Major Organs and Cancer —
Training activity: 7

Details

Interpret and report the results of calculated tests to include:

• Renal disease
  • AKI
  • CKD
  • Creatinine clearence
  • eGFR
• Iron studies
• Lipids
• ACR or PCR
• Adjusted Calcium
• Anion gap
• Osmolar gap

Type

Entrustable training activity (ETA)

Evidence requirements

Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion. ​

Reflection at multiple timepoints on the trainee learning journey for this activity.

Considerations

• Method selection, including assay advantages and limitations, quality parameters, and interferences
• Equipment calibration and maintenance
• Quality control; EQA and IQC
• National and international guidelines
• Report formats

Reflective practice guidance

The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.

Before action

What does success look like?

• Identify what is expected of you in relation to accurately interpreting and reporting the results of calculated tests (e.g., eGFR, adjusted calcium, anion gap).
• Consider how the learning outcomes apply, specifically in relation to interpreting the calculated value in the clinical context and demonstrating awareness of national guidelines that utilise these parameters.
• Discuss with your training officer to gain clarity of what is expected of you in relation to the specific formulas used for calculations and the standards for reporting these calculated parameters.

What is your prior experience of this activity?

• Think about what you already know about common calculated tests such as eGFR, adjusted calcium, or Iron studies calculations.
• Consider possible challenges you might face during the activity, such as understanding the assumptions of complex formulas (e.g., eGFR formulas) or correctly applying correction factors (e.g., for adjusted calcium).
• Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if an unexpected result for a calculated test (e.g., osmolar gap) requires verification of the formula input data, or if interpretation in a specific patient population is complex.
• Acknowledge how you feel about working with and interpreting calculated biochemical data.

What do you anticipate you will learn from the experience?

• Consider the specific skills you want to develop, such as mastering the interpretation and clinical utility of complex calculated parameters (e.g., AKI staging or creatinine clearance).
• Identify the specific insights you hope to gain into the clinical utility of these calculated tests in diagnosing and monitoring conditions like chronic kidney disease (CKD).

What additional considerations do you need to make?

• Consult actions identified following previous experiences of interpreting calculated biochemical results.
• Identify important information you need to consider before embarking on the activity, such as the specific formulas used for calculating parameters (e.g., anion gap), the relevant reference ranges, and applicable national guidelines (e.g., CKD guidelines), including the source of equations used.

In action

Is anything unexpected occurring?

• Are you noticing anything surprising or different from what you anticipate whilst interpreting calculated tests (e.g., eGFR, adjusted calcium, anion gap, iron studies)?
• Are you encountering situations such as:
  • A calculated result (e.g., osmolar gap or creatinine clearance) is highly discordant with the patient’s clinical state or other measured parameters?
  • Difficulty arises in verifying the input data used in the calculation, or you suspect the formula limitations are being exceeded (e.g., for eGFR in specific populations)?
  • The interpretation requires application of complex national guidelines (e.g., AKI staging or CKD diagnosis) that you are currently unsure of?

How are you reacting to the unexpected development?

• How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to verifying the calculation integrity or seeking clinical context?
• Consider the steps you are taking in the moment, such as:
  • Immediately re-checking the calculation parameters to ensure accurate input data was used (e.g., checking albumin concentration for adjusted calcium)
  • Consulting the relevant national guidelines (e.g., CKD guidelines) to accurately stage the patient’s disease
• How are you feeling in that moment? For instance, are you finding it difficult to understand the limitations of the calculation? Is it affecting your confidence in interpreting the clinical significance of the calculated value?

What is the conclusion or outcome?

• Identify how you are working within your scope of practice. For example, are you successfully verifying the calculation and interpreting the result in line with clinical context? Or are you needing support because an unexpected osmolar gap result requires investigation into potential exogenous toxins necessitating senior consultation?
• What are you learning as a result of the unexpected development? For example, are you mastering the accurate application of correction factors or staging criteria (e.g., AKI/CKD)? Or gaining insight into the clinical utility and interpretation pitfalls of tests like anion gap or lipids calculation?

On action

What happened?

• Begin by summarising the key steps you took when interpreting and reporting calculated tests (e.g., eGFR, adjusted calcium, anion gap, AKI staging).
• Consider specific events, actions, or interactions which felt important, such as verifying the input data used for the eGFR calculation or the systematic process followed to apply correction factors for adjusted calcium.
• Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately seeking clarification when an osmolar gap result appeared inconsistent with the measured electrolytes.
• How did you feel during this experience, e.g., did you feel confident in applying complex national guidelines (e.g., CKD staging) or cautious about interpreting a highly calculated parameter like creatinine clearance?

How has this experience contributed to your developing practice?

• Identify what learning you can take from this experience regarding interpreting and reporting derived biochemical parameters. What strengths did you demonstrate, e.g., accurate application of necessary correction factors?
• What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the limitations or assumptions of specific eGFR formulas in different patient populations?
• Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in correlating calculated tests (e.g., AKI staging) with the patient’s overall clinical picture?
• Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding interpreting a calculated test (e.g., anion gap) that suggested potential exogenous toxins (e.g., methanol) outside routine clinical biochemistry scope, and how you reacted to this.

What will you take from the experience moving forward?

• Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving the accuracy and clinical utility of calculated test interpretation.
• What will you do differently next time you approach interpreting a calculated test, for instance, by proactively verifying all raw input data before finalising the interpretation?
• Do you need to practise any aspect of the activity further, such as reviewing the criteria for AKI staging or key learning outcomes related to applying national guidelines?

Beyond action

Have you revisited the experiences?

• How have your subsequent experiences of interpreting complex patient profiles (e.g., renal disease cases or metabolic disorders) or engaging in academic study of pathophysiology since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, how subsequent exposure to a case involving unexplained osmolar gap forced you to re-evaluate the simplicity of your initial assumptions regarding the input parameters for these calculated tests.
• Considering what you understand about formula limitations (e.g., eGFR in non-standard populations), correction factors, including the use of locally derived equations (e.g., adjusted calcium), and the application of national guidelines (e.g., AKI/CKD staging) now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your critical evaluation of calculated results and application of clinical guidelines based on further learning and experiences? For example, how you proactively reviewed and integrated the national criteria for classifying acute kidney injury (AKI) to accurately stage renal impairment based on calculated Creatinine clearance and eGFR.
• Has discussing calculated test limitations or complex cases involving anion/osmolar gaps with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a time when misinterpretation of an anion gap led to a delay in investigating a metabolic acidosis refined your understanding of the critical need to confirm input data accuracy.

How have these experiences impacted upon current practice?

• How has the learning from this initial training activity, in combination with subsequent metabolic and renal disease interpretation experiences, contributed to your overall confidence and competence in critically evaluating derived parameters and applying national guidelines, particularly in preparing for assessments like Case-Based Discussions (CBDs)? For example, how your accumulated ability in understanding the limitations of eGFR calculations and interpreting the anion gap now enables you to confidently discuss metabolic balance and renal function during a CBD assessment.
• How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to interpreting calculated biochemical parameters? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from the duty biochemist immediately when an unexpected calculated result (e.g., high osmolar gap) suggests potential exogenous toxins or formula limitations have been exceeded, recognising this requires specialist toxicological or metabolic review.
• Looking holistically at your training journey, how has this initial calculated test interpretation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to analysing and interpreting biochemical data and applying knowledge of national guidelines? For example, how this foundational experience has supported your development in critically evaluating all biochemical data and applying complex parameters (e.g., AKI staging) in a clinical context.

Relevant learning outcomes

#	Outcome
# 1	Outcome Perform biochemical assays involved in the assessment of major organ function and cancer diagnosis and monitoring.
# 2	Outcome Analyse and interpret biochemical data generated in the assessment of major organ function and cancer diagnosis and monitoring.
# 3	Outcome Evaluate the national guidelines for diagnosis and management of diseases associated with the major organ systems and cancer.