INTRODUCTION
Hematology is a diverse speciality embracing clinical and laboratory aspects of adult and pediatric hematological disorders, both malignant and non-malignant. It is one of those few disciplines where translations of technology from the “bench to the bedside” has taken place at a rapid pace. Hematologists have been taking advantage of the Polymerase Chain Reaction (PCR) technology since its discovery and the globin gene was one of the first genes to be fully sequenced even much before the Human Genome Project. In fact today's hematology laboratory looks more like the control room of a space-station. But technological advances bring with them their own limitations. It has been seen that there is an inverse relation between the simplicity of the technology and the usefulness of the information it provides.
Hence, the appropriate utilization of these diagnostic tests is necessary for optimal patient care. Use of diagnostic laboratories has increased over the last several decades in many medical jurisdictions around the world. Hematologists want to be doubly sure for the correct diagnosis. Moreover, it has become essential, as patients are well aware about the correct diagnosis. The medical insurance often wants the diagnosis to be backed by laboratory support. Clinician prefer to safeguard their interest as more cases are being registered with consumer courts. In Ontario, Canada's largest province, the total number of tests performed annually has increased by more than 2130 percent between 1976 and 1992. The cost of increased laboratory utilization has been considerable, rising from an annual expenditure (in inflation-adjusted dollars) of can $33.29 per person in 1979 to can $103.36 in 1992. Similarly, in India, the number of diagnostic tests performed on a single patient has increased by several folds. Unfortunately these diagnostic tools generate an overwhelming volume of data, which may not be always relevant and at times may confuse the clinician or misguide him in his endeavor to make a final diagnosis.
The diagnostic facilities in hematology should be directed to answer the basic questions as given below:
- Is the patient suffering from a primary hematological disorder?
- Am I certain of the disorder?
- Is the disorder easily amenable to treatment?
- Would further tests change the course of treatment?
- What would be the course of the disorder?
- What is the ideal therapy? Is a targeted therapy available?
- How would the patient behave to my prescribed therapy?
- Has the disorder responded to the therapy given?
- What is the chance of recurrence of the disorder?
- Can the disorder be prevented?
Advances in flow cytometry, cytogenetic and molecular techniques alongwith sophisticated automatic cell counters and coagulometers have made the diagnostic facilities in hematology well-equipped to handle the queries of the clinicians. However, for optimal patient care, sophisticated modern investigations of hematologic disorders should be interpreted in the light of peripheral blood features as well as the clinical context.
CLINICIANS' EXPECTATIONS FROM A LABORATORY
Most clinicians are unable to keep themselves abreast with the pace with which the advances are taking place in diagnostics. Thus many clinicians/hematologists expect hematopathologists to help or guide him on how to proceed with least possible investigations while investigating his cases in the minimum 3possible time. Therefore, good morphology interpretation of peripheral blood and bone marrow or biopsy is essential. A clinician, however needs to be aware of the limitations in which a laboratory works. The hematopathologist has to depend mostly on his or her skill coupled with the clinical features provided to him by the clinician. In addition, he is under stress as clinicians expect the results soon, without realizing that special stains/procedures require time. Sophisticated tests are often time consuming, expensive and may require confirmation. Often the clinicians order tests which may not be essential and add to complexity of diagnosis. Even under such conditions he expects solution from laboratory.
Clinicians expect full support from laboratory colleagues in event of wrong treatment or incorrect diagnosis. In such a situation, they often make full use of hematopathologist's data for insurance or consumer courts, without realizing that every test has its specificity and sensitivity. A clinician has to use its own judgment with full knowledge of complete history, examination findings, data from various reports and course of the disease.
CLINICIAN'S DILEMMA
A clinician is always under dilemma when the battery of tests do not go in hand and glove with his diagnosis. Other situations are also of great concern to clinicians such as:
- When the laboratory data is unexpected, e.g. very low hemoglobin than clinical judgment or coagulation profile
- When data from two different laboratories are quite different
- When data from the same laboratory is different on two consecutive days or at short intervals with no therapeutic intervention
- When laboratory data shows worsening condition while patient is improving or vice versa
- When the laboratory data is normal and clinically patient is sick
- Antenatal diagnosis states that fetus is normal but after birth baby is found to have inherited disorders.
Some of these dilemma can be significantly reduced if the laboratory maintains close liasoning with clinicians and has strict internal and external quality assessment.
BIBLIOGRAPHY
- Bain BJ. Diagnosis from the blood smear. N Engl J Med 2005; 353: 498–507.
- Blessing JH, Fleisher TA. Immunophenotyping. Seminars in Hematology 2001; 38 (2): 100–10.
- Danzon PM, Manning WG, Marquis MS. Factors affecting laboratory test use and prices. Health Care Financ Rev 1984; 5: 23–32.
- Fowkes FG. Containing the use of diagnostic tests. Br Med J (Clin Res Ed) 1985; 290: 488.
- Laboratory Services Review—Report to the Ministry of Health. Ontario Ministry of Health Toronto: 1994.
- Salient features of the Laboratory Industry in Ontario, 1992–93. Ontario Ministry of Health Toronto: 1995.
- Showstack JA, Schroeder SA, Matsumato MF. Changes in use of medical technologies, 1972–1977: A study of 10 inpatient diagnoses. N Engl J Med 1982; 306: 706–12.
- Staudt LM. Molecular diagnosis of the hematologic cancers. N Engl J Med 2003; 348: 1777–85.