MDs playing lab tech?

David Shlaes is lamenting the passing of the good old days, when clinicians ran diagnostic tests right there in the ward. Gram stains, differential culture - the whole shebang. Even collected specimens themselves, they did. I'm sure this was great fun, and there is certainly value in having MDs get a little hands-on experience, if only to gain an appreciation of what can go wrong.

David is a smart guy, and knows way more about antibiotics than I will ever hope to - but this is plainly silly. There may be some overlap between doctoring skills and lab skills, but it is pretty slight, in my experience. There are very few MDs (usually MD-PhDs) I've met that I would want to have working in my lab. Not because they weren't smart enough, but because they weren't skeptical enough of their own genius to repeat "interesting" results over and over to see if they were real.

There's a reason why diagnostic tests are run by dedicated personnel who have to demonstrate proficiency and document their methods and results thoroughly. It's not to maintain full employment of lab techs, but to ensure reliability.

But his larger point is very real: the benefit of rapid diagnostic tests is pretty much lost when it takes half a day to get the specimen to the lab, and another half day to report the results. Real-world turnaround times for 2 hour PCR tests are typically 12-18 hours, pretty much destroying their usefulness.

The solution to this lag is not to put a GeneXpert on every floor and let MDs play with them. It's to stop treating microbiology labs like the red-headed stepchildren of the hospital family. Few microbiology tests are reimburseable; the hospital has to pay for them, and thus administrators see micro labs as cost centers to be squeezed, or better, eliminated.

The results are predictable - half of all S. aureus bacteremia patients are on the wrong antibiotic, because MDs are forced to guess at the appropriate treatment absent timely lab results. As more bugs become resistant to more antibiotics, this situation will only get worse.

The rapid (technically, accelerated) MRSA/MSSA test that my team developed at MicroPhage was a commercial failure. This was largely because there was no constituency in hospitals to pay for faster susceptibility results. The healthcare system as a whole would have saved substantial amounts of money as a result of fewer hospital and ICU days incurred by appropriately treated patients. But additional testing means additional lab costs, and few lab managers were interested.

The economic incentives to develop rapid tests are still all wrong. Until that gets fixed, patients will still suffer and die from inadequate treatment, no matter how many doctors we let play lab tech.

 

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