What challenges are clinical labs currently facing? Laboratory medicine has been defined as a “profession without a face”, as it often lacks visibility to patients and to the public, both as a medical discipline and as a vocation. Within healthcare, laboratory specialists are often perceived simply as lab equipment managers, and not as peers who hold a position of shared clinical leadership. This challenge is coupled with the significant economic pressures that we’re under to cut costs and operate on an increasingly limited budget. The result is often consolidation and regionalization, in some cases with one lab working with multiple healthcare facilities. This disconnect could undermine the influence of lab professionals, and further distance them from clinical decision-making. The winds of change are coming though, and as our test repertoire and workload increases, we need to work harder to ensure we increase the appropriateness of test requests, for example, by decreasing the number of unnecessary and redundant tests – but that can only happen if we improve our profile, and communicate more effectively with our clinical colleagues in healthcare. Right now, I don’t think laboratory scientists advocate well for themselves.
So lab specialists need to take an active role in reducing unnecessary testing? Absolutely. With their knowledge of diagnostic tests and the rationale behind them, lab specialists are in a unique position to advise clinicians on selecting the appropriate test, interpreting the results, and therefore influencing treatment decisions. However, given the profession’s low profile, and the lack of collaboration with clinical colleagues, means this doesn’t always happen. Cardiac troponin is a useful example – when it replaced previous tests for myocardial infarction diagnosis, a significant number of false positive tests was eliminated, saving a huge amount of money in costs of unnecessary therapy – this demonstrates that when lab medicine assumes a central role in introducing new tests, and ensuring obsolete ones are removed, patients and healthcare providers benefit. More recently, so called “highly sensitive” troponin assays have gained popularity, and have demonstrated an increased ability to reduce morbidity and mortality, by better identifying high-risk patients. However, emergency departments and cardiologists have not welcomed the introduction of highly sensitive assays, as the increased sensitivity affects the interpretation of the results, which leads to confusion if clinicians are not correctly educated. It is therefore of critical importance that lab professionals are involved in conversations around new test introductions and their interpretation from the beginning. Studies have also shown that requests for certain tests can vary hugely from practice to practice, in a way that can’t always be explained by differences in disease prevalence – for example, in the UK, the annual rate of requests for carbohydrate antigen 125 testing shows a nine-fold variation between practices! Creating recommendations to encourage the correct use of the test should potentially greatly lessen the number of tests ordered, therefore saving money, without adversely affecting patients.
How do lab specialists go about effecting change? We must take on a continuous active advisory role, in order to improve clinician understanding of what tests to order, when to order them, and how they should be interpreted. The vast majority of lab-related diagnostic mistakes occur at the laboratory-clinical interface, and involve test demand (pre-pre-analytical phase) and result interpretation (post-post-analytical phase). Improving the way the lab and the clinician collaborate will help to reduce these errors. When it comes to interpretation, there is also a need to make results clear so that the appropriate action can be taken. In a recent US survey, about 20 percent of primary care physicians reported experiencing challenges and uncertainty in interpreting different laboratory report formats – this translates into millions of patients every year who risk being adversely affected by unclear, or poorly understood, test results.
What challenges do you anticipate? I have observed a general reluctance to get more involved in structuring tests and providing input on which tests are ordered, as I think lab professionals often assume that all tests the clinician requests must be necessary. The communication between the lab and the ward is sometimes very poor, and integration isn’t easy. In order to play a central role in healthcare and improve the clinical impact of laboratory testing, we need to change our own attitude, become more outward looking and innovative, and create opportunities to demonstrate the value of our profession. We play a pivotal role in healthcare delivery, by providing clinicians with the information they need to provide the right care to patients, and we need to make our voices heard.
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