Clinical pathology: a vanishing discipline in Nepal?

It appears Nepali pathology labs are in a race to bottom and most pathologists think that their future is doomed. Is it true? And if yes, why?

"Pathology is like a stem of a tree whose roots are formed by the basic disciplines of anatomy, physiology, etc. The other disciplines are like the branches of the tree." says Dr. H P Dhakal, one of the senior pathologists of Nepal and former director of of BPKMCH, Chitwan.

"In coming ten years, there will be zero scope for pathology. It is before we can find some more dependable option that we are forced to cling to it. There is no point on placing too much hope on this lost subject." says a pathologist serving in the same hospital now.

So what is pathology? Is it a glorious and crucial subject in medical science or just a dumping ground for few people who do not end up with other clinical subjects?

The irony is that Dr. Dhakal who stresses the importance of pathology as a discipline so aptly, a highly acclaimed pathologist having already published at least six articles in international journals in the field, is now abroad; having been snubbed by the institution which he helped to establish. "What I did was best for me and the timing I left was also exact", recollects Dr. Dhakal in a short trip to Nepal.

The depressing expression of another pathologist are followed by the explanation as to why the Nepali pathologists would vanish in a decade's time. While the world at large and the neighbors like India are making big strides in the field of pathology thereby unfolding the mystery of the diseases one after another, this pathologist foresees Nepal as the most profitable collection center for foreign pathology labs.

While the expression may have exaggerated the reality, the troubles of the discipline in Nepal are ominous.



While not all of it, most of the blame for the sorry state of pathologists and the field of pathology falls squarely on the clinicians on whom the pathology labs are absolutely dependent. The reason: with increasing shoddiness in the medical profession, most if not all clinicians feel it to be their legitimate right to get certain amount of 'cut' or 'commission' from the laboratories. As a result a race is underway among the laboratories to pay the highest cuts to the clinicians so as to get the highest number of 'clients'. Obviously, the mega-enterprises of Indian labs are so comfortably placed in the race that a test that costs Rs 500 to perform in Nepal can be performed for as little as Rs 50 because of the sheer bulk of the samples there. Even if they give a cut of Rs 150, they can keep the price for the test at Rs 250 and so on. This predatory pricing is literally killing the Nepali labs in Biochemical tests.

What is wrong then, if the consumer get the services at lower cost? It does not appear so at first, but there are problems. First, it is not reasonable and even possible to send all the specimens/samples to India for the tests and we do need some laboratories back home from the perspective of consumers also. Now that we have labs here, they have to be viable in the long run and moreover, they have to constantly upgrade the quality of the service so as to give accurate results. The tragic part of the story is that, the race to appease the clinicians and the drain of money in the process is forcing the labs in Nepal to a bottom to race: they cannot simply afford the things like quality control and accreditation because if one laboratory does so by rigorously upgrading every facility, the other one with total disregard for the quality will get all the samples by giving bigger and bigger cuts to the clinicians and will flourish.

"To be dependent on other disciplines is the greatest curse of pathology as a discipline", laments one prominent pathologist in Kathmandu, who does not want to be identified.

A race to top is a good thing even when one is relatively sluggish. But in a race to bottom, everyone is a looser; the faster the worse. So long as the practice of giving and taking cuts persists, this race to bottom is sure to continue.

Meanwhile, the people in the field of clinical pathology have to answer some unavoidable questions: what does the future hold, for the discipline as well as the pathologists? While everybody may not be equally gloomy, the anxiety is palpable among most of the clinical pathologists. And the answer? Well, that is the difficult part.

As such, pathology will not vanish in a decade's time. Pathologists too will exist. But it is utterly nonsensical for us to remain in archaic conditions both in terms of infrastructure and expertise as the world around us is rapidly progressing. If pathology labs in Nepal continue the today's race to bottom, the pathologists in Nepal will remain as the mere shadows because while we are stuck in cyto-morphology, the labs across the border will provide the state-of-art facilities including molecular cytogenetics. To remain viable in the long run, a constant betterment is a must. You stop growing and you will stop to live altogether.

While other factors may also be at play, the central reason behind the predicted doom of pathology as the discipline is the phenomenon of giving cuts to the clinicians, which starts a vicious cycle that ends up incentivizing most unworthy of the competitors who are ready to go to any length to fleece the patient and appease the clinicians.

While pathology will definitely suffer, all other clinical fields are going to suffer as well in the long run and so are the patients in general. Less incentive means less number of less qualified people will be interested in pursuing the career in pathology (as seen by the no. of vacant seats in pathology in KU medical colleges this time). While the greediest of the clinicians will be happy with the situation, the honest and hardworking clinicians will be handicapped in absence of a strong support from clinical pathology.

If things remain as they are today, this is what will happen; once again in the words of the pathologist in BPKMCH whom I quoted above: "The competition is already so tough and clinicians demand so big cuts; you have to give all you take from the patients to the clinicians and give reports from there itself without performing the tests." This he said to the two agents who had come to invite him to the inauguration of a new collection center in Chitwan for a new foreign lab.

To put it in one sentence, it is just unacceptably unjust for both the patients as well as the pathologists.