical Chemistry Rigshospitalet DK-2100 Copenhagen Denmark
EDITORIAL
Scand J Clin Lab Invest Downloaded from informahealthcare.com by Osaka University on 12/01/14 For personal use only.
Clinical Chemistry - Quo Vadis? A first golden age for the introduction of chemical methods in the medical field occurred in the first part of the 19th century at various European universities and hospitals. It was recognized that disease was a result of abnormal physiological, biochemical, and anatomical processes and that chemical determinations of various kinds might be of great importance diagnostically. Chemical methods were used first of all on urine, and many new tests, now bearing the names of their discoverers, were proved to be useful in clinical work. Names like Gmelin, Schlesinger, and Gunzburg are still familiar to clinical chemists of today, many having performed their tests frequently on urine, gastric fluid, and so forth. A second golden age for the application of chemical methods in medicine occurred about 1910, with the introduction of venous puncture for obtaining blood for chemical analyses. During the first decades of this century, methods were published for determining urea, creatininium, protein, uric acid, cholesterol, glucose, oxygen, carbon dioxide, and so forth in blood and plasma, and methods named after Folin, Ciocalteau, Liebermann and Burchard, and van den Bergh are still in daily use in clinical laboratories. Many of the methods were based on the principle of colorimetry, which had come into general use in chemistry after Duboscq’s introduction of the visual colorimeter in 1854. The variable quality of the chemical methods inherited from the previous century and the fruitful growth from the beginning of this century were evaluated in the twenties by the man whom clinical chemistry today looks on as its founder, Donald D. Van Slyke, whose book Quantitative Clinical Chemistry was published in 1932 with Peters as co-editor. This book accelerated the introduction of chemical methods in hospitals, which again led to the establishment of clinical chemistry as a special field to take care of the theoretical, technical and organizing aspects, which were related to the economical expediency and quality guarantee of having a centralized laboratory service within each hospital. The new departments improved considerably the clinical laboratory service through practical reforms of various kinds, by improving the quality of analytical results, and by increasing the variety of analyses offered. This resulted in a continuous and steep increase in the number of specimens received, which necessitated strengthening of the internal organization of the laboratories, simplification and standardization of analytical procedures, and use of computers. Today the clinical chemists might seem to be at the height of their importance, ruling over well-manned castles with enormous gun power in the form of a great variety of chemical methods and an abundance of modern equipment of numerous kinds. Out1
- Scand. J. d i n . Lab.
Invest
Scand J Clin Lab Invest Downloaded from informahealthcare.com by Osaka University on 12/01/14 For personal use only.
2
Editorial
side observers might therefore come to the conclusion that a third golden age of the application of chemical methods in medicine is occurring right now. This is obviously true in the sense that never before have so many chemical tests been available and performed for diagnosing diseases and controlling treatment. But is it true also for clinical chemistry as a clinical specialty and an academic discipline? The departments of clinical chemistry have borne the stamp of increasing complexity of equipment during the last one or two decades, mainly to cope with increasing amounts of specimens, demands for fast delivery of results, and a relative shortage of medical technologists. This increased complexity might open the way for technocracy, which may be unfortunate in itself. It might also, as a consequence of the inflexibility of a large internal organization due to the huge amount and variety of specimens, create a tendency t o methodological conservatism, characterized by hesitation in changing chemical procedures and analytical programs, changes that may be necessary t o guarantee the proper production and distribution of the results of the day. The clinicians’ well-known marked preference for old tests rather than new ones will generally add to a tendency towards methodological conservatism. To this has to be added that the use of automation and computers has not generally renewed the chemical methods; actually some disimprovements have even had to be accepted here and there. Therefore, despite methodological progress in some areas, it is questionable to talk about a new golden age for the departments of clinical chemistry in the sense that they have achieved new fundamental biological and medical knowledge to an essential degree, at least in comparison t o the golden ages during the 19th and early 20th centuries. Another feature has occurred in many places: medically trained people seem to be less interested in choosing clinical chemistry as a career discipline, at least in Scandinavia, proibably due to the increasing technical complexity of the machinery and their own decreasing participation in the clinical interpretation of results; this again is partly caused by the heavy workload in the laboratories, which leaves too little time for proper communication with the clinicians. Chemists, electronic engineers, and other nonmedically trained people now take more responsibility for the daily production of results, and for many of the hospital personnel the discipline has become synonymous with centralized laboratory service. Today the medically trained staff in the departments feels hesitant t o take time from their research work to learn to master adequately the complexity of the routine techniques, It has to be emphasized that in medical research chemical methods are used in many departments other than those of clinical chemistry, and the young physician motivated for research chooses his department more for its reputation for ideas and results than for the quality of the research tools themselves. Were the latter the case, physicians would crowd to departments of clinical chemistry, since they are the laboratories with indisputable expertise concerning chemical methods.
Scand J Clin Lab Invest Downloaded from informahealthcare.com by Osaka University on 12/01/14 For personal use only.
Editorial
3
The existence of some clinical chemical departments with a good reputation for professional skill and medical research should not moderate the endeavors of the discipline for new creativity. The ingenuity demonstrated by many clinical chemists in mastering the overwhelming routine workload should now be aimed more at the application in laboratory medicine of new discoveries in the basic sciences, leading to new biological and medical approaches of clinical significance. And to make the profession more attractive to medically trained people, the relation of the clinical chemical departments to patients should not be restricted just to the specimens. An open-minded cooperation between the laboratories and the clinical departments for studying, diagnosing, and treating diseases should be encouraged, and it should not be unfamiliar to the laboratories themselves to participate more in the therapeutic process and the control of patients with diseases inside fields in which the laboratory has the ability to advise owing to professional experience or special research activities. Also outside the hospitals should collaboration be encouraged between clinical chemistry and fields where interpretation is needed - for example, general practice and industrial toxicology. It is the responsibility of the present heads of clinical chemistry departments to make them attractive to the gifted chemist as well as the gifted physician devoted to research and professional skill. Without this attractiveness the future development and flourishing of the discipline cannot be assured.
Poul Astrup Dept. of Clinical Chemistry Rigshospitalet DK-2100 Copenhagen Denmark
