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Medical Director of Clinical Chemistry and Point of Care Testing, Department of Pathology, Baystate Medical Center; Assistant Professor of Pathology, Healthcare Delivery and Population Sciences, UMass Chan Medical School; Founder Director, Foundation for Advancement of Essential Diagnostics, USA and India

Biggest challenge in pathology? Pathology and laboratory medicine practices are struggling under the weight of reimbursement and cost containment pressures across health systems in the United States. The approximate Diagnosis-Related Group (DRG) payment under Medicare for clinical laboratory services is less than three percent. That restricts access to timely and accurate diagnosis by making hospital laboratories financially stumbling. 

Globally, access to diagnostic tools and technologies for patient care in low- and middle-income countries remains the biggest challenge. In the developed or the developing world, the biggest challenge facing the field of pathology and laboratory medicine is access to the diagnostic toolbox for patients for the best practices in medicine. 

Exciting developments and trends? One of the most exciting developments over the past decade has been the technological advancements in pathology. From the draft map of the human genome published in 2000 to the complete telomere-to-telomere (T2T) human genome sequencing in 2022, the excitement is never ending. A draft map of the human proteome was also published in 2014 and a more comprehensive chromosome-centric map is currently in progress. Overall, our understanding of "pathos" (disease) and "logos" (a study) in pathology has never been more advanced than it is today in 2024. 

The emerging trend is the use of a generative AI-based technological sandbox to obtain deeper insights into diseases. Anatomic pathologists will also adopt these AI-driven image analysis tools, making slide reviews more effective and efficient in day-to-day practice.

Missing from the diagnostic toolbox? One important aspect missing from the diagnostic toolbox is the integration of pathology and laboratory medicine into the actual practice of healthcare. We should ask ourselves: How many medical students graduate from medical institutions with a solid fundamental understanding of concepts such as the ‘two-step Fagan's nomogram and interpretation of a diagnostic test result’ with pre-test and post-test predictive values? This foundational knowledge is often overlooked and lacks proper reinforcement. That’s why I have made it my life’s mission to bring pathology and laboratory medicine to the forefront of healthcare delivery and medical education.

Controversial opinion? I am against the consolidation of pathology and laboratory practice into two or three for-profit reference laboratories in the United States. Let me be very clear, I am not opposed to for-profit reference laboratories – they are an essential component of the bigger pathology and laboratory medicine (PALM) ecosystem. However, we must also protect academic medical centers and hospital-based clinical laboratories to ensure the future of best practices in pathology and laboratory medicine. 

The pressures of negative reimbursement and cost containment across health systems in the United States are making it difficult for the hospital administration to see the value of clinical laboratories in healthcare delivery and patient care. Access to the ‘diagnostic toolbox’ is neither part of our DNA (genetic material) nor part of our Community Health Needs Assessment (CHNA). We collectively fail to recognize that 70–80 percent of all clinically actionable information for a patient is generated from clinical laboratories, yet we often complain about missed or incorrect diagnoses. 

On the issue of workforce shortages in pathology and laboratory medicine, my opinion is that every clinical test outsourced by academic medical centers to external reference labs is a lost educational opportunity and a lost clinical vignette for next-generation pathology residents and subspecialty fellows. When an academic medical center and hospital sells their outreach laboratories to for-profit companies, training and learning opportunities for pathology residents and subspecialty fellows are diminished or lost entirely. Then we wonder why we don’t have enough pathologists and subspecialty experts. I have specific solutions to address this issue, but I will reserve those for another day.