Search

Pathologists are under siege by corporate medicine, managed care systems, or varieties of government-initiated health care restructuring. The pressure is on us to attend at least equally to fiscal pressures, as well as to our patients' medical needs. These pressures must be accommodated within the limits of our professional duties and responsibilities. We must have more than an intuitive sense of what it is to be a professional and to work in a system that is overseen typically by a directorate and that includes managers and innovators. The example of the failure of the corporate managers and directors of a national blood transfusion service highlights the need to balance the inter-relationships of managers, professionals, and innovators by a directorate knowledgeable in these complex systems.

The clinical laboratory is described as a system with an enquiry component or demand side, where control of test utilization is the mandate of the clinical physician or surgeon, and a production component or supply side, where answers to clinical questions are generated and control of test data production is the mandate of the laboratory physician. Supply side unit costs are maintained by increased production effectiveness brought about by the judicious manipulation of supply costs; labor costs; and capital expenditures for automated equipment, robots, and information technologies. The pathologist's prime role as controller of the supply side is outlined, as are the clinical physician's prime role and pathologist's subsidiary role in control of test use on the demand side.

The concept of structuring complexity is described as a process in which, during medical investigation, intensity of laboratory examination is escalated as the perceived complexity of diagnostic need increases. Application of this concept to laboratory controlled testing protocols is discussed. A clinical chemistry protocol for thyroid testing of ambulatory care patients in British Columbia resulted in a 15% reduction in test use and a 12% reduction in laboratory charges to the third party paying agent over a two-year period. The need to develop medically acceptable laboratory protocols that encourage selective test utilization and reduce cost is emphasized.

A conceptual framework is outlined as the basis for analysis and evaluation of laboratory test-ordering patterns. This framework highlights the input, process, and output phases of the laboratory inquiry system. Data are presented from a contemporary Canadian study to show that the cost of laboratory testing is escalating and represents a sizable proportion of hospital costs. Practical policy interventions intent on reducing the costs in this complex system will require thorough analysis within a conceptual framework such as is outlined here and will require ultimately sophisticated control programs at various levels in the laboratory inquiry system.