AJCP / Original Article
Building Capacity in Laboratory Medicine in Africa
by Increasing Physician Involvement
A Laboratory Medicine Course for Clinicians
Jeannette Guarner, MD,1 Timothy Amukele, MD, PhD,2 Meheretu Mehari, MD,3
Tufa Gemechu, MD,4 Yimtubezinash Woldeamanuel, MD, PhD,4 Anne M. Winkler, MD, MSc,1
Daniel Asrat, MD, PhD,4 Michael L. Wilson, MD,5 and Carlos del Rio, MD6,7
Key Words: Laboratory medicine; Clinician education; Africa; Case-based learning; Clinical pathology; Medical Education Partnership Initiative
Am J Clin Pathol March 2015;143:405-411
DOI: 10.1309/AJCPNYT1WPSRCLC6
ABSTRACT
Objectives: To describe a 4-day laboratory medicine course
for clinicians given at Addis Ababa University, Ethiopia,
designed to improve the use of laboratory-based diagnoses.
Methods: Each day was dedicated to one of the following
topics: hematology, blood bank/transfusion medicine and
coagulation, chemistry, and microbiology. The course
included lectures, case-based learning, laboratory tours,
and interactive computer case-based homework. The same
12-question knowledge quiz was given before and after the
course.
Results: Twenty-eight participants took the quiz before and
21 after completing the course. The average score was 5.28
(range, 2-10) for the initial quiz and 8.09 (range, 4-11) for
the second quiz (P = .0001). Two of 12 and 8 of 12 questions
were answered correctly by more than 60% of trainees on the
initial and second quiz, respectively.
Conclusions: Knowledge and awareness of the role of
the laboratory increased after participation in the course.
Understanding of laboratory medicine principles by
clinicians will likely improve use of laboratory services and
build capacity in Africa.
© American Society for Clinical Pathology
Upon completion of this activity you will be able to:
• recognize the limits of nonlaboratory (syndromic)-based diagnosis.
• assess the gaps in knowledge clinicians in Africa have regarding
principles of laboratory medicine.
• present a curriculum on laboratory medicine for clinicians in Africa.
The ASCP is accredited by the Accreditation Council for Continuing
Medical Education to provide continuing medical education for physicians.
The ASCP designates this journal-based CME activity for a maximum of
1 AMA PRA Category 1 Credit ™ per article. Physicians should claim only
the credit commensurate with the extent of their participation in the activity. This activity qualifies as an American Board of Pathology Maintenance
of Certification Part II Self-Assessment Module.
The authors of this article and the planning committee members and staff
have no relevant financial relationships with commercial interests to disclose.
Questions appear on p 461. Exam is located at www.ascp.org/ajcpcme.
Previous work has demonstrated that many laboratories
used by sub-Saharan African communities are of low quality
and clinically unreliable.1,2 This poor quality has a substantial
negative impact on health care systems in sub-Saharan
Africa.3-6 The negative impact includes delayed diagnoses,
unnecessary interventions, and an erosion of trust among
clinicians.7,8 Significant resources by the American Society
for Clinical Pathology, The World Bank, World Health
Organization, Centers for Disease Control and Prevention,
Clinical and Laboratory Standards Institute, and others are
now being invested in the clinical laboratory infrastructure
of sub-Saharan Africa to address the underlying quality
problem. However, initiatives to improve physician trust in,
knowledge of, and engagement in the clinical laboratory are
lacking.
The lack of trust and engagement can undermine the
impact of robust health interventions.9,10 In the laboratory
setting, this lack of engagement results in an overreliance
Am J Clin Pathol 2015;143:405-411405
DOI: 10.1309/AJCPNYT1WPSRCLC6
CME/SAM
From the Departments of 1Pathology and Laboratory Medicine and 7Medicine, Emory University School of Medicine, Atlanta, GA; 2Department of
Pathology and Laboratory Medicine, Johns Hopkins University, Baltimore, MD; 3Clinical Laboratory, Black Lion Hospital, Addis Ababa, Ethiopia;
4College of Health Sciences, School of Medicine, Addis Ababa University, Addis Ababa, Ethiopia; 5Department of Pathology and Laboratory Medicine,
University of Colorado, Denver; and 6Hubert Department of Global Health, Rollins School of Public Health of Emory University, Atlanta, GA.
Guarner et al / Laboratory Medicine Short Course for Clinicians
on syndromic diagnosis and a strong tendency to ignore test
results in favor of clinical intuition. This pattern of low trust
in laboratory results among sub-Saharan African clinicians
leads to treatment decisions based on clinical judgment,
regardless of tests results.7,8 One way to counter this lack of
trust and improve engagement is to educate clinicians about
the clinical laboratory.
In the United States, the Academy of Clinical Laboratory Physicians and Scientists (ACLPS) published a
proposed curriculum delineating what medical students
should know about laboratory medicine.11 By defining a
knowledge base in laboratory services, the authors lay the
foundation for a better understanding of the role of clinical
laboratories and expectations regarding quality of results,
turnaround time, and reporting of critical values and reference ranges. Using the foundations of the ACLPS curriculum and modeled on a problem case-based approach that
has been used for medical students at Emory University
School of Medicine,12 a 14-contact-hour short course on
clinical laboratory principles was designed for physicians
at Addis Ababa University under the framework of the
Medical Education Partnership Initiative, which seeks to
increase the numbers and quality of physicians and health
professionals trained and retained in sub-Saharan Africa.13
The objectives of this course included bringing awareness
of the function of the clinical laboratory, showcasing the
ACLPS laboratory medicine foundations, and engaging
physicians in a dialogue with the laboratory. In addition,
courses that highlight the role of a clinical pathologist are
imperative to attract medical students to the profession. In
this article, we describe the course and its implementation
and evaluation.
Materials and Methods
The 14-contact-hour course was divided into 4 half-days
(3.5 hours per day). The topics taught included hematology,
blood bank/transfusion medicine, microbiology, chemistry,
urinalysis, and coagulation. Each day started with 1.5 to
2 hours of lectures, followed by 1.5 hours of case-based
learning solved in groups, and ended with a discussion of
the cases (0.5 hours). The trainees were divided into three
groups that included all the clinical specialties that participated in the course, and every day one group had a guided
tour of the clinical laboratory at Black Lion Hospital as part
of the curriculum.
Lectures
The four faculty clinical pathologists toured the
Black Lion Hospital Clinical Laboratory the day before
the course started so that their lectures were tailored to
406 Am J Clin Pathol 2015;143:405-411
DOI: 10.1309/AJCPNYT1WPSRCLC6
❚Table 1❚
Topics for Lectures and Cases for Case-Based Learning
Area
Hematology
Lecture
Cases for
case-based
learning
Chemistry
Lecture
Cases for
case-based
learning
Description of Lecture Topic and Case
Different methods for obtaining complete
blood cell count results and their impact on
interpretation
Reference ranges for different ages, sexes, and
geographic locations
Quality control used in the laboratory for
hematology and other areas
Correlation of results from hematology with
other areas of the laboratory
1. Lymphocytosisa (64-year-old woman with
fatigue and lymphocytosis)
2. Microangiopathic anemia in an HIV-positive
patient
3. Malaria
Scope of laboratory testing (type of specimens,
number of tests)
Diagnostic and analytical sensitivity and
specificity
Preanalytical variables that can affect laboratory
results
Interpretative results (using as example protein
analysis in serum and urine)
Characteristics of urinalysis, including possible
false-positive and false-negative results
1. Diabetic ketoacidosis in a pregnant patienta
(25-year-old pregnant woman with shortness
of breath and dizziness)
2. Paraproteinemia
3. Abnormal urinalysis
Microbiology
Lecture
Principles of microbiology as several separate
disciplines
Diagnostic approaches: direct observation of
the organism, culture, indirect detection, and
molecular methods
Role of microbiology in patient care and public
health
Correlation of clinical, microbiology, and
pathology
Cases for
1. Cryptococcal meningitis in an HIV-positive
case-based
patienta (22-year-old man with persistent
learning
headaches and fatigue)
2. Tuberculosis in an HIV-positive patient
3. Sepsis
Blood bank/transfusion medicine and coagulation
Lecture
Whole blood collection and processing
Pretransfusion testing
Blood products and indications for transfusion
Complications of transfusion, including infections
and noninfectious hazards
Coagulation tests and approach to the bleeding
patient
Cases for
1. Anemia in patient with colon cancera
case-based
(50-year-old man with lightheadedness,
learning
fatigue, and shortness of breath)
2. Patient with sickle cell anemia with
alloantibodies
3. Hemophilia
HIV, human immunodeficiency virus.
a Interactive homework case (http://path.emory.edu/EPeP/; in the section Laboratory
Principles for Clinicians, use EPeP as username and password).
© American Society for Clinical Pathology
AJCP / Original Article
❚Table 2❚
Questions Given in the Knowledge Quizzes
Topic
Question
Normal ranges
A healthy 12-year-old male who is on the school soccer team comes for his annual physical. His laboratory
results were within the reference range for each analyte except for AST, which was 45 U/L (reference range
10 to 42 U/L). Which statement is most correct about this patient’s results?
You receive a call from the laboratory reporting a critical potassium level of 6.2 mmol/L. This result is from a
patient with chronic renal failure whose potassium usually averages around 5.6 mmol/L. You are annoyed
since the laboratory technologist is asking you to repeat the patient’s name and value back to her. Which
statement is correct regarding critical values?
If a screening test for a particular disease has many false-positive and false-negative results, this test has:
How are anti-A and anti-B formed?
One unit of packed red blood cells should increase the hemoglobin by:
Which statement is true regarding variability when counting white blood cells in a sample?
If multiple blood samples were drawn in the following order: blood cultures, prothrombin time, complete blood
count (CBC), complete metabolic profile (CMP); which one of the following results could you expect for the
CMP?
Hemolysis after blood is drawn causes elevated serum:
When interpreting glucose results that have been obtained using point-of-care devices (POC), health care
providers have to take one of the following into consideration:
A prozone phenomenon or hook effect results in a:
Which statement is true regarding results of bacterial cultures?
Which special stain is used in histopathologic material to highlight the cell wall of fungi?
Critical values
Sensitivity and specificity
Blood bank
Blood bank
Hematology
Order of draw
Chemistry
Chemistry
Serology
Microbiology
Microbiology
AST, aspartate aminotransferase.
locally available test menus. The chemistry and hematology lectures presented the general clinical laboratory
foundations from the aforementioned ACLPS curriculum.
Selected laboratory principles delineated in the ACLPS
curriculum specific to the different areas were integrated
in all lectures given by the clinical pathology faculty. In
addition, there were two local invited speakers. The first
was a representative from the African Society for Laboratory Medicine who described the activities and plans
of this organization that are dedicated to strengthening
clinical laboratory capacity throughout Africa. A second
invited speaker from the Central Blood Bank in Ethiopia gave a lecture on the history and future plans of the
Ethiopian National Blood Transfusion Service. Last, one
infectious disease clinician from the United States gave a
presentation on how he uses laboratory results in clinical
care. ❚Table 1❚ presents the topics addressed in the lectures
based on the different areas.
Case-Based Learning and Discussion
We prepared 12 cases for case-based learning and
discussion, three for each day of the course. Table 1 lists
the topic of each case. These clinical cases included questions that highlighted laboratory principles covered during
the lectures. Printed versions of the cases were brought to
the classroom so that the trainees could take notes as they
were answering the questions and could be used as future
reference. One faculty member was a facilitator for each
group of trainees. Trainees were encouraged to use multiple
sources to solve the questions in the cases. These included
textbooks on laboratory medicine, blood bank/transfusion
© American Society for Clinical Pathology
medicine, coagulation, and hematology that were brought
by the faculty, as well as Internet resources. After the groups
had finished answering the questions, they each had to give
a brief oral presentation to the rest of the class summarizing
their case, the discussion that had occurred while solving
the case questions, and a list of three to five brief points
(“pearls”) that they had learned about laboratory medicine
from their case.
Participants were given a USB drive at the beginning
of the course with course materials including the 12 cases
prepared for case-based learning, four interactive learning
modules, and reference reading materials. Trainees were
asked each day to do an interactive computer-based case
that was present in the USB drive as homework to affirm
the concepts learned during the day. The interactive cases
were based on one of the three cases that had been discussed
during that day’s session (see Table 1).
On the first day, we performed an assessment of
attitudes regarding laboratory services as well as a
12-question knowledge quiz regarding laboratory medicine ❚Table 2❚. A total of 28 trainees completed the quiz
and attitude assessment. Eighteen trainees completed and
returned these documents on the first day, and 10 more
trainees did this on the second day. At the conclusion of
the course, the same knowledge quiz that had been given
at the beginning of the course was administered, with
21 trainees completing it. To define if the differences in
scores were statistically significant between the knowledge quiz before and after, an unpaired two-tailed t test
using the online QuickCalcs t test calculator (GraphPad
Software, La Jolla, CA) was performed.
Am J Clin Pathol 2015;143:405-411407
DOI: 10.1309/AJCPNYT1WPSRCLC6
Guarner et al / Laboratory Medicine Short Course for Clinicians
7
Pre
Post
No. of Trainees
6
❚Table 3❚
Likert Scale Regarding Attitude Toward the Laboratory
Scale, No. (%)a
5
4
3
2
1
0
1
2
3
4
5
6
7
Score
8
9
10
11
12
❚Figure 1❚ Knowledge assessments. The x-axis shows the
number of correct answers and the y-axis the number of
trainees with the correct answers. In blue are the results
from the knowledge quiz performed before the course and in
red those of the quiz done after the course.
Results
Of the 28 participants who completed the assessment
before the course, there were 21 residents, three faculty
members, and four individuals who work in the laboratory.
All participants were from Addis Ababa University, except
for one resident who was from Jimma University. The
clinical specialties represented included anatomic pathology, internal medicine, surgery, dermatology, obstetrics,
and anesthesia. Most participants (61%) came to the course
because their supervisor suggested it, while 38% stated that
they were interested in the topic.
The class mean score in the precourse knowledge quiz
was 5.28 (range, 2-10), with only two of 12 questions being
answered correctly by more than 60% of the participants.
The topics of the questions answered correctly included
reference ranges and diagnostic sensitivity and specificity.
The class mean score on the same knowledge quiz done
at the conclusion of the course was 8.09 (range, 4-11).
Eight questions were answered correctly by more than
60% of participants. In addition to the previously correctly
answered questions, the gains were present in all areas
(blood blank/transfusion medicine, hematology, chemistry,
and microbiology). ❚Figure 1❚ graphs the number of correct
answers before and after the training. The improvement in
knowledge based on the two tests was statistically significant (P = .0001).
All 24 participants who did not work in the laboratory
stated that they had had interactions with the laboratory
since most had come to retrieve results or for obtaining
blood products for their patients. Two participants said they
had come to the laboratory because they had unexpected
results on their patients, and one said that he or she wanted
to know about reference ranges. Likert scale results regarding interactions and trust in the laboratory and use of results
are presented in ❚Table 3❚. Of note, although no participant
408 Am J Clin Pathol 2015;143:405-411
DOI: 10.1309/AJCPNYT1WPSRCLC6
Attitude
1
2
Interaction with laboratory
personnel
Trust in hospital laboratory
results
Results used for diagnosis
Results used as prognostic
indicators
Results used to follow up
patients
Results used to treat patients
0
6 (25) 9 (38) 4 (17)
5 (21)
0
7 (29) 9 (38) 7 (29)
1 (4)
a
3
4
5
0
0
1 (5) 1 (5)
6 (26) 10 (43) 7 (30)
7 (32) 9 (41) 4 (18)
1 (5) 1 (5)
7 (32) 9 (41)
4 (18)
2 (10) 7 (33) 8 (38)
4 (19)
0
Scale ranges from 1 (least valuable or used) to 5 (most valuable or used).
rated the interaction and trust in the laboratory as least valuable, most responses were neutral. Regarding use of laboratory results, most responses were either neutral or slightly
above neutral. Of the participants, 57% sent laboratory tests
to the hospital laboratory, 14% to outside laboratories, and
29% to either. Reasons to send the specimens to the hospital
laboratory included low cost, accessibility, and ease for the
patient and clinician; those sending specimens to outside
laboratories cited unavailability of tests and lack of trust in
results obtained at the hospital laboratory. When asked what
they did when they thought there was a laboratory error,
50% of participants said they repeated the test in an outside
laboratory, 29% said they would repeat the test in the hospital laboratory, and 33% said that they would communicate
with the laboratory. When asked about barriers between the
laboratory and clinicians, participants cited poor communication and isolation from each other (32%), personal differences such as lack of understanding of what each group does
(32%), lack of time (21%), and lack of tests needed (10%).
The assessment of attitudes performed after the course
was filled out by 11 participants who came to the entire
course, nine who came on 3 days, and one who came on
1 day. Nineteen participants said they had changed their
attitude toward the laboratory as they had learned and
appreciated what the laboratory does to render results and
the importance of communication between clinicians and
the laboratory. All participants said that the course would
be used in their daily work: 39% stated that the increased
knowledge would make them more aware of the different
issues that occur in the laboratory, 33% stated that they
would communicate with the laboratory when they have
problems, 22% said that the course will help them with
interpretation and utilization of tests, and 11% commented
that they now have a positive attitude toward the laboratory.
Likert scale self-assessment of the different topics learned is
presented in ❚Table 4❚. Of interest, for the majority of topics,
the participants felt very comfortable with the knowledge
© American Society for Clinical Pathology
AJCP / Original Article
❚Table 4❚
Likert Scale Regarding Self-Assessment of Topics Learned
During the Course
Scale, No. (%)a
Self-Assessment
1
2
3
Normal values (reference ranges)
Sensitivity and specificity
False-positive and false-negative results
Variability of results depending on method
Interferences
Preparation of patient and specimens
Result interpretation using different
methods
Laboratory quality control measures
Critical values
Interaction with laboratory professionals
Turnaround time
Use of the tests discussed
Interpretation of point of care
0
0
0
0
3 (15)
0
0
3 (15)
4 (20)
1 (5)
3 (15)
6 (30)
1 (5)
6 (30)
17 (85)
16 (80)
19 (95)
17 (85)
11 (55)
19 (95)
14 (70)
2 (10)
1 (5)
1 (5)
2 (11)
0
1 (5)
4 (20)
4 (20)
0
4 (21)
3 (15)
4 (20)
14 (70)
15 (75)
19 (95)
13 (68)
17 (85)
15 (75)
a
Scale ranges from 1 (not comfortable) to 3 (very comfortable).
gained, although there were a few topics with which few participants did not feel comfortable, including interferences,
laboratory quality control measures, and turnaround time.
Eighty-five percent of participants rated case-based learning as most valuable, followed by 81% rating the case discussion with the entire group as most valuable. Lectures were
rated as most valuable by 65% of participants. None of the
previously mentioned activities were rated as least valuable.
The interactive homework cases were rated as most valuable by 39% of participants, and one (6%) considered it least
valuable. Participants were divided regarding the laboratory
tours, with more leaning toward it being valuable. We asked
participants to choose five of 21 descriptive words regarding
the course. The most frequently chosen words included very
useful, stimulating, interesting, well organized, and informative. All participants said the course should be offered again
and that they would recommend it to others. Suggestions for
improvement included using videos and online material and
getting more laboratory technologists and faculty involved.
In addition, faculty members were very impressed with the
questions asked while participants were solving their cases
and how they used their different resources.
Discussion
Knowledge regarding the foundations of laboratory
medicine was improved using a 14–contact-hour course
delivered using lectures, case-based learning, case discussions, and interactive cases as demonstrated by the knowledge quizzes. Participants had good base knowledge regarding normal ranges and diagnostic sensitivity and specificity
prior to the course, while gains in knowledge were observed
© American Society for Clinical Pathology
in laboratory principles specific to all areas. In the evaluation performed after the course, participants commented
they had changed their attitude toward the laboratory as they
gained knowledge of what happens in the laboratory. In
addition, all participants stated they would incorporate what
was learned in their daily practice. Although the quiz and
assessment can measure only a small amount of knowledge
acquired recently and an initial intent to change behavior,
the participant engagement observed leads us to believe
there will likely be a change in attitude toward the laboratory. Probably the most important gain that came through in
the evaluation performed after completion of the course was
the realization by participants that more communication with
laboratory personnel is necessary when issues arise so as
to improve patient care and laboratory services. A study of
physicians’ and nurses’ satisfaction with laboratory services
in Gondar, Ethiopia, stresses the need for communication
between clinicians and laboratorians for quality improvement and interventions.14 Ultimately, having physicians
who understand laboratory medicine principles will likely
promote evidence-based medicine with modern laboratories
and evolve into having a subspecialty in clinical pathology,
either as a standalone subspecialty or integrated with anatomic pathology in Ethiopia.
It was not surprising that trainees liked case-based learning and discussions best. Case-based learning is structured
so that trainees explore clinically relevant topics using openended questions with well-defined goals.15 In our course, the
cases were structured targeting the laboratory tests available
to them in the hospital and exploring the principles behind
them. Many medical schools have transitioned to case-based
curricula as they have shown to increase student enthusiasm
for learning, enhance performance on tests, and improve
attendance to class.16-19 Case-based learning in postgraduate training has been used as a way to expose residents to
clinical scenarios they do not encounter frequently.20-22 In
particular, case-based curriculum is currently used to teach
clinical microbiology in a multidisciplinary approach where
faculty, residents, fellows, and students of different specialties meet during microbiology rounds.23 To our knowledge,
this is the first publication of a short course that uses a casebased curriculum highlighting general laboratory principles
to clinicians in the postgraduate setting.
The homework interactive cases did not receive as
high a rating as the case-based learning and discussions. A
5-year review of Duke University’s web-based informatics education also showed that students consistently rated
their person-to-person, on-campus portion of the training
as their favorite,24 although this seems to contrast with
the fact that some of the trainees suggested more online
material and videos for the course. Computer-based training has become very popular because it expands education
Am J Clin Pathol 2015;143:405-411409
DOI: 10.1309/AJCPNYT1WPSRCLC6
Guarner et al / Laboratory Medicine Short Course for Clinicians
programs that can be delivered to people in many locations
worldwide and can breach time restrictions.25,26 Popular
formats include lectures and videos placed on websites,
virtual patients or interactive exercises, tutorials, synchronous and asynchronous forums, and other formats27,28;
however, creating e-learning material that is of good quality and is useful for trainees takes time.24,29 We created four
interactive cases for the course that were not only given to
trainees in USB drives but can also be accessed through the
web (http://path.emory.edu/EPeP/; in the section Laboratory Principles for Clinicians, use EPeP as username and
password). In these cases, there is immediate feedback
after a trainee answers the multiple-choice questions. Each
module is designed to highlight laboratory principles in
a case-based format and should take between 15 and 20
minutes to complete.
Based on the assessment performed before the course,
interactions of participants with the laboratory are frequent
in the Black Lion Hospital. Most participants had gone to the
laboratory to find out results on their patients. In the United
States, this rarely occurs since physicians (including medical
students, residents, and fellows) have access to laboratory
results via electronic medical records without having direct
interaction with the laboratory. Another reason for participants to go to the laboratory included retrieval of blood
products. In the United States, this may happen, although
nurses and technicians are frequently sent on these tasks.
Thus, it is not surprising that for participants in this course,
touring the laboratory was not a highlight of the program
as it is in the United States when we take medical students
to tour the clinical laboratories.12 Nonetheless, it is imperative that physicians visit the laboratories where tests on
their patients are performed so that they realize the type of
instrumentation available and that laboratory technologists
know their trade, which are two laboratory facets that may
not be evident by going to the laboratory to pick up results
or retrieve blood products.
In our initial survey, we found that more than half of
the participants send their laboratory work to the hospital
laboratory since this is convenient for them and the patient
and the work is affordable. However, some basic tests may
not be available in the hospital laboratory because there
are no reagents or the instrument is down due to lack of
maintenance, so trainees said they send samples to other
laboratories. It is well known that higher volume of testing
allows for better quality since it requires dedicated trained
personnel and supports staff competency.1 Thus, physicians
should advocate to hospital administration the need to have
a clinical hospital laboratory with competent staff, regular
procurement of reagents, and proper instrument maintenance
rather than having clinicians send specimens to outside
laboratories.
410 Am J Clin Pathol 2015;143:405-411
DOI: 10.1309/AJCPNYT1WPSRCLC6
In conclusion, we delivered a course that highlighted
laboratory principles to clinicians using multiple formats,
of which case-based learning and case discussions were the
ones most accepted by the trainees. The 14–contact-hour
course enabled trainees to perform better on a knowledge
quiz. We believe that courses like this bring awareness to
what is performed in the laboratory, improve use of laboratory services, make clinicians advocates for laboratory services, and ultimately improve patient care.
Address reprint requests to Dr Guarner: Dept of Pathology and
Laboratory Medicine, Emory University Hospital, 1364 Clifton
Road NE, Atlanta, GA 30322; [email protected].
Supported in part by grant T84HA21124-08-00 from the
Medical Education Partnership Initiative.
References
1. Elbireer A, Jackson J, Sendagire H, et al. The good, the bad,
and the unknown: quality of clinical laboratories in Kampala,
Uganda. PLoS One. 2013;8:e64661.
2. Petti C, Polage C, Quinn T, et al. Laboratory medicine in
Africa: a barrier to effective health care. Clin Infect Dis.
2006;42:377-382.
3. Peter T, Rotz P, Blair D, et al. Impact of laboratory
accreditation on patient care and the health system. Am J
Clin Pathol. 2010;134:550-555.
4. Urdea M, Penny L, Olmsted S, et al. Requirements for
high impact diagnostics in the developing world. Nature.
2006;444(suppl):73-79.
5. Nkengasong J, Mesele T, Orloff S, et al. Critical role of
developing national strategic plans as a guide to strengthen
laboratory health systems in resource-poor settings. Am J Clin
Pathol. 2009;131:852-857.
6. Jonkman A, Chibwe R, Khoromana C, et al. Cost-saving
through microscopy-based versus presumptive diagnosis of
malaria in adult outpatients in Malawi. Bull World Health
Organ. 1995;73:223-227.
7. Bates I, Mundy C, Pendame R, et al. Use of clinical
judgement to guide administration of blood transfusions in
Malawi. Trans R Soc Trop Med Hyg. 2001;95:510-512.
8. Polage C, Bedu-Addo G, Owusu-Ofori A, et al. Laboratory
use in Ghana: physician perception and practice. Am J Trop
Med Hyg. 2006;75:526-531.
9. Wiltsey-Stirman S, Kimberly J, Cook N, et al. The
sustainability of new programs and innovations: a review
of the empirical literature and recommendations for future
research. Implement Sci. 2012;7:17.
10. Higgins J, Green S, eds. Cochrane Handbook for Systematic
Reviews of Interventions. Version 5.1.0. Oxford, UK: The
Cochrane Collaboration; 2011. www.cochrane-handbook.
org. Accessed March 18, 2014.
11. Smith B, Aguero-Rosenfeld M, Anastasi J, et al. Educating
medical students in laboratory medicine: a proposed
curriculum. Am J Clin Pathol. 2010;133:533-542.
12. Molinaro R, Winkler A, Kraft C, et al. Teaching laboratory
medicine to medical students: implementation and
evaluation. Arch Pathol Lab Med. 2012;136:1423-1429.
© American Society for Clinical Pathology
AJCP / Original Article
13. Collins F, Glass R, Whitescarvers J, et al. Developing health
workforce capacity in Africa. Science. 2010;330:1324-1325.
14. Addis Z, Birhan W, Derseh D, et al. Physicians’ and nurses’
satisfaction with the clinical laboratory service of Gondar
University Hospital, northwest Ethiopia. Am J Clin Pathol.
2013;140:324-328.
15. Srinivasan M, Wilkes M, Stevenson F, et al. Comparing
problem-based learning with case-based learning: effects
of a major curricular shift at two institutions. Acad Med.
2007;82:74-82.
16. Blewett E, Kisamore J. Evaluation of an interactive, casebased review session in teaching medical microbiology. BMC
Med Educ. 2009;9:56-65.
17. Chamberlain N, Stuart M, Singh V, et al. Utilization of case
presentations in medical microbiology to enhance relevance
of basic science for medical students. Med Educ Online.
2012;17:1-7.
18. Ciraj A, Vinod P, Ramnarayan K. Enhancing active learning
in microbiology through case based learning: experiences
from an Indian medical school. Indian J Pathol Microbiol.
2010;53:729-733.
19. Hoag K, Lillie J, Hoppe R. Piloting case-based instruction
in a didactic clinical immunology course. Clin Lab Sci.
2005;18:213-220.
20. Fields R, Bowman M, Freeman B, et al. Implementation of
an “after hours” resident educational program in a general
surgery residency: a paradigm for increasing formal didactic
training outside of the hospital setting in the era of the
80-hour workweek. J Surg Educ. 2009;66:340-343.
© American Society for Clinical Pathology
21. Cook D, Thompson W, Thomas K. Case-based or non-casebased questions for teaching postgraduate physicians: a
randomized crossover trial. Acad Med. 2009;84:1419-1425.
22. Feist M, Ciccarelli M, McFerron B, et al. Methods and effects
of a case-based pediatric gastroenterology online curriculum. J
Pediatr Gastroenterol Nutr. 2013;56:161-165.
23. Spicer J, Kraft C, Burd E, et al. The value of case-based
teaching vignettes in clinical microbiology rounds. Am J Clin
Pathol. 2014;14:318-322.
24. Goodwin L. Web-based informatics education: lessons
learned from five years in the trenches. Proc AMIA Symp.
2002:300-304.
25. Smith A, Tasioulas T, Cockayne N, et al. Construction and
evaluation of a web-based interactive prescribing curriculum for
senior medical students. Br J Clin Pharmacol. 2006;62:653-659.
26. DaJusta D, Mueller T, Barone J. Accreditation Council for
Graduate Medical Education competency–based on-line
computer course in pediatric oncology for urology residents.
Urology. 2008;71:818-820.
27. Schilling K, Wiecha J, Polineni D, et al. An interactive
web-based curriculum on evidence based medicine: design
and effectiveness. Fam Med. 2006;38:126-132.
28. Kamin C, O’Sullivan P, Deterding R, et al. A case study of
teaching presence in virtual problem-based learning groups.
Med Teach. 2006;28:425-428.
29. Choules A. The use of elearning in medical education: a review
of the current situation. Postgrad Med J. 2008;83:212-216.
Am J Clin Pathol 2015;143:405-411411
DOI: 10.1309/AJCPNYT1WPSRCLC6