Clinical Chemistry: a Professional Field for Physicians and Natural Scientists in Europe1)

Büttner: ClinicaJ chemistry äs profession

Clinical Chemistry: A Professional Field for Physicians and Natural Scientists in Europe1)

By 7. Büttner Institut für Klinische Chemie I im Zentrum Laboratoriumsmedizin, Medizinische Hochschule, Hannover, FRG

(Received September 8, 1990)

Summary: A detailed analysis of the profession of clinical chemistry reveals the following facts. 1. Clinical chemistry is definitely an interdisciplinary subject between natural science and medicine. The major part of clinical chemistry is natural science and therefore theoretical science. To a lesser extent, however, clinical chemistry is practical science or "action science" which is aimed at a certain action. 2. The question "Is clinical chemistry a Professional field for physicians, for scientists or for both?" can be answered with the Statement: It follows from its historical development and its characteristic theory and practice, and is de facto true throughout the world, that clinical chemistry is a Professional field for physicians and natural scientists. 3. The broad scope of the technical field and the challenges to be expected in future within the framework of the European Community will require the recruiting aspiring clinical chemists both from medicine and from the natural sciences. 4. Qualified postgraduate training is more important than the nature of the initial study course. 5. Apart from providing special knowledge and particular abilities, postgraduate training must make the younger generation familiär with the ways of thought of the physician and of the natural scientist. 6. Successful work äs a clinical chemist requires "extra-functional" qualifications, such äs the ability to conduct dialogüe and teamwork with the clinician. 7. The national differences which exist in the definition of the Professional pattern "clinical chemist" are a hindrance to the future development of the discipline in the European Community. The starting point for recognition of the profession must be an agreed definition among the Professionals of the countries of the European Community of the Professional field of the clinical chemist.

"If I am not both a chemist and a physician, thenl am nothing; have considerable national differences. Such differ- but the difficulty of my existerice is in that combination" ences are found to a particular degree in the profes- J. W. L. r/iitt/fc/iMw(1869)(lv ) siona. l, area ofr clinicar · il chemistryu · <. . In some ofr, thue countries, clinical chemistry is definitely a medical subject ro uc on whereas in other countries the natural science content The European market and the unification of the Fed- of the discipline is emphasized. Adaptations will be eral Republic of Germany with the German Demo- cratic Republic will make it necessary to adapt and ~~. . - . . _, . 1 ,.. ) Based on a lecture at the Conierence "Clinical chemistry and harmomze m rnany areas. This also applies to the the European internal market 1992", Bonn, 5.-7. 7. 199(X Professional fields of the scientific disciplines which of the Deutsche Gesellschaft für Klinische Chemie

Eur. J. Clin. Chem. Clin. Biochem. / Vol. 29,1991 / No. l Büttner: Clinical chemistry äs profession necessary in the course of the current and forthcoming medicine, at first under various names such äs "path- political changes, and for this reason we are con- ological chemistry", "clinical chemistry" or "chemical fronted with the question: Is clinical chemistry a pro- pathology". It is important to note that the new fessionalßeld for physicians.for scientisis orfor both? discipline did not arise by the Splitting or specializa- tion of "mother subject", äs is the rule in scientific This question cannot be answered on the basis of development. On the contrary, clijijcal chemistry was superficial political, sociopolitical or economic argu- formed by a fusion of several disciplines äs a well- ments. Nor should local aspects give rise to hasty ad- defined interdisciplinary subject in the field of inter- hoc decisions. On the contrary, the problem requires action between medicine and chemistry. Characteristic deep and thorough analysis, taking into account the differences arose in the individual countries, depend- peculiarities of the subject "clinical chemistry". The ing on which "mother subjects" predominated in the question touches the very concept of clinical chemis- development. Thus, in German-speaking countries the try. Other interdisciplinary subjects, for example med- influence of internal medicine was very important, ical physics, genetics or molecular biology, find them- whereas in Anglosaxon countries pathology was of selves in a similar Situation, being located in the field greater impact. In the 20th Century, in the U.S. A., of interaction between medicine and the natural sci- "clinical biochemistry" (4) develpped with a very pro- ences. nounced orientation towards natural sciences. Finally, in France, pharmacy had and still has the inajor Before answering the question, various aspects of the influence. subject of clinical chemistry will be considered with the aim of deriving from them arguments for a ra- tional solution of the problem. It should be pointed The Professional Field of Modern Clinical Chemistry out that the term "clinical chemist" in the following (5-8) observations always includes both sexes. To define the Professional field of present-day cliliical chemistry, a brief answer will first be given to the questions: "What is clinical chemistry?", "How does History of the Subject of Clinical Chemistry clinical chemistry operate?", "Where does clinical Clinical chemistry has been a separate Professional chemistry take place?". Finally, the question "What field since about 1840, i.e. for about 150 years. De- Professional qualifications are necessary for the clin- tailed studies of the historical development of clinical ical chemist?" will be discussed, being of special in- chemistry, which have been published in recent years terest in the present context. From these various fa- (2, 3), show that its roots lie in chemistry, materia cets, the "professional field qualification" or the "per- medica, pathology and clinical medicine (fig. 1). The sonnel profile" of the clinical chemist can then be new subject originated with the Start of "scientific" derived.

Before 1800 1800 1840 1880 20th Century

Chemistry Animal of the 3 reigns chemistry^

Clinical chemistry Pathological chemistry Clinical biochemistry Clinical chemistry Biologie clinique Materia Chemical pathology medica Clinical pathology

medicine

Fig. 1. Development of clinical chemistry äs a discipline in the 19th Century - f

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In our time, various definitions have been proposed tive determinations of substances in biological mate- for "clinical chemistry" and we shall pick out one rials. The extreme complexity of biological materials, here which has to some extent assumed an official whether body fluids, cells, tissues or other materials, character. It is the proposal made by Manuel C. Sanz requires the use of numerous analytical techniques & Per Lous for the International Föderation of Clin- which are based on chemical, physical, molecular bio- ical Chemistry (IFCC) (9): logical, immunological or biological principles. Thus, "Clinical chemistry encompasses the study ofthe chem- in addition to the classical methods of chemical and ical aspects of human life in Health and illness and the biochemical analysis, and depending on the analytical application of chemical laboratory methods to diagno- problem in question, automated analyses involving sis, control of treatment and prevention ofdisease". complicated Instruments are being increasingly used. In view of the complexity of the analysed material, The first part of this defmition indicates the interdis- high-resolution Separation methods, such äs HPLC ciplinary nature of the subject and can only be inter- are indispensable. Inadequate analytical specificity preted in the sense that the "study of the chemical and sensitivity of many classical methods of analytical aspects of life in health and illness" must be carried chemistry has led to the use of enzymatic and im- out jointly with clinical medicine. munochemical methods. Finally, DNA analysis offers new possibilities and new horizons. It follows from the defmition that the subject clinical chemistry itself covers various areas which are sum- The procedural protocol of clinical chemistry differs marized in table l. The first area covers the important according to the objective. The "centralized analytical task of clinical chemistry in health care. For this, Poul activity" includes all Steps shown in abbreviated form Astrup coined the term "centralized analytical activ- in table 2. In research, the initial emphasis lay in the ity" (10) which points to the centralized hospital lab- investigation of body fluids to find disease indicators. oratory (11). Research in clinical chemistry includes Today the aims have changed, and the pathogenesis subject-oriented parts, such äs methodology and the of disease is now investigated with cytobiologically development of new clinical chemical tests; on the oriented methods, utilizing the fmdings of modern other band, research on biochemical aspects ofdisease molecular biology. is part of basic medical research. It cannot be the domain of clinical chemistry alone and should be a Tab. 2. Correct clinical chemical investigation substantial part of basic research in many clinical Preanalytical phase disciplines (12). choice of the quantity to be measured preparation of the patient for the examination obtaining patient material for the examination Tab. 1. Areas of clinical chemistry Analytical phase "Centralized analytical activity" choice of the method — Investigations of patient material with analytical chemical carrying out the analysis methods for diagnosis, therapy control and prevention of disease. Post-analytical phase analytical evaluation of the result — Organization, management and operational control of centralized laboratories. medical evaluation of the result Interpretation, consultation with t he clinician Research - "Study of the methqd": Analytics As a consequence of these activities clinical chemistry — "Study of the phenomena": related to the clinical use of is conducted not only in laboratories of primary quantities ("functional aspects"). Thepry of clinical chemical tests. health care; it can also be an essential activity of research institutions and industrial laboratories — Research on biochemical aspects of diseases (pathobiochemistry (äs part of basic medical research)). (tab. 3). Tab. 3. Where does clinical chemistry take place? Teaching, ineluding further training and postgraduale study University Institutes, teaching hospitals Hospitals It is not possible to deal in detail here with method- Laboratories of out-patient care Research Institutes ology. This applies in particular to that area of re- Industrial laboratories search, where new techniques are applied. Basically, diagnostica and diagnostics equipment manufacturers clinical chemistry will always be analytical chemistry pharmaceutical industry research & development, application laboratories with the aim of carrying out qualitative or quantita-

Eur. J. Clin. Chem. Clin. Biochem. / Vol. 29,1991 / No. l Büttner: Clinical cheraistry äs profession

Clinical Chemistry from the Viewpoint of Theory of How does clinical chemistry fit into this scheine? There is not doubt that the major part of clinical Science chemistry is natural science, i. e. theoretical science, From the outset, clinical chemistry was an interdis- since its analytical methods and pathobiochemistry ciplinary subject between medicine and natural sci- belong to this category. To a lesser extent, however, ences. What is the difference between medicine and clinical chemistry is practical seiende. This is at least natural sciences? This question requires a short ex- partly true in the assessment and Interpretation of cursion into the theory of science. In a remarkable laboratory Undings. Thes.e are always Singular State- book (13), the American medicine theoretician Alvan ments related to a unique pätient, even when they are R. Feinstem wrote about "two cultures", "art" and based on the theories and results of theoretical science. "science", which, in medicine, exist alongside each Accordingly actions should follow from the findings. other. According to this author, "art" in medicine This is clearly shown by examples such äs coagulätion denotes the skilled practicing of the clinician and tests or therapeutic drug monitoring. In both cases, "science" the scientific research of the clinician. The the laboratory finding determines the subsequent ther- idea of the "two cultures" goes back to the English apy for a specific pätient. In conclusion, clinical chem- writer and physicist Charles Percy Snow, who de- istry is not only a theoretical science, since it also scribed the gap between the areas of the natural contains a small büt not insignificant proportion of sciences and the liberal arts or humanities (14). Fein- practical science. In contrast, basic medical disciplines stem (13) sees a similar contrast between "art" and like anatomy, physiology, biochemistry äs well äs "science" in medicine. pathobiochemistry, seem to be exclusively theoretical This contrast is also discussed in the modern theory sciences in the sense of our definitions. It is this of science (15). Thus, a distinction is made between peculiarity which gives clinical chemistry its bridging "theoretical sciences" and "practical sciences". The- function between natural sciences and clinical medi- oretical sciences are aimed at obtaining knowledge, cine. whereas practical sciences are aimed at performing actions. The natural sciences are for example described äs theoretical sciences. They explain very The Profession of the Clinicäl Chemist clearly the nature of thought in theoretical sciences: In the above remarks clinical chemistry has been The "natural scientific method" consists in setting up considered mainly äs scientific discipline. However, in theories on the basis of data obtained by observation the present discussion, it is just äs important to con- and experiment. Frequently, the theories postulated sider clinical chemistry äs a profession. In the sqcio- serve to clarify causal relationships. In contrast, clin- logical theory -of professions a distinction is made ical medicine is described äs a practical science or between the positions of the professions in accordance "action science" which is aimed at a certain action with the degree of their professionalization. A pro- (l 6). As a practical science, clinical medicine certainly fession is distinguished by an Obligation to the society utilizes the results of theoretical sciences, including and by a systematized and specialized knowledge. A medical disciplines. The essential differences of theo- classical description of the profession was given by retical and practical sciences are summarized in Carr-Saunders & Wilson (17): table 4. Tab. 4. Theoretical and practical science "The practitioners [of a profession], by virtue of pro- longed and specialized intellectual training, have ac^ Theoretical science Practical science quired a technique which enables them to render a science "art" specialized Service to the Community. This Service they Objecüves knowledge actions perform for a fixed remuneration whether by way of generally valid State- Singular Statements fee or salary. They develop a sense of responsibility for ments the technique which they manifest in their concern for Modes of investigations, ex- decisions at present Operation periments, postu- on the basis of data the competence and honour of the practitioners äs a lation of theories from theoretical sei- whole — a concern which is sometimes shäred with the ences state. They buildup associations, upon which they erect, Requires in intelligence, reason- judgement, experience particular ing with or without the co-operation ofthe state, observance of certain Standards of conduct. Material considera- Typical radicalness in ques- search for reasonable tioning and compromise tions of income and Status are not neglected, but the method distinguishing and overruling characteristic is the pos- Examples way of thought of way of thought of the session of a technique. It is the existence of specialized the scientist physician intellectual techniques, acquired, äs the result of pro-

Eur. J. Cliti. Chem. Clin. Biochem. / Vol. 29,1991 / No. l Büttner: Clinical chemistry äs profession

longed training, which gives rise to professionalism and detailed analysis shows that these are predominantly accountsfor its preculiar features". those countries having a public health System. In contrast there are about 29% ofthe countries in which In table 5 criteria indicative of a profession are sum- the demands are met "indirectly", i. e. through pro- marized (18, 19). Nearly all these criteria are fulfilled fessional selfgoverning bodies or social insurance Sys- for the profession of the clinical chemist. To this tems (22). extent, this profession does not differ in nature from that of a physician or a lawyer. The question of In Germany the Situation is presently very compli- interest for our subject is how the professions develop, cated. In the Federal Republic there is no law gov- and how the Professional requirements for their mem- erning the profession of the clinical chemist (23, 24) bers, i. e. the "Professionals", are established. This can whereas clinical chemists in the German Democratic be done within scientific societies or Professional or- Republic are accredited by the government. In several ganizations, but also by legal defmition by the legis- European countries (Bulgaria, Czechoslovakia, Aus- lator. In this connection, the sociologist Hansjürgen tria, Hungary) the position of a director of the hos- Daheim remarks (20): "The legalßxing ofthe require- pital laboratory is reserved for physicians (25). ments has in most cases nothing to do with the performance but no doubt resultsfrom the relationship of the position to the central values ofthe society or from Professional Qualification the power held by the organized holders of this Posi- One of the most important questions with regard to tion". clinical chemistry is the Professional qualification. Tab. 5. Criteria for a professionalized career position This is the qualification which anybody wishing to be successfully active äs clinical chemist must have. — Specialized and systemized knowledge — Abilities based on theoretical knowledge This is not an easy question to answer because clinical — Acquisition of abilities by training and practice — Competence must be verified by an examination chemistry is an interdisciplinary subject of consider- — The profession is organized able scope and in addition, äs we have seen, various scientific society or modes of thinking are used alongside other within the Professional organization discipline. To take up an old proverb, a qualified — Service ideal — Validity of a special "code of ethics" profession requires training of mind, heart and hand, — Standard tariffs for payment i. e. cognitive knowledge, an emotional attitude in line with the profession and finally also "skill", i. e. certain psychomotoric abilities (26). To obtain an overview of the international and Eur- opean Situation regarding the legal definition of the To summarize the knowledge and abilities required profession of clinical chemistry, the study "Education by a clinical chemist figure 3 deals with the basic and Training for Clinical Chemistry" (21) carried out knowledge. It corresponds to individual subjects by the IFCC bas been analysed (fig. 2). Worldwide which are taught within the scope of a medical or in aböut 63% of the countries there is a direct legal scientific study. This basic knowledge forms the sci- definition of the profession by national laws. A more entific background for clinical chemistry. In addition

Science Medicine

"directly" by national laws Automation Physical |mmunology Anatomy chemistry Inorganic chemistry Analytical Pathophysiology Histology chemistry Organic Biochemistry Physiology chemistry Instrumental / Clinical analysis \ Chemistry / Pathobiochemistry Physics Analytical Pathology different in biochemistry Nosology single states Statistics of a country Biochemistry Internal medicine Epidemiology Theory of Haematology errors Molecular Microbiology biology Endocrinology "indirectly" by Professional bodies Electronic data or social insurance processing/lnformatics Cell biology

Fig. 2. Legal definition of the profession of clinical chemistry Fig. 3. Scfentific background required for clinical chemistry in 35 countries (Data from M. Rubin & P. Lous (21))

Eur. J. Clin. Chem. Clin. Biochem. / Vol. 29,1991 / No. J 8 Büttner: Clinica! chemistry äs profession there is also a body of specialist knowledge to be and the ability and readiness to carry out interdisci- acquired in clinical chemistry. This knowledge is ex- plinary research in a team. Generally speaking, the emplified in table 6. The essential knowledge in clin- clinical chemist should be able to look far beyond the ical medicine is very difficult to define. Such a defi- borders of his own discipline. nition requires a detailed subject catalogue, äs sub- mitted for example by the German Society of Clinical Chemistry (27). Finally, for the area of "centralized Recruiting Scientific Personnel for the Professional analytical activity" some further special knowledge is Field of Clinical Chemistry important, without which a hospital laboratory can- Having outlined the professional qualification for not be effectively managed (tab. 7) (28). It would be clinical chemistry the question arises äs to where suit- going too far to discuss here the qualifications for the ably educated persons can be found to train for the field of research in clinical chemistry. With regard to profession of clinical chemist? This question will first pathobiochemical research, attention is drawn to the be answered empirically, using the already mentioned comments of Trautschold (29) and Gerok (30) at the international study of IFCC. Figure 4 shows which Merck Symposium 1977, which are still valid today. entry qualifications are usual at present. In 76% of the countries (European countries 57%) clinical chem- Tab. 6. Necessary special knowledge for conducting clinical ists are recruited both from physicians and from sci- chemistry entists. The various subjects outside human medicine Analytical methodology are classified again in figure 5. As can be seeü, worldwide, biochemistry with 41% contributes a larger Examples: Proportion than chemistry and pharmacy. In Euro- optical methods substance separating methods pean countries, chemistry, biochemistry and phar- e. g.: chromatography, ultracentrifugation macy show the same proportion of abpüt 29% each. mass spectrometry immunochemical methods molecular biological methods haematological methods (iiicluding coagulation) endocrinological methods International European special toxicological methods mechanization/automation

Use of clinical chemical tests in clinical medicine for: diagnostics, prognostics, preventive medicine, therapy control including therapeutic drug monitoring

Evaluation of clinical chemical tests including: interference factors and influence factors Fig. 4. Entry study for education in clinical chemistry (Data from M. Rubin & P. Löus (21)). Left side: international (42 countries), right side: European (21 countries) Tab. 7. Special knowledge for "centralized analytical activity" Management Organization of the laboratory and its working flow International European

Use ofelectronic data processing for: work control, evaluation of fmdings, presentation of fmdings, performance statistics, accounting Personnel management

Economic management

Finally, äs for any other demanding Professional position, certain "extrafunctional qualifications" (31) are Fig. 5. Non-inedical subjeets äs qualifications for entry to clinical chemistry (Data from M. Rubin & P. Lous (21)). desirable for a clinical chemist. Examples of this are Left side: international, right .side: European. The un- the ability to enter into a dialogue with the clinician labeled sector represents veterinary medicine

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These empirical data reflect various influences. Firstly, cific courses lasting several years at universities. An the historical differences mentioned lead to preference example which can be mentioned is the American of certain subjects in different countries, for example program (34) which was created at the start of the pharmacy in France. Secondly, with some exceptions seventies under the pressure of a manpower crisis in it has become increasingly difficult to win physicians clinical chemistry, and which mean-while has led to to the profession of the clinical chemist (32). It would Ph. D.'s playing an outstanding part in American clin- appear that in a period of rapid advances in clinical ical chemistry. The concept of & further training in the medicine the subject of clinical chemistry is far down Professionalposition (German term "Weiterbildung"), the popularity scale. which has been the ususal one for medical specialists for a long time, was developed particularly in Europe. As seen from the detailed analysis of clinical chemistry If this path of qualification is followed, the incoming äs a scientific discipline and äs a profession, the in- clinical chemist acquires the necessary knowledge and terdisciplinary aspect of the subject is a special feature. abilities äs an assistant in a clinical chemistry labo- A necessary result of this is the need to win over to ratory under the conditions and demands of daily clinical chemistry both persons with a medical training routine work in a period of about 3 to 5 years; this and persons with an education in science. Only then knowledge and these abilities must then be tested in will it be possible to cover the entire broad scope of a concluding examination. This path has the advan- this discipline. Apart from this discipline-oriented ar- tage of being close to practice and if it is correctly gument, Professional and social arguments also show devised permits the absolutely essential insight into the need to open up access to the profession both to clinical medicine. For postgraduate training, various physicians and to scientists. Daheim puts it like this international and national curricula exist. An IFCC- (33):te The Professional circle must decide whether they IUPAC recommendation of 1982 describes a two-year want to take in only members who have gone along the training course based on a university degree in chem- prescribed path or whether they also want to take in istry, biochemistry, pharmacy or biomedical technol- by way of exception qualified members of auxiliary ogy (35). Table 8 is intended to briefly compare the and related professions äs well If this is not the inten- present training provisions in some European coun- tion then in future the profession will attract mainly tries (taken from Breuer (36)). individuals lookingfor a secure career and the "enthu- siasts" will stay away." Attention should also be drawn to a special aspect resulting from our analysis of clinical chemistry, which concerns the theory of science. The clinical chemist Acquiring the Necessary Qualifikation for the Subject must learii to adopt two ways of thought, that of of Clinical Chemistry theoretical science and that of practical science. The What is the best way of acquiring the necessary qual- Polish medicine theoretician Ludwik Fleck drew at- ification for the profession of a clinical chemisl? This tention to the social dependence of thought (37). He question touches the very difficult problem of post- coined the term, "thought style" ("Denkstil") which graduate training and requires careful consideration. develops in a group of scientists (a "thought collective"). The thought style "is characterized by common In the pioneering days of the discipline, it was con- features in the problems ofinterest to a thought collec- sidered expedient in Germany to acquire the necessary tive, by the judgement which the thought collective knowledge in a double study, for instance chemistry considers evident, and by the methods which it applies and medicine. In recent years, this approach has be- äs a means of cognition" (38). A research group, coine increasingly problematic. Firstly, with the pres- scientists of an Institute or the scientific Community ent lengths of courses the Student finishes his exami- of a discipline are examples of a thought collective nations too late. If the rising generation does not which can develop a characteristic thought style. If enter the actual professipnal field until it is about 30 these ideas are accepted, the clinical chemist just be- years old, the phase of creative activity in many cases ginning would best be able to learn the way of thought will be too short for outstanding scientific achieve- in a suitable group of scientists with constant inter- ments. Secondly, in spite of the double study, impor- change of ideas. An example may help to explain this. tant parts of the necessary qualifications still had to The natural scientist who is used to thinking in natural be acquired later. laws and probabilities will learn from a constant ex- The alternative concept which has now established change of ideas with the clinician that, in contrast to itself throughout the world is to impart specifically natural science, his findings are Singular Statements the qualification for the profession of a clinical chem- which relate only to a specific patient. He must learn ist by postgraduate training or further education. to investigate whether the abstract concept of the Postgraduate training takes place in the form of spe- disease is applicable to the individual case (39).

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Tab. 8. Training of thc clinical chemist in the countries of the European Community (taken from Breuer (36))

Counlry Entry studies (years) Poslgraduate training Remarks

Belgium chemistry 4 5 years-1 year haematology pharmacology 5 l year microbiology medicine 7 l year clinical chemistry

Federal medicine 6 5 years-3—4 years in hospital labora^ examinatiön at the end of post-graduate Republic biochemistry 6 tories training; no recognition by the govern- of Germany chemistry 6 ment

Danmark Akademiingeni0r 5 years only physiciaris can acquire the title of biochemistry clinical chemist Civilingenior pharmacy medicine

Germ an biology 5 5 years in specialized läboratories about 80% of the hospital laboratories are Democratic biochemistry 5 directed by "special chemists for medi- Republic chemistry 5 cine", about 20% by laboratory physicians pharmacy 5

France medicine 6 1. examinatiön 4 examinations during postgraduale train- pharmacology 5 2. 8 Semester "concours de Tinternat ing; at tlie end of postgraduale training des hospitaux" in microbiplogy, certification äs clinical chemist = biplo- haematology, clinical chemistry, giste clinique parasitology 3. l Semester in a hospital

Greece chemistry 4 years in biochemical laboratories nearly all clinical chemists graduated in medicine chemistry pharmacology

United Kingdom chemistry 5 — 8 years in an accredited laboratory different examinatiön depending on entry biochemistry qualification (medicine)

Netherlands chemistry 2 years clinical chemistry; examinatiön in difTerent areas of clinical ehem. technology 1 — 1.5 years haematology; chemistry; l year study in analytical bio- pharmacy 0.5 — 1 year special areas of clinical chemistry before postgraduale training in chemistry; clinical chemistry biology at least 4 years in a hospital laboratory

Ireland biochemistry 4—5 years in a clinical chemieal or clinical biochemical laboratory

Italy chemistry clinical chemistry only chemists are allowed to perform clin^ ical chemieal analyses. Analyses in other fields only by physicians

Luxembourg chemistry 4 years because many students froin Luxembourg pharmacology finish their studies in foreign countries, medicine nearly all qualifying examinations are rec- ognized

Portugal biochemistry 4 3 years practical work at a laboratory a clinical laboratory can be directed only biology after graduation in medieine or pharmacy chemistry chemical-engi- neering medicine veterinary medicine pharmacy

Spain chemistry 5 4 years in a cliincal chemieal labora- medicine 6 tory; examinatiön in all of the 4 entry pharmacy 5 subjects; examinations «yearly during biology 5 postgraduale training

Eur. J. Clin. Chena. Clin. Biochem. / Vol. 29,1991 / No. l Büttner: Clinical chemistry äs profcssion 11

The Change of the Professional Field of Clinical Chem- A fourth factor which will influence clinical chemistry istry in the Future in the future is the economic Situation of the health System in many countries. The struggle for the distri- Like broad areas of the biosciences and of rnedicine, bution of the resources in the health System is already the discipline of clinical chemistry is undergoing an in füll swing. In this context, it is important for clinical extremely rapid change at present. There are several chemistry that in many countries a not inconsiderable reasons for this. part of a physician's fees comes from clinical chemical The predominant factor here is the explosive growth investigations. ofknowledge due mainly to the successes of molecular The aforementioned influences are a great challenge biology, immunology, and cell biology. This growth to the clinical chemist in the next decade. We shall be of knowledge will also influence and change clinical able to meet this challenge only if clinical chemistry chemistry. The classical methods of clinical chemical is further developed äs an interdisciplinary subject, if investigations, which were restricted predominantly it is opened up fully to physicians and scientists, and to the body fluids and the extracellular compartment, if it willingly accepts teamwork with the clinical dis- will be replaced by new investigation techniques. The ciplines. These changes will require continuous ad- new possibilities will bring about rapid advances in aptation of the knowledge which the clinical chemist the research of the pathogenesis of diseases. must acquire. This is where universities and scientific specialist societies are expected to Update curricula A second factor is directly related to this. The rapid for postgraduate studies and further training and increase in knowledge leads to a flood of Information above all to offer effective training facilities. which must be controlled with suitable methods. We shall have to wait and see whether the artificial intel- Clinical Chemistry in the European Community ligence of Computers and expert Systems will be suitable and adequate to do this. The political development within the European Com- munity means that clinical chemists will work more A third factor governing the change in clinical chem- closely together than in the past when they were istry resides in the still increasing mechanization and separated by borders. The differences in the profes- automation of methods. Modern Instruments devel- sional field of clinical chemistry may prove a hin- oped by industry are, however, hardly transparent to drance here. On the other band, äs this analysis has the user. The effects of an error for instance in an shown, this variety is an expression of the interdisci- apparatus component on the whole analytical System plinary nature which must be preserved if the disci- can no longer be assessed. The clinical chemist runs pline to be able to meet the challenge of our future. the risk of loosing the control over his Instruments. It is therefore a matter of urgency for the Professionals The philosophy of technology describes this under the that clinical chemists of the countries of the European concept of "technocracy" (40): With the advance of Community jointly define the framework for the cli- technical development the actions of man finally be- nical chemist in the European Community (see also come dependent only on technical factors, "material the editorial in this Journal (41)). A concept of the constraints". Mari loses the possibility of taking a free Professional field supported by all those involved decision on the use of the machine. When using his opens up the possibility of recognition by the Euro- machines, the clinical chemist is also threatened by pean Commission. This is the only way of avoiding technocracy. The aim here must be to recover the one-sided regulations that are inadequate and inap- freedom of decision by $elf-expertise. propriate to the nature of the discipline.

References 1. Thudichum, J. W. L., in a letter to Rudolf Virchow from 5. Büttner, H. & Hillmann, G. (1964) Die Ausbildung des 1869. Quoted by Drabkin, D. L. (1958) Thudichum. Chemist klinischen Chemikers. Mitteilungen des Berufsverbandes ofthe Brain. University of Pennsylvania Press, Philadelphia, Deutscher Internisten 1964, 5—6 (Nr. 2). Supplementum p. 253 (Translation from the German). to: Internist 5, Heft 2, 1964. 2. Büttner, J. (Editor) (1983) History of Clinical Chemistry. 6. Stamm, D. & Breuer, H. (1969) Berufsbild des Klinischen Walter de Gruyter, Berlin, New York. Chemikers und Klinischen Biochemikers. Z. Klin. Chem. 3. Büttner, J. & Habrich, C. (1987) Roots of Clinical Chem- Kiin. Biochem. 7, 644-646. istry. GIT-Verlag, Dannstadt. 7 N. N. (1987) Die Klinische Chemie und ihre Stellung in der 4. Kohler, R, E. (1982) From Medical Chemistry to Biochem- Medizin. Derzeitiger Stand und zukünftige Entwicklungen. istry. The Making of a Biomedical Discipline. Cambridge Bericht über eine Kleinkonferenz der österreichischen Ge- University Press, Cambridge, London, New York. See also: sellschaft für Künische Chemie, Wien 5.-7. 12. 1986. Be- o. c. (3), chapters 5 and 6. richte der österreichischen Gesellschaft für Klinische Chemie 10, 161-173. Eur. J. Clin. Chem. Clin. Biochem. /Vol. 29,1991 / No. l 12 Büttner: Clinical chemislry äs profession

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