Have you seen what is going on in our stores lately? Maybe everybody's noticed drones taking off from parking lots to deliver groceries, but watching a flying lawnmower with a cargo box underneath it take off the other day got us thinking: what other kind of specimens could be transported?
Could you package up a few tubes of blood, strap them underneath that flying machine, and send them to a laboratory? Probably. And if you can do that reliably, how much laboratory testing needs to happen where it happens now?
Laboratories have always been at least partly constrained by geography. A core laboratory has advantages, but one of the most durable has been incredibly boring. Sure, it is close to the patients – but that's beginning to matter a lot less as transportation becomes better and faster.
Health systems and reference laboratories figured this out a long time ago, because once specimens can be moved reliably and turnaround times are still clinically acceptable, scale becomes attractive. Why do you need four identical pieces of equipment if all of those specimens can be moved to a central location?
Drones don't change that logic, but they demonstrate how far that logic might eventually spread. Suppose travel becomes fast and inexpensive. Could a regional lab absorb more of the routine testing currently performed? Probably. Could a national reference lab absorb all of it? Probably not. Eventually, biology gets to have an opinion. Some specimens travel well, but others impose practical limits through stability, turnaround time, processing requirements, clinical urgency, or some combination of all of them. Drones can fly over traffic, but they can't fix preanalytics.
That raises an interesting hypothesis: maybe every test has some sort of "centralization radius." (A Harvard MBA somewhere is cringing because they have a much more elegant term.)
For some esoteric testing, the clinical difference between a result today or tomorrow is almost irrelevant. So, if the expected turnaround time is measured in days or weeks, put that specimen on an airplane. But at the other extreme, there are assays where the correct centralization radius is approximately the length of a pneumatic tube. As transportation gets faster and technology improves, the boundary might move, but it still exists.
There is a similar force moving us in the opposite direction, trying to move testing closer to patients. We can see it in the raw numbers: point-of-care testing has expanded substantially, and testing sites outside traditional hospital laboratories have proliferated. Increasingly sophisticated platforms have allowed testing to be pushed outward into clinics, procedure areas, pharmacies, even ambulances and homes. But that direction also has a limit because moving the test closer to the patient also moves QC, reagents, training, maintenance, troubleshooting, utilization oversight, connectivity, and cost closer to the patient as well. For a lot of assays, that trade-off is worth it. But for others, it will never make sense. There is no compelling reason to put a mass spectrometer next to a clinic's office printer.
The laboratory can feel like it is being squeezed from both directions. On one side, we're being pushed by large centralized operations using scale and sophisticated logistics. On the other side, we're being squeezed to test ever closer to the patient. In the center of this sandwich, where all the best ingredients reside – the meat, mayo, and mustard – sits the conventional hospital laboratory. (The question of which part of the lab represents the mayonnaise is still up for debate.)
How far could each side push before it ran into some practical limit? Pretty far, probably, but not forever. Eventually, centralization runs into biology, and decentralization runs into complexity, quality, and cost.
The physical middle, where specimens are processed, is protected by exactly those characteristics. Centralization eventually hits constraints. Decentralization eventually encounters complexity and cost. Those boundaries might move over time, but there's probably a durable middle that will persist. That's the space whose business case is driven by consolidation, logistics, capital, drones, test menus, and the future of large-scale laboratory testing. The Vanishing Middle.
But is there, perhaps, another middle that is disappearing at the same time? What if an analyzer reports a potassium of 6.2 mmol/L? Everybody knows what's coming next. The logical questions are things like, is it real? Was the specimen hemolyzed? Has there been some sort of contamination? Is the result consistent with the patient's renal function or medications? Is it discordant with previous tests and results? So maybe we should check the chart. Maybe the patient needs urgent treatment, or maybe the patient just needs another test. Once the 6.2 is resulted, the analyzer's work is finished, but the clinical work has just begun.
We are all aware of the enormous amount of work between the analytical result and clinical action. Test selection, specimen quality, potential interferences, reflex and confirmatory testing, longitudinal interpretation, patterns that emerge across multiple results, diagnostic stewardship, and technical challenges are just a few of the things that need to be considered when assessing that result. Technically correct numbers do not tell the whole story because if they did, all we would need is a technologist, an analyzer, and a large language model.
So, yes, there is another middle – a whole other sandwich that we need to consider. It is the space between “6.2 mmol/L” and the beginning of the next sentence: “Therefore, the patient has … and we should …” Unfortunately, this is a middle that has no natural boundary.
Specimens cannot reject physics, no matter how much hospital administrators would like to make that happen. But there's no equivalent law reserving interpretation for laboratory professionals. There is no economic, physical, or chemical boundary that determines how much of that interpretive space must remain within laboratory medicine.
Clinicians can occupy that space, decision support systems can take some of it, manufacturers and analyzer companies are likely to embed interpretations into their systems, AI is absolutely going to take part of that space. And, in many cases, all of those things should happen. The worrying part is that lab medicine spends most of its energy defending the first middle – the business middle – but quietly neglects the second one.
If our role is primarily focused on producing the 6.2, then the economic forces around consolidation and decentralization can start to appear existential. Those threats will likely ebb and flow until they reach some sort of natural equilibrium. We are much less certain there is any natural equilibrium in the second middle.
The physical location of laboratory analysis is probably going to become increasingly fluid. Some testing is going to migrate closer to the patient, while other testing will migrate farther away. Specimens will travel through pneumatic tubes, courier networks, and maybe even ride under flying lawnmowers or drive autonomously. And laboratory testing volume will probably keep increasing anyway.
The more durable question for the field is what happens after the result exists. Who determines if the analysis makes sense? Who connects those results to a diagnostic pattern rather than treating them as unrelated or as a snapshot in time? Who understands enough about both the assay and the patient to recognize when things aren't properly aligned? Who helps decide what test should be done next anyway? And when?
This cognitive, or intellectual middle, doesn't exist simply because a laboratory does. It exists if we decide to keep it. The lab testing business middle will probably keep shrinking until technology runs into practical limits. And if laboratory testing volumes continue to increase, it won't necessarily be catastrophic. But the professional middle increasingly seems to have no protections whatsoever. That seems like the one worth worrying about.
Although, it will still be fun to see what happens when Walmart starts flying test tubes around the neighborhood...
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