For a leader in a field at a pivotal moment of transition, Brian R. Smith, M.D., is modest, equating his role as chair of the Department of Laboratory Medicine to mostly “filling out pieces of paper.” But Smith’s department, with a mission that combines both service and research, is critical to patients at Yale-New Haven Hospital (YNHH) and many other institutions in New England and beyond, as well as to the work of other medical school departments.
Members of the department study the components of blood and other bodily fluids to better understand and treat disease, including those measured in the familiar lab tests ordered by doctors. Each day the department produces about 75,000 lab results for patients at YNHH and for Yale Medical Group, the medical school’s clinical arm.
The department’s research mission is necessarily broad, says Smith, professor of laboratory medicine, medicine, and pediatrics, because “our discipline covers essentially all of physiology and pathophysiology,” with the strongest focus on immunology, hematology, and cellular therapy. Smith’s own research has explored the interface between the immune and coagulation (clotting) systems in blood diseases, cardiovascular disorders, and metastatic cancer. His work on these two critical physiologies may ultimately help to reduce complications associated with heart-lung bypass machines and the administration of blood transfusions.
After attending Princeton as an undergraduate, Smith received his M.D. from Harvard Medical School, and completed his internship and residency in internal medicine at the Peter Bent Brigham Hospital in Boston. He completed fellowships in hematology, oncology, hematopathology, and research pathology at the Brigham, the Dana-Farber Cancer Institute, and Children’s Hospital in Boston before joining Harvard’s faculty in 1981. He came to Yale in 1989.
Fifty years ago, a patient’s laboratory tests might include analyses of two or three factors, and a technologist might spend a full day generating the results. Now, Smith says, it often takes less than an hour to obtain 20 or more results for one patient. As technology alters the medical landscape, the field is facing an information explosion that demands new ways of managing and interpreting the data. Genomics alone, which now allows rapid sequencing of the billions of base pairs in the human genome, has brought formidable challenges to laboratory medicine.
Labs will soon routinely perform complex genomic and proteomic analyses impossible just a few years ago, vastly improving diagnosis but increasing reliance on informatics. “Humans are very good at some qualitative pattern recognition, but computers are far better at consolidating multiple quantitative analyses for diagnostics or following the results of therapy.” But aside from technical problems, maintaining vast stores of patient information raises ethical questions. If whole genomes of patients are sequenced many years before genetic advances reveal new risk factors for diseases, “Do we try to find every patient previously sequenced and call each of them back with the new information?” Smith asks. He predicts an ever-increasing interaction of specialists in laboratory medicine with other physicians to evaluate the clinical significance of the rapidly proliferating options available in laboratory diagnostics.
The increasing adoption of electronic medical records may help pave the way for improved informatics systems. But the information overload about to take place in medicine is unprecedented, Smith says. “We need a national debate, and I think we’re moving in that direction,” he says.