Pilsen’s Second-Biggest Export: Pathology

Pilsen (or Plzeň to its inhabitants) is a city with many claims to fame. The fourth largest city in the Czech Republic, it served as the cultural capital of Europe in 2015. But of course, it’s best known for Pilsner beer, which was created many years ago in one of the breweries of that medieval town. The Plzeň of today still brews beer in enormous quantities, but now there’s something even more noteworthy about it – it’s the home of Bioptická Laboratoř (BL), the biggest pathology laboratory in the Czech Republic. I recently had the opportunity to ask Michal Michal, the head of this enterprise, a few questions about it. You might be interested in finding out how he became the richest pathologist in the Czech Republic!

Let’s start with some history. How did you expand Bioptická Laboratoř from a small, rented flat into the largest laboratory in Eastern Europe?

Bioptická Laboratoř was established in 1993. The name translates to “Biopsy Laboratory” in English, a reflection on the fact that, at the very beginning, we only did biopsies – cytology investigations began four years later, and genetics six. When we started, we didn’t have any money. There was one small microscope shared between three pathologists, and instead of a table and chairs, we used empty plastic beer cases arranged around the box from a computer monitor. We rented a small flat in a house in the center of Plzeň that belonged to my brother, but when his small business went bankrupt, we faced a dilemma: whether to buy the house so that my brother could repay his debts, or simply move out. In the end, we took out a loan from the bank for the price of the house – CZK3,000,000 (about US$100,000). At the time, that was a lot of money; the net salary of a pathologist was only about CZK3,000 per month. The same house would cost 10 times as much today, but luckily, we started early. Now, we’ve expanded to six neighboring buildings in a block in the middle of town – including an old cinema called Eden, which used to be the biggest cinema in communist Czechoslovakia. We have entirely rebuilt it and brought our laboratory space up to 8,500 m².

I am happy to confirm the rumors circulating about our lab’s size! There’s no question that Bioptická Laboratoř is by far the biggest private laboratory in Eastern Europe. We process over 160,000 biopsies and 800,000 cytological specimens a year, as well as 10,000 consultation biopsies from around the world and 80,000 immunohistochemical stainings. Next year, we expect to process biopsies and cytological examinations for over a million patients!

What does Bioptická Laboratoř do now?

This year, we’ve started something new: producing immunohistochemical slides for other pathology departments. We employ about 450 primary antibodies in our immunohistochemical laboratory – more than any other laboratory in the Czech Republic can store, to the point where some hospitals have replaced their immunohistochemical laboratories altogether with our services. Our IT technicians wrote a program that we install on the hospital computers, so that pathologists can just input a patient’s number and click to select the tests they want us to conduct. We produce the slides, scan them with a whole slide scanner, and send the virtual slide back. The real slides follow a day later by car.

Fifteen years ago, we expanded our services to include molecular biology. Since then, the demand for it has grown rapidly, especially in recent years. We offer nearly 100 genetic tests necessary for hematopathology, solid tumors (especially soft tissue neoplasms), germline mutations (especially Lynch syndrome), familial adenomatous polyposis, BRCA mutations, Brooke-Spiegler syndrome and many others. The last test we introduced has been in great demand; it detects mutations in the promotor of the telomerase reverse transcriptase gene TERT. When found in urine sediment, these mutations are practically specific for urothelial carcinoma of the urinary bladder and upper urinary tract, with a sensitivity of 85 to 87 percent.

How much trouble did you have with issues like permissions, licenses and logistics?

It was not difficult at all to license a private laboratory in 1993. The entire Czech healthcare system belonged to the state, and the Ministry of Health declared that anybody who wanted a private license could ask for one, but had to do it by the end of the year. Our biggest logistical problem was organizing the collection and reading of classical cervical-vaginal Pap smears. When you read 800,000 Pap smears a year, it’s hard to avoid mixing up specimens – so we had our technicians develop a unique program using barcodes. We provide two barcodes for each test: one for the slide and one for the accompanying documents. That prevents mix-ups without requiring any identifying information. When our pathologists receive the slides, they scan the barcode to get the patient’s gynecological history. After examination, the result is sent electronically both to the gynecologist and directly into the patient’s file – and if there are any abnormal findings, the gynecologist receives an automatic text message as well.

Now that we’ve grown so much larger, we’ve had to develop ways of providing pathology services to the entire country (Figure 1). As a result, our lab owns 90 cars, employs several professional drivers to collect specimens, and has secretaries who also work as part-time specimen collectors (spending mornings visiting clinical clients and afternoons on secretarial work to break up the monotony). We have a unique pay structure for this kind of work; as secretaries, they are paid for every word they type, and as specimen collectors, they are rewarded based on mileage and number of visits. It works for us and for them because it’s a very flexible system that grows when we do.

We are also large enough that we don’t need to market our services. Our only advertisements are our publications and the lectures our pathologists give worldwide. We pay our pathologists to give those lectures, and talks aimed at clinicians are better paid than those intended for pathologists. We also have a “price list” for papers, to motivate our pathologists to publish in highly ranked journals – so a paper accepted for publication in, for instance, the American Journal of Surgical Pathology, will earn the pathologist much more money than one published in a journal with a lower impact factor. We also run regular courses for pathologists (see www.patologie.cz for more information) and some quite popular Saturday pathology courses for clinicians.

How does the laboratory work as a business?

We don’t set our own prices. The costs of pathological and cytological services are regulated by healthcare insurance companies, and the prices of genetic tests are regulated by clinicians. Each clinician has a budget allotted by insurance companies for all laboratory examinations, and if they go over budget, the companies fine them – so they’re the main regulators of cost. That said, the prices in our country are consistently much lower than in western countries. For example, insurance companies pay us €6–9 for one immunoslide, whereas in Western Europe the same slide would cost three to six times more.

We have quite a large profit margin on our tests, but we also spend a huge amount of money on things we can’t sell – laboratory research and scientific publications. Our pathologists publish between 60 and 80 scientific papers a year (see Figure 2), of which more than half have appeared in high-impact journals. Nowadays, nearly all of those papers include genetic and molecular data, which we pay for without reimbursement. We can’t even get government funding because the system of grants is quite corrupt in our country. Instead of fighting the societal problem of that corruption, we’ve chosen to concentrate on pathology, provide a first-class service to the public, and use the money we earn for science. Our laboratory has been recognized nationally and internationally as a major research center. Our pathologists have been internationally credited for the first descriptions of several tumor types discovered right here in Pilsen (1–8). And of course, we’re always expanding; the last few years of income have been spent on renovating the former Eden cinema into a laboratory. We own several blocks of houses in the center of Pilsen and anticipate acquiring even more real estate. As you can see, pathology, business, science and education are all intricately interconnected, and our model of integrating all of these laboratory activities has proven to be a winning formula!

Almost all of the profits that don’t go to research are reinvested into the laboratory and its personnel. We don’t only buy buildings for the laboratory – we arrange housing for our staff as well, including 15 flats for our pathologists and two apartment houses for other employees. We also pay for services like childcare, car care and household help. In fact, we even have a private mobile phone network that has grown to over 7,000 SIM cards and includes not only our employees, but also our clinician clients and their families. Naturally, all of this costs a lot of money, but we consider it a good investment!

What are some of the most interesting activities at Bioptická Laboratoř?

The 12 geneticists and 10 technicians in our genetic laboratory specialize in the pathology of various syndromes, including many neoplasms and infectious diseases. In that laboratory, we also conduct forensic genetic testing (for instance, paternity testing for legal purposes or genealogical analysis of family lines) and perform 20,000 HPV tests a year. It’s our fastest-growing division and I anticipate a lot of interesting work in that area in the future.

We also run an outreach program for pathologists from former communist countries. We invite them, reimburse their travel expenses, and provide accommodation in one of the laboratory’s six visitor apartments. We collaborate with pathologists in a number of post-communist countries, working on joint projects with us that they couldn’t afford by themselves, and we welcome them frequently for visits. Fortunately, we are well equipped for group projects, with a number of conference rooms and other collaborative facilities – even a multi-head microscope with 31 heads! These facilities have allowed us to host national and international meetings, including a conference of the Arkadi M. Rywlin International Pathology Slide Seminar Club, several on urological or head and neck tumors, and many smaller meetings. And since our 2012 accreditation by the International Committee of Dermatopathology-European Union of Medical Specialists as a Specialty Training Center in Dermatopathology, the number of guests we receive has  only grown.

What are you most proud of so far – and what do you hope to do next?

I am most proud of the community in our laboratory. We work together as a sort of kibbutz and have great relationships. Our laboratory has 270 employees, and in the 23 years of its existence, only two have ever voluntarily left our employ! It makes me very pleased to think that practically all of the employees who enter our laboratory will stay with us forever.

A major plan of mine is currently in its final stages. We’re implementing full electronic communication with all of our clinical clients in over 3,000 locations. Soon, we won’t need to use paper documentation for biopsies, cytological examinations or genetic examinations. For that, we’ve employed four excellent IT technicians, and we’re now working on getting permission from all the healthcare insurance companies to allow us to go paperless. Paperwork is mandated by law in our country, so we need to overcome that obstacle – but technically, the project is ready!

I have one other dream: to build a restaurant in one of our houses to serve our employees, visitors and the public. I’m well known for my interest in enology – my private wine collection includes about 13,000 bottles – and our laboratory manager’s son is one of the best sommeliers in the Czech Republic, so we often dream of making this a joint project. We’ve already decided that it will be a French wine restaurant, so now we’re just waiting for the right space to be available!

Do you have any secrets that help you beat the competition?

Just one – namely, that almost all of our main managers are women. In our laboratory, women order and men obey. I generally consider women to be more responsible, more focused, and more psychologically stable. We have a joke in our country that when the women take power, they will send all the men to live in the zoo. If that comes to pass, I hope they’ll reserve the biggest cage for me.