Eur J Clin Chem Clin Biochem 1997; 35(7):495-499 © 1997 by Walter de Gruyter · Berlin · New York
INVITED OPINION
Clinical Laboratory Work — Concepts and Terms
Rene Dybkaer
Hovedstadens Sygehusfaellesskab, Afdeling for Laboratoriemedicin, Kommunehospitalet, Copenhagen, Denmark
Summary: An appropriate term is sought for the concept embracing the different types of clinical laboratory work.
The defining characteristics of the concept are therefore described, i. e. site, goal, objectives, activity, field, and
participating professionals. It is proposed that the superordinate concept should be "medicine" while the subordinate
concept under discussion is defined on the basis of the characteristics, thereby distinguishing it from coordinate
concepts, i. e. from other branches of medicine. The principles used for establishing existing terms in other branches
of medicine are presented, together with a discussion of existing terms in the clinical laboratory field. It is suggested
that the current term 'laboratory medicine' has several advantages. The workplace may be called a 'department of
laboratory medicine' or 'clinical (or medical) laboratory'. It is further suggested that the term 'clinical chemistry'
should not generally be replaced by 'clinical biochemistry'.
Introduction
Site
Appropriate definitions and terms for the concept of the
totality of work and services performed by clinical
laboratories of all types have been debated for several
decades. Recently, Fuentes-Arderiu and Castineiras argued that the term Clinical Laboratory Sciences would
have the two advantages of not being traditionally used
in the European Union and of not being in conflict with
the diverse systems of university education of the professionals involved (1,2).
The profession essentially exercises its discipline(s) in
laboratories. The ISO/IEC definition of a "testing laboratory" is 'body that calibrates and/or tests'1 (6). That definition is too restrictive in the present case where types
of examination other than tests are also performed and
calibration is not a service usually provided. A working
definition of this superordinate concept could be
Büttner stressed the need to distinguish between a scientific discipline and its professional application (3). He
pointed out that as Fuentes-Arderiu's proposal was for a
term related to the concept of the professional field, the
word 'sciences' would not be appropriate because it suggested a scientific discipline. Büttner concluded that, at
present, no universally acceptable term exists for the multidisciplinary laboratory application, especially due to the
various national regulations governing laboratory practice.
For the present purposes a subordinate concept relevant to
the present discussion will be
laboratory: body equipped for performing examinations of properties of objects.
clinical laboratory; medical laboratory: laboratory
dedicated to health services
Note 1: A clinical laboratory is usually connected
with a hospital.
Note 2: The objects being examined are usually related to patients.
Thus, it is tempting to examine whether a harmonization
of terms is possible (4).
The connection of the professional work to laboratory
premises excludes the clinician's activities in obtaining demographic and anamnestic data, as well as clinical signs
by manual bedside examination, but some near-the-patient
procedures may also be used in a clinical laboratory.
Concept
Goal
In terminological work, it is proper initially to study the
'contents' of the concept, then to attempt a definition,
and finally to select a preferred term (5). Consequently,
the characteristics of the profession being discussed
should first be outlined.
The goal of the clinical laboratory profession is to provide clinical medicine in the widest sense and the health
1
Double quotation marks ("...") indicate a concept, single quotation marks ('...') a term or quotation.
496
care system in general with laboratory data and related
information, essentially pertaining to individuals and
aiming to promote their health.
The stakeholders of the health care system are patients
and other health care recipients, health care providers,
administrations, authorities, and the public.
Objectives
The data and information must be relevant, timely, reliable, adequately accurate, and understandable in context,
all in aid of prevention, diagnosis, therapy, monitoring,
and prognosis of disease. Obviously, the service must
also be cost-effective.
Activity
The goals and objectives are mainly achieved through
physical, chemical (including molecular biological and
immunological), and biological laboratory examinations
of samples from individuals and their secretions and excreta. Additional duties may comprise preparation and
sampling of the examinee, as well as examination of an
entire individual (e. g. metabolic studies and other functional examinations) and of environmental living or inanimate objects (e. g. microbiological and toxicological investigations). Furthermore, some work may take place
outside the laboratory proper, such as sampling and nearthe-patient examinations in wards and patient homes.
To fulfil the requirements of reliability and accuracy of
results, any examination must occur under statistical
control and results must be traceable to the highest possible point in the hierarchy of reference.
The profession also has important advisory functions
towards other health care stakeholders regarding selection and requesting of relevant properties, sampling procedures, interpretation and utilization of results and information, even therapy (e. g. anticoagulant treatment
and transfusion of blood components). Furthermore, the
profession must participate in research and development
of clinical laboratory techniques and in clinical research.
Finally, there is a general obligation to support fieldrelated education and training of laboratorians and other
health care personnel.
Rene Dybkaer: Clinical laboratory work — concepts and terms
ince of roentgenologists, clinical physiologists, and clinicians. The clinical laboratory, however, may well use
principles applying such physical phenomena on samples. In practice, there is often overlap between the
activities of the clinical laboratory and those of departments of clinical physiology, nuclear medicine, and
even medicine.
Professionals
It is characteristic of the field that its practitioners, even
the staff of a single large laboratory, generally comprises
members of different primary disciplinary background,
such as biochemists, biologists, chemists, pharmacologists, physicians, as well as those combining more than
one discipline. This multidisciplinarity was described in
detail for "clinical chemistry" by Büttner (7).
Definition
Assuming that the multidisciplinary profession could
agree with this outline of its goal, objectives, activity,
field, and types of participating professionals, a definition may be discussed.
The permutations of professional subfields found in past
and present clinical laboratories are so numerous that it
is impractical to give an extensional definition (8) of the
concept by listing all combinations.
An intensional definition identifies the nearest superordinate concept and the characteristics that differentiate
the given concept from coordinate concepts at the same
level of the concept system (8).
Superordinate concept
In view of the professional goal outlined above and the
important stress on the function of advising clinicians,
the medical relation is important. It is therefore suggested that the nearest superordinate concept is "medicine", here taken in the most general sense including
"internal medicine", "surgery", "obstetrics", and several
specialities from "dermatology" to "nuclear medicine".
For the present purposes, the definition of The Concise
Oxford Dictionary (9), which is shorter than that of several other dictionaries, may serve.
Field
The combination of subfields of work occurring in a
clinical laboratory depends on its size, type of any parent
hospital or other institution, and national or regional tradition and regulations. Some important scientific disciplines that may be applied in a clinical laboratory are
shown in table 1.
It is generally accepted that imaging examinations, utilizing, e. g. X-rays, radioisotopes, nuclear magnetic resonance, and ultrasound directly on persons, are the prov-
Tab. 1 Important scientific disciplines that may be professionally
applied in a clinical (or medical) laboratory.
Physics, chemistry, biology
Anatomy, histology, cytology
Physiology, biochemistry, immunology
Genetics, molecular biology
Microbiology, parasitology
Endocrinology, haematology
Pharmacology, toxicology
Pathology, pathophysiology
Metrology, statistics, information technology
497
Rene Dybkaer: Clinical laboratory work — concepts and terms
medicine: science or practice of the diagnosis, treatment,
and prevention of disease
The entry continues', esp. as distinct from surgical
methods', but here the more general sense is assumed
to apply.
Note 4: As hi other branches of medicine, this field
has obligations of research and development, education and training.
Term
Characteristics
Principles
The outline of the concept of the field of the clinical
laboratory profession given above mentions several
characteristics which are paraphrased in table 2.
The various branches of medicine have coined their respective preferred term according to a number of principles as shown in table 3. No terminological rule has
been followed throughout or between languages.
Wording
In fashioning a definition, it is not generally considered
terminologically appropriate to incorporate all identifiable characteristics. Rather, only those should be selected that are necessary and sufficient to position the
concept in a concept system, which here consists of
"medicine" and its many branches, perhaps with some
additions to make the definition understandable on its
own (5). Less important information may be given in
notes.
Definition proper
The essential characteristics amongst those shown in
table 2 seem to be Nos 1, 2, 4, and 6. They may be
combined as follows:
branch of medicine providing the health care system
with laboratory results and related information and
advice pertaining to the clinical state and treatment
of health care recipients
Notes
Note 1: The results are usually obtained on samples,
using physical, chemical, and biological principles of
examination, related to demographic and clinical data.
Note 2: The results must be traceable and sufficiently
accurate for the purpose of prevention, diagnosis,
treatment, monitoring, or prognosis of disease.
Note 3: The clinical laboratory profession is populated by laboratorians of various primary education,
such as biochemistry, biology, chemistry, medicine,
and pharmacy.
Tab. 2 Important characteristics of the concept of the field engaged in by the clinical (or medical) laboratory profession.
1
2
3
4
5
6
Functions essentially in a (clinical) laboratory
Provides clinical medicine and health care system
with patient-related laboratory data and information of adequate quality
Uses many principles of examination, mainly on samples
Advises the health care system
Conducts research, development, education, and training
Is staffed by professionals of various disciplines (tab. 1)
The choice of a preferred term is difficult, not only for
terminological and linguistic reasons, but also because
the stakeholders of the clinical laboratory field have different disciplinary backgrounds and professional interests. This pluridisciplinarity is expectable, inasmuch as
the superordinate concept "(clinical) medicine" is a
workplace for many types of professional, such as nurse,
physical therapist, physician, porter, psychologist, secretary, and social worker.
Current possibilities
For the branch under discussion, the field of the professionals manning the different types of clinical laboratory,
several terms are in use (tab. 4). The numbers of retrievals in Medline® during 1995 give a rough indication of
the usage of different departmental names.
'Biomedicine' is etymologically weak, even tautologous, as "medicine" by itself is concerned with life.
The terms 'biopathology', 'medical biopathology', 'clinical pathology', and 'chemical pathology' focus on deviation from health, but prevention and exclusion of disease are important subjects in the field. Furthermore,
they give no indication of the laboratory aspect. 'Chemical pathology', in addition, stresses "chemistry" unduly.
'Clinical analysis' (from Spanish) is used in English
only for an analysis of clinical findings hi general.
The term 'clinical biology' could, by its etymology
(κλινικοσ, Greek = pertaining to a bed), be a synonym
for 'medicine' and there is no indication of laboratory
work as separate from, e. g. imaging.
The term 'clinical laboratory sciences' (1,2) stresses science rather than its application and is therefore - as
pointed out by B ttner (3) - more appropriate as a term
for the scientific multidiscipline.
In various countries, the terms 'clinical chemistry',
'clinical biochemistry', 'medical biochemistry', and
'molecular pathology' are quite prevalently used in a
rather multidisciplinary sense (Medline® references 650,
409, 484, and 208 respectively). These terms, however,
linguistically convey a monodisciplinary meaning and
are often used in this narrower sense, especially exclud-
498
Rene Dybkaer: Clinical laboratory work — concepts and terms
Tab. 3 Principles of term formation for branches of "medicine".
Principle
Examples1
1. Adding a modifying adjective or adjectival noun to 'medicine' indicating the type of examination
or treatment
2. Independent, single-word term indicating type of examination
3. Independent, single-word term indicating demographic type of person concerned
4. Independent, single-word term indicating organ of central interest
5. Independent, single-word term indicating type of treatment
6. Independent, single-word term indicating type of disease
nuclear medicine;
physical medicine
radiology
gynaecology; paediatrics
dermatology; stomatology
anaesthesiology
allergology; rheumatology
Terms according to the European Union of Medical Specialists (UEMS)
ing clinical microbiology, haematology, and pathology.
In the present search for a term denoting the general
field, they cannot be acceptable candidates and are
therefore not included in table 4.
It would be possible to introduce other terms, for example 'clinical laboratory services' or the sporadically used
'clinical laboratory diagnostics' (or clinical laboratory
diagnosis (10)), as complements to 'clinical laboratory
sciences', but then a participation in education, research,
and development would not be perceived as a natural
function.
In order to stress the importance of the medical contents
of the professional field, institutionalized in a clinical
(or medical) laboratory, it is suggested that the first principle shown in table 3 be followed, that is to build on
the basis of the term 'medicine' for the superordinate
concept and form 'laboratory medicine' for the subordinate one.
Tab. 4 Usage of terms indicating the general field of the clinical
(or medical) laboratory profession.
No.
Term1
1
2
Biomedicine
Biopathology
(UEMS3; Italy)
Chemical pathology
Clinical analysis
(analisis clinicos, Spain)
Clinical biology
(biologie clinique, Belgium, France)
Clinical laboratory science
Clinical pathology
(SEPaC4; Medline® Thesaurus term)
Laboratory medicine
(ECLM5)
Medical biopathology
(UEMS3)
3
4
5
6
7
8
9
Medline®
refs2
55
25
193
116
35
10
298
985
0
1
Parenthetic reference to countries are given when the term is
mainly used there.
2
Medline® 1995-01/1996-01 (Silver Platter Information); the
terms are mostly found in names of originating departments.
3
European Union of Medical Specialists
4
European Society of Clinical Pathology, World Association of
Societies of (Anatomic and Clinical) Pathology
5
European Confederation of Laboratory Medicine
'Laboratory medicine'
This term has some advantages.
1. The term 'medicine' traditionally designates a sum
of activities comprising prevention, diagnosis, therapy,
monitoring, research, teaching, and service.
2. The fields under "medicine" are of necessity staffed
by health care providers of various backgrounds.
3. A "Department of Laboratory Medicine", by its very
name, would be expected to provide medical expertise
and advice.
4. The term 'laboratory' immediately conveys an essential characteristic of the field (Site and table 2, line 1).
5. A hospital "Department of Laboratory Medicine" is
perceived as an equal partner with other medical departments, which is psychologically valuable for reasons of
status and collaboration.
6. The combined term 'laboratory medicine' is entrenched in the English language (tab. 4) and is also
used, e. g., in German ('Laboratoriumsmedizin'), Italian,
and Polish. Thus, there is already considerable term harmonization as advocated by ISO (4). This should be
compared to the proposal of a near neologism (1,2).
7. Several organizations use the term, such as the European Confederation of Laboratory Medicine (ECLM)
and the Polish College of Laboratory Medicine (KMLP).
Also, the International Federation of Clinical Chemistry
(IFCC) on the front pages of its Journal of the IFCC
(since 1992) and its Strategic plan (1996) uses the
phrase 'Serving laboratory medicine worldwide'.
Science and Practice
The concept of "medicine" is often polysemically understood to comprise both scientific and applied aspects.
When in doubt, the subordinate concepts "theoretical medicine" and "clinical medicine" are sometimes used. The
same problem is less likely to arise for "laboratory medicine" where the original academic study of the laboratorian is usually more specific, such as biochemistry, chemistry, medicine, microbiology, and pharmacology, and
where the word 'laboratory' suggests a practical field.
499
Rene Dybkaer: Clinical laboratory work - concepts and terms
Should the need for a clear separation arise, the term
'clinical (or medical) laboratory sciences' would be adequate for the pluripotential scientific discipline.
The Laboratory
If the term 'Department of Laboratory Medicine' is inappropriate in view of the magnitude of a given body, it
would be natural to call it 'Clinical Laboratory' or — as
a derivative of the term for the field - 'Medical Laboratory'.
Clinical Chemistry?
Some of the terminological types of problem discussed
above also apply to the terms 'clinical chemistry' for a
scientific discipline and 'department of clinical chemistry' or 'clinical chemical laboratory' for the sites of application.
The term 'clinical chemistry' originated in Germany as
'Klinische Chemie' when Johann Joseph Scherer set up
his laboratory in Würzburg (Germany) 1841 (11). It became widespread with the monograph of Peters & Van
Slyke entitled 'Quantitative Clinical Chemistry' (12).
Lately, a change to the term 'clinical biochemistry' has
become the vogue. This seems strange as "biochemistry", being subordinate to "chemistry", implies a smaller
scope. Furthermore, the principles of examination and
many of the properties examined under that heading are
not particularly characteristic of biochemical studies
which centre on processes. It is suggested that the timehonoured term with 'chemistry' and the sufficiently explanatory adjective 'clinical' (or 'medical') be retained.
This is also in accordance with the name of the International Federation (IFCC).
Conclusion
Term formation preferably should rely on the intension
of the concept, its superordinate and coordinate concepts, and attempts at harmonization. Due to the diagnostic and advisory functions of the clinical laboratories,
it seems natural to view the professional field as a part
of "medicine" and to choose a term showing that the
type of work place is an essential characteristic. Thus
the proposed outcome is
laboratory medicine: branch of medicine providing
the health care system with laboratory results and related information and advice pertaining to the clinical
state and treatment of health care recipients
with further characteristics presented in notes (see Definition proper).
Being a part of "medicine", it is natural that "laboratory
medicine" contains professionals from various scientific
disciplines. When necessary, this may be reflected in a
term for the overall scientific discipline, for example
'clinical (or medical) laboratory sciences' (treated as
singular).
References
1. Fuentes-Arderiu X, Castineiras MJ. Laboratory medicine or
clinical laboratory sciences? [letter]. J Int Fed Clin Chem
1992; 4(4): 136.
2. Fuentes-Arderiu X. Searching for an international name for an
old discipline [letter]. Eur J Clin Chem Clin Biochem 1996;
34:661.
3. Büttner J. Finding the right name for our field of activity [reply
and editorial comment]. Eur J Clin Chem Clin Biochem
1996; 34:663.
4. International Organization for Standardization. Terminology
work — harmonization of concepts and terms. ISO 860. 2nd
ed. Geneva: ISO, 1996:iv + 6 pp.
5. International Organization for Standardization. Terminologywork - principles and methods. ISO/CD 704.2. Geneva: ISO.
1995:iv + 36 pp.
6. International Organization for Standardization, International
Electrotechnical Commission. General requirements for the
competence of calibration and testing laboratories. ISO/IEC
Guide 25. 3rd ed. Geneva: ISO. 1990:iii + 7 pp.
7. Büttner J. Clinical chemistry: a professional field for physicians and natural scientists in Europe. Eur J Clin Chem Clin
Biochem 1991; 29:3-12.
8. International Organization for Standardization. Terminology
work — vocabulary — Part 1: theory and application (partial
revision of ISO 1087: 1990). ISO/CD 1087-1.2. Geneva: ISO.
1996:20 pp.
9. Allen RE, editor. The concise Oxford dictionary. 8th ed. Oxford: Clarendon Press, 1991.
10. Wood WG. United we may stand, divided surely fall [letter].
Eur J Clin Chem Clin Biochem 1996; 34:933.
11. Büttner J. The origin of clinical laboratories. Eur J Clin Chem
Clin Biochem 1992; 30:585-93.
12. Peters JP, Van Slyke DD. Quantitative clinical chemistry. Baltimore: The Williams and Wilkins Company, 1931.
Received January 30/April 7, 1997
Corresponding author: Dr. Rene Dybkaer, Department of
Standardization in Laboratory Medicine, Copenhagen Hospital
Corporation, Kommunehospitalet, Oester Farimagsgade 5,
DK-1399 Copenhagen K, Denmark
Fax: +45-33 38 37 89