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Outside the Lab Biochemistry and molecular biology, Profession, Training and education

Overcoming the Silos of Indian Medicine

When I began my pursuit of medicine in 2003, there was a clear hierarchy in my options. Most students wanted to become physicians or surgeons – the so-called “clinical” fields. Least popular was the trifecta of clinical laboratory medicine: biochemistry, pathology, and microbiology. These were considered to be “leftovers” or “paraclinical” fields, chosen only by those whose performance did not earn them a coveted spot in “clinical medicine.”

From childhood, I had loved solving jigsaw puzzles. The search for the missing pieces and the slow discovery of the full picture excited my curiosity – but as I grew up and made career plans, it seemed to me that I had to abandon that childhood pleasure. Medicine was a serious profession. Surely there was no place in it for the joy of a jigsaw puzzle – or was there?

The first Great Divide
Where did this gulf between “clinical” and “paraclinical” medicine in India arise? Although my peers and I perpetuated it, we didn’t create it. Rather, we fell into stereotypes gleaned from the archaic system of medical education in our country.

India’s current approach to medical education was borrowed from the British system of modern allopathic medicine nearly a century ago. Pathology, biochemistry, and microbiology are taught in the first two years of medical school – and never revisited after graduation. Unfortunately, this leads many students to believe those disciplines are purely academic and have little scope for practice or clinical relevance.

In my opinion, every undergraduate medical program should revisit pathology and laboratory medicine each time a new condition is discussed.

I myself was among the medical students caught in that belief. Fortunately, my preparations for the postgraduate entrance exam offered a wonderful opportunity to look back at the basics of all areas of medicine – including the laboratory. Rather than skim these areas for the sake of a passing grade, I dove deep into biochemistry, microbiology, and pathology; I found that they were not “paraclinical” at all. Every aspect of those disciplines feeds into clinical decisions about more than two-thirds of all patients! This realization allowed me to ignore tradition and fall in love with the lab.

But why did I have to rediscover these fields myself? Why didn’t they feature throughout my education? In my opinion, every undergraduate medical program should revisit pathology and laboratory medicine each time a new condition is discussed. After all, few of these conditions can be diagnosed without the aid of the laboratory!

The second Great Divide 
Ultimately, I chose to pursue clinical biochemistry. My three years of postgraduate training were overseen by supportive teachers who coached and guided me through the curriculum. But as a student of medicine, I was surprised – and dismayed – to discover that laboratory medicine education is academically oriented, rather than skills-based. When I entered the real world of clinical laboratory medicine, I discovered that I had not been taught the skills I needed. Of course, my teachers are not to blame for this; most medical colleges don’t offer exposure to clinical laboratory culture. We are not “just” clinical biochemists; we are leaders, human resource managers, financial consultants, IT coordinators, teachers, innovators, communicators, and creators!

All of this is what leads us to the second Great Divide. Every doctor who successfully graduates from a biochemistry, pathology, or microbiology program must now ask the question: who am I? 

In my professional life, this question pulled me into a whirlpool of confusing thoughts. Is clinical biochemistry an academic or a clinical profession? Why is there compartmentalization between the three areas of clinical laboratory medicine? Is the concept of integrated laboratory medicine a reality – and, if so, where?

The jigsaw of integrated lab medicine
Traditionally, the clinical biochemist’s role was focused on the research, development, and production of methods – including instruments and reagents that are now closed boxes (1). This evolution has led some physicians to believe that, if machines and technologists can do the work and generate results, clinical biochemists are superfluous. Although clinical biochemists actually play a much more significant role, we need to make even greater changes to our profession if we are to survive. In my opinion, we must become consultants to the physicians. We must show our worth through value-added services. I envision a relationship in which the clinician presents a diagnostic problem to the clinical biochemists (“What type of hepatitis does the patient have?” “Does the patient have hyperthyroidism?”), rather than just ordering a set of laboratory tests.

    A clinical biochemist should have:

    • the ability to adapt to ever-changing technology
    • the ability to deal with objective, quantitative information
    • the skill to define and solve problems at the interface between the medical and administrative domains

    Physicians ideally seek help from a single source who can transcend the boundaries that traditionally divide the clinical laboratory. If clinical biochemists want to be that source, we must also learn more about clinical medicine (to understand how physicians think) and expand our knowledge of the other branches of laboratory medicine so that we can provide broad input. Diseases, after all, are not categorized by laboratory subdiscipline.

    From Sanger to Sherlock
    Buddha famously said, “When a student is ready, a master will appear.” My intense search for a master led me through seven long years of discrimination, depression, and difficulty – but, in 2014, I finally found the mentor I had sought. Both of us were eccentric, out-of-the-box thinkers, and both of us shared a passion for laboratory integration. His favorite saying was, “Each laboratory specimen is a patient.” That drop of blood or scrap of tissue represents an entire life – and one whose treatment and outcomes depend on a laboratory diagnosis.

    Arriving at a laboratory diagnosis is like solving a jigsaw.

    Arriving at a laboratory diagnosis is like solving a jigsaw with pieces of evidence from each division of the clinical laboratory. The puzzle cannot be solved without all of the pieces – which can only be obtained through the integration of lab medicine. It seems there is a place in medicine for the jigsaw puzzle after all!

    Frederick Sanger belonged to an extraordinary league of scientists (two Nobel Prizes!), but today’s laboratory medicine – and the clinical jigsaw puzzles found within – require people who share more in common with Sherlock Holmes than with Sanger.

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    1. “The future of clinical chemistry and its role in healthcare: a report of the Athena Society”, Clin Chem, 42, 96 (1996). PMID: 8565242.
    About the Author
    Satish Ramanathan

    Division Head of Clinical Biochemistry, Serology, Hematology, and Clinical Pathology; Deputy Division Head of Transplantation Immunology and Molecular Diagnostics; and Deputy Quality Manager of Laboratory Medicine at MIOT International, Chennai, India.

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