July 2010

Stephen N. Bauer, MD

Global impressions

I recently traveled with CAP teams to China, India, and the United Arab Emirates (UAE), all countries in which there has been increasing interest in CAP laboratory improvement programs. The journeys were long but the effort was worthwhile. No secondhand accounts could have taught us so much so quickly; some things have to be experienced personally.

The challenges we talk about at home pale beside those our peers face in some other parts of the world. The pathologists we met share our commitment to quality care for their patients, but where we have deep resources, they often have steep challenges.

The International Monetary Fund provides an estimate of gross domestic product that takes cost of living into account. By this measure, the average person in the U.S. earns $47,123 annually while the average income in China is $7,518, and in India, $3,290. Of course, this is changing rapidly, as these economies are growing much faster than ours, but, needless to say, resources to care for much of the world’s population today are greatly stretched.

We met with an administrator in Mumbai responsible for 16 public hospitals providing care at no charge to anyone in need. Her budget for all 16 is a fraction of what we spend on one hospital.

Medical practice varies from country to country. For example, India grapples with resource constraints and a high prevalence of infectious disease. When our colleagues there see granulomas in a colon biopsy, their first thought is tuberculous enterocolitis, not Crohn’s disease. Despite the differences in our medical and resource issues, the pathologists we met are interested in our laboratory improvement programs because of their commitment to durable quality. However, as in the U.S., there is cost associated with quality. There, as here, pathologists must justify every investment against competing priorities.

There is an enormous and growing demand for laboratory services in India and China; the worries I sometimes hear about U.S. laboratory work being outsourced to Asia are currently exaggerated. Physicians there struggle to keep up with the demand in their own country. If anything, there could come a day when specialized or consultation work would flow in the opposite direction.

The situation in the UAE differs in several respects. Although weakened in the recent financial downturn, the UAE’s economy is healthier. The average annual income in the UAE is $36,973. As in India and China, UAE pathologists have been advocating for improved standards for some time. Now with strong government support, UAE pathologists can do more of the things they would like to do for quality improvement. The CAP already has accredited, or is in the process of accrediting, the majority of large government and independent laboratories in two emirates of the UAE (Abu Dhabi and Dubai). While I was there, we signed an agreement to conduct a CAP accreditation readiness assessment in three hospitals and two primary care centers in two of the smaller emirates.

The CAP now accredits 36 laboratories in India and 15 in China. Most are larger independent laboratories and laboratories that conduct research for pharmaceutical companies. There is growing interest in adopting CAP standards in hospital- and pathologist-operated laboratories where greater resources are also more often available.

A number of the Indian pathologists we met operate their own laboratories. Their practices involve a good deal of direct patient care and are often referred to as clinics. (In Delhi, the sign outside my laboratory might simply say, “Dr. Bauer’s Pathology Clinic.”) Many of their patients come to them before deciding what primary care they may need, and many have come to the same pathologist for this care for 20 or 30 years.

On a bus trip that our group took to see the Taj Mahal and to meet with pathologists in Agra, I had an opportunity to see this practice model in action. A pathologist seated near me took a call on his cell phone from a patient’s mother. Her child’s studies had indicated a urinary tract infection; the mother was alarmed. The Indian pathologist explained to her that a UTI is of concern but readily treatable. He comforted her. I could see why he was so satisfied in his practice.

This primary care model of pathology might not work in the U.S., but it was a fine illustration of a pathologist providing a valuable service by interacting directly with patients for primary care. Patients in the U.S. with serious conditions like cancer might welcome the opportunity to consult with their pathologists. A pathologist who communicates well with patients would bring great value to the new accountable care organization practice model as well.

The CAP Foundation and Transformation Program Office (TPO) cosponsored patient consultation simulation exercises at CAP ‘10 that were extremely well received. Participating pathologists, more than half of whom had been in practice for more than 20 years, met with a trained “patient” in a scenario involving news of a positive biopsy for breast cancer. The pathologists explained the diagnosis and the significance of tumor markers and showed the patients their slides. The experience was rated “excellent” by 70 percent and “good” by the remainder. The only serious complaint was insufficient time to talk with the patient.

The Foundation and TPO plan to sponsor at least three more patient consultation simulation opportunities, including two before CAP ’11. They have not yet announced the sites; state pathology meetings are one possibility. I participated at CAP ‘10 and strongly suggest taking part if you have the opportunity.

We learn so much about ourselves when we are in foreign situations. On our journey we learned, for example, that there is an opportunity for the CAP to participate in raising the quality of care internationally. But perhaps the most valuable thing we learn through such personal experience is that everyone has something to teach us as well.