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Lab pathology?

Posted Oct 02 2008 2:20pm
I received this note many months ago from a member of our Pathology Department, expressing some opinions and concerns based on a lecture he heard at an annual meeting. I had meant to post it back in March, when I received it, but the delay does not affect its relevance. I do not have the expertise to offer an opinion on this matter, and so I present it for your consideration and comments.

Dear Paul,

I just returned from our Academy of Pathology meeting in Denver. Chris Fletcher from Brigham and Women's Hospital delivered a pessimistic keynote lecture on the "future of academic pathology."

He cited commercial labs as one of the major threats. These labs claim to offer a faster, cheaper service, and often hire prominent pathologists to enhance their letterhead. Due to their sample volume and available capital, these labs can offer expensive specialized clinical tests before university hospitals.

Dr. Fletcher argued that these labs siphon off low complexity cases (small biopsies and chemistry tests) from the market and leave the low profit margin cases to us. With the resulting strain on salaries and budgets it will become increasingly difficult for academics to maintain the staff and resources needed to train new residents and maintain research programs. In the worst case scenario (my extrapolation, not Fletcher’s), we are currently training residents to work for those private labs–academic salaries will not be able to keep them. In future, the companies could start their own resident training programs away from university affiliations and clinical colleagues, and all research requiring human tissues would depend on commercial for profit tissue banks.

There is no doubt that these labs provide a good service. Probably 90%+ of the lab samples and biopsies are routine (I could train any ‘top 10% of his class’ college graduate to report a diagnosis). The letterhead experts act as consultants for that last 10%. The labs are faster since they do not have the delays and expenses intrinsic to a residency-training program. They have good marketing people and customer service (i.e. you will get a glossy colorful report with a well worded, yet automated, interpretation).

However, academic labs do offer added value. Lab data is not a printout from a machine. It has to be interpreted, and interpretation without clinical context leads to poor patient management and wasteful test utilization. A doctor’s office-manager does not think twice about splitting up a panel of blood-tests between labs to save a buck; never thinking that that those labs use different reference values or testing methods. Clinicians may not understand the limitations of the particular testing methods and are forced to rely on marketing menus rather than the confidence of a pathologist colleague.

Hospital based labs facilitate communication and consultation. Most patients who have never visited a Tumor Board Conference or Multidisciplinary Conference would be shocked to learn that their surgeon or obstetrician does not run their lab tests like on television (House or CSI). They have no idea that two women with a pathology report for stage 2 uterine cancers might be treated differently because of pathologist input.

How can we compete when our own doctors are using these labs?

Inform the public. Patients shop around for oncologists and surgeons: Why not pathologists? Tell patients to ask where their samples are being sent. The answer, "a reputable lab that has been certified by the College of American Pathologists" is not good enough. Does your doc know his pathology colleague?

Commercial lab reports tend to be simple and easy to read, using templates. Template based reporting can clarify communication (and perhaps we should take their lead), but template are also a way of covering up for cheap inexperienced staff. Our own BIDMC oncologists insist on internal pathology review prior to therapy to identify such frequently missing information. Biology does not conform to multiple-choice answers-and I don’t choose my doc based on how they did on their board exam.

As for being cheaper, we know that the listed cost of a hospital-based test has very little to do with the negotiated charge billed to an insurer or the government. As for speedy results, the turn-around-time for blood test is probably similar in commercial and academic labs; for small biopsy where academics is slower, the rush is not driven by patient care since the results will not get to the patient until the follow-up visit a week later.

Of course, academic labs such as ours could and should offer better service, but we already offer better care. This message should be broadcast before it is too late.
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