The Future of Pathology and Laboratory Medicine—again

Michael L. Wilson, MD

Disclosures

Am J Clin Pathol. 2018;150(2):93-95. 

We are in an era with unprecedented challenges in global health and health care, challenges caused by growing and aging populations, increased incidence and prevalence of noncommunicable diseases, worsening antimicrobial drug resistance, and continued emergence of infectious diseases that threaten global health security. Providing universal health coverage (UHC) will be an essential component for addressing these challenges, but it must be aligned and integrated with the rapid emergence of new diagnostic technologies; new treatment options; better information technology, including the emergence of mobile health technology; and a recognition that technology is not the solution to our global health challenges but rather one part of the solution.[1–4] A key question is whether pathology and laboratory medicine (PALM) will help develop and implement diagnostic solutions to these challenges—or be reactive and follow the lead of others. If we do want to develop and implement these solutions, we need to think and do more about the future role of PALM as part of the global health community.

The most important future challenge for PALM will be workforce capacity and skills enhancement. As identified in a number of recent publications, the global PALM workforce is wholly inadequate and will only become more so as demand for PALM services increases around the world.[1,5,6] In the United States, for example, pathology is one of the few medical specialties that has had an absolute decrease in workforce in the recent past: since 2010, the number of pathologists has decreased more than 10% while during the same time period, almost all other medical specialties have had an increase in the number of practitioners.[1,7] In most of the world, particularly in low-income and middle-income countries, the situation is even more dire: the number of pathologists per population is about 10% of that in high-income countries.[1,5,6] Many countries do not have even a single pathologist.[1] While there are many reasons for this gap in workforce capacity and many potential solutions for addressing it, there are no simple or quick solutions because it takes many years to create a stable and self-sustaining workforce. Therefore, we need both short-term as well as long-term solutions to address the issue of inadequate and insufficient workforce capacity. Long-term solutions to address global PALM workforce capacity will require careful strategic planning as well as sustainable and robust investment.

Two critical issues need to be addressed as part of increasing the global PALM workforce. First, we need to reevaluate and change what we teach students and train postgraduates to allow them to succeed as part of the future of health care. For pathologists, this will mean shifting emphasis away from diagnoses based on traditional morphologic analysis to use of integrated diagnostic approaches combining image-based analysis, molecular diagnostic testing, and increased use of artificial intelligence and other information technology. Increased integration of histopathologic observations with the results of other clinical, laboratory, and medical imaging findings also will become a cornerstone of future PALM services and practice. It is likely that morphologic analysis will remain the basis of histopathologic diagnosis for the near-term future, because morphologic observations drive the sequential and branching testing that increasingly is needed to generate accurate diagnoses, but at some point in the future, morphologic analysis will be replaced by other testing modalities. This shift away from morphologic-based diagnosis should not be viewed as a threat to the profession but rather as an opportunity, yet as with all opportunities, it has to be seized and taken forward. In light of these changes, we need to begin a serious analysis of the role of pathologists and laboratory scientists within future health care systems. There have been some efforts to think about this issue,[8,9] but given the rapid pace of change, this needs to become a priority. If we do not define our future for us, others will do so.

The second critical issue regarding the global PALM workforce is changing public and professional perceptions of PALM in comparison with those for other medical specialties. A distressing number of policy makers, the general public, and even other health care providers know little of what we do, how we do it, why we do it, and what it means for patient care. To the public, pathologists are medical specialists who perform autopsies. This is understandable given the history of pathology and the highly visible role of forensic pathologists in medicolegal systems. Even a cursory Internet search of books or movies about pathology and pathologists yields almost nothing but forensic pathology and autopsy pathology. We need to change this perception, not because we do not value forensic and autopsy pathology but rather because PALM services are so much broader in scope and are critical components of health care, health care policy, global health security, and UHC. We cannot address the gaps in global PALM workforce capacity unless we are able to attract more students, yet as with the general public, many medical and graduate students have little awareness of what PALM specialists do and therefore do not view PALM as a potential career choice. Building a sustainable workforce requires advocacy and awareness at all levels so that PALM specialists are perceived as essential members of health care systems; until this happens, we are unlikely to attract sufficient students to be able to address the gap in global PALM workforce capacity.

A second major challenge for PALM in global health is the lack of affordable, evidence-based national and international quality standards and systems of accreditation. As a result, for much of the world, PALM standards and accreditation are either lacking or are inadequate.[1] Because meeting standards and accreditation uses resources that are severely constrained in much of the world, we should only pursue those with clear evidence as to their effectiveness at maintaining and improving quality. There are, however, surprisingly little published data as to the effectiveness of many standards; clearly, we need a robust research agenda to better define where to allocate scare resources in meeting standards and accreditation.[10] In addition, although no one is in favor of regulation for the sake of regulation, it is clear that in the absence of standards and regulations, most laboratories are unlikely to provide high-quality PALM services.[11,12] Ministries of health and other parts of governments need to become involved in both setting guidelines and standards but also for ensuring compliance.[13]

A third major challenge is inadequate and insufficient systems of financing for providing access to PALM services in many countries.[1] While it is easy to argue that following models such as those in place in countries with national health systems (eg, Canada or the United Kingdom) is the most sensible, those systems have taken decades to develop and were built around societies with large middle classes with high levels of employment and stable economic systems, well-developed public and private sectors, and generally high levels of educational attainment. Because many low-income and middle-income countries are not yet at this level of economic development, other systems of financing for health care and PALM services will be needed. At the least, transitional systems will be needed to bridge the gap from current fee-for-service systems of finance to systems such as those that exist in many high-income countries. To ensure that PALM services are an integral part of UHC, it does matter who pays for PALM services, that economically vulnerable patients have financial protection, and that financial systems are aligned with other efforts to improve quality.[3]

At the highest level of capacity building, there is no cohesive strategic plan for PALM in most countries and almost no international agreements/standards to guide countries wanting to develop one. While it would be naive to believe that the many components of PALM—professional societies, different boards providing certification, regulatory agencies, membership, advocacy groups, and others—will always work in harmony and in a single direction, there does need to be at least consensus for the overall direction we are moving, defining long-term goals, and how to achieve these goals. Although a few countries have national strategic health systems that include national strategic laboratory systems and plans, which can be used as models, these are in the minority.[2] In the United States, where health care lacks a single national strategic plan, access to and use of PALM services is driven by local medical practice patterns (often at the individual hospital or clinic level), managed care systems, reimbursement systems such as coverage by insurance networks, and availability of specialized services that are provided only by reference laboratories. In contrast, the US public health system has a long tradition of integrating services across a system of tiers, with definitions of what roles each tier plays within the system at national, state, and local levels.[14–17] This type of system integration is lacking in most of the world. To change this and in order for PALM services to become an integral part of efforts to achieve UHC, we need a coalition or alliance to bring together the diverse parties to identify common interests, learn from existing best practices and approaches, and create a global strategy for increasing and improving access to PALM services in all countries.[1–3] This alliance will need to work closely with other parts of health care that provide diagnostic services. What most emphatically is not needed is a perpetuation of the silo approach of developing diagnostic tests for single diseases to be used outside existing laboratory systems or in the absence of laboratory systems. To avoid this "vertical" approach, we need to better define how tiered laboratory networks should be structured, what is needed at each tier within these networks, how they should interact with other parts of the diagnostic network as well as the broader health care system, and objective ways to measure and define success. Efforts toward this already have been made, but there is much still to do.[18,19]

In 2008, the inaugural edition of Critical Values contained a paper with the title "The Future of Pathology and Laboratory Medicine: An ASCP Task Force Report"—a report that highlighted many of the same issues presented in this commentary.[20] The report was based on the findings of two task forces that convened in 2005–2006 and 2006–2007, making the findings as much as 13 years old. Laudable for its prescience and the continued relevance of its findings, it is nonetheless concerning that today we still need to address most of the issues contained in that report and that some of the concerns expressed therein have only increased over time. We are not making progress fast enough.

Achieving the above recommendations will require leadership at all levels but especially at national and international levels. In the past, PALM has had minimal visibility (let alone sway) with organizations such as the World Health Organization or even within national governments. As noted in the American Society for Clinical Pathology task force report, "Pathologists and other laboratory professionals have been rather passive participants in the evolving health care system."[20] To address that, we need to develop a new generation of leaders who can argue persuasively at all levels, especially at national and international levels, for improvements in workforce capacity, better systems of finance, investment in infrastructure, improved standards and systems of accreditation, and development of integrated tiered laboratory systems that will enable PALM to become indispensable components of UHC.

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