A Century of Hospital Laboratory Stewardship

By Andrew Fletcher - February 14, 2022

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Editor's note: This essay is part of an ongoing series about the evolution of the laboratory over the past century, and part of ASCP's 100th Anniversary celebration.

As we celebrate the 100th anniversary of the American Society for Clinical Pathology (ASCP), it is interesting to examine how hospital laboratories have evolved over the last century. One hundred years ago, an American Medical Association (AMA) survey showed only 48% of hospitals in the United States had a laboratory.1 One such institution was Finley Hospital, a 106-bed hospital in Dubuque, Iowa.2 In September and October of 1923, Dr. F.P. McNamara, a pathologist in the Finley Hospital laboratory and a prominent member of his medical community, published a two-part report in the journal The Modern Hospital on the utilization of the hospital’s laboratory from July 1921 to January 1923.2 In the papers, he noted that there were “numerous discussions concerning small hospital laboratories which have occurred during the past five years” and laboratories “are having a hard time” proving their worth.2 He then described the success of the Finley Hospital laboratory (Figure. 1). In 1922, the Finley laboratory offered 45 clinical laboratory tests, and the lab performed 8,386 tests over the 18-month period ending in January 1923. Regarding specific tests, over the course of those 18 months, the lab performed 988 “white blood counts,” 136 “blood chemical” tests, 31 blood cultures, and 4 sugar tolerance tests.2 Per Dr. McNamara: 

“The report of the clinical work shows first, that a large number of tests have been done and second, that most of the usual tests were included. The average number of tests each month was 466. Very little other comment is necessary. We are proud of what has been accomplished...”2  

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Figure 1. View of main laboratory, Finley Hospital, circa 1922.2 

Although Finley’s laboratory was progressive and successful as compared to its counterparts, Dr. McNamara noted that in the medical community, there is an element of “criticism by clinicians that [laboratories] have assumed too great an importance,” and in “small hospital communities there are physicians who rarely use the laboratories.”2 Although underutilization was no doubt an issue Dr. McNamara faced, so was overutilization: 

“Many hospital authorities advocate routine orders as a method of increasing the amount of laboratory work. While this will undoubtedly increase the amount, it will not necessarily increase the value of the work. We are opposed, therefore, to having routine orders for any great variety of tests.”3  

Furthermore, Dr. McNamara stated: 

“As a rule other tests should be asked for when there is some definite indication for them or when an actively functioning cerebral cortex believes they might be of value. If routine orders are given for a large number of tests the laboratory will be overwhelmed by a mass of work which is of little practical value to the patient.”3  Also, laboratorians “should not be expected to make so many tests” as “automatons or as technicians simply because they are requested to do so.”2 

At the close of part 1 of his report, Dr McNamara argued that laboratory professionals should educate members of the medical community to address the appropriate use of laboratory testing.2  He noted that laboratory “sciences are developing so rapidly that it is practically impossible for the practitioner to keep in touch with all the advances.”2 

Fast forward 100 years. The U.S. now has more than 29,000 clinical laboratories,4 and laboratories are ubiquitous in all hospitals. At least 7 billion lab tests are performed in the U.S. each year,5 with a laboratory market of $67 billion dollars per year.6 In addition, the laboratory industry continues to grow, with the addition of at least 10 new genetic tests per day.7 How has the Finley Hospital laboratory evolved over the past century? The lab that offered 45 unique laboratory tests in 1922 today performs 185 in-house tests and has an average monthly volume of 14,439 tests (R. Marx, MLT, personal communication, October 2021). Instead of an 18-month volume of 8,386 tests, as in 1922, today’s 18-month volume is approximately 260,000 tests. (Figure 2)      

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Figure 2. View of main laboratory, UnityPoint Finley Hospital, October 2021, with lab supervisor Rodney Marx. 

As we look back at 1922, it is clear much has changed in clinical laboratory medicine over the past 100 years. We no longer need to demonstrate our importance or convince physicians of our relevance, as did Dr. McNamara. The availability of testing is widespread, and there has been exponential growth in both volume of testing and tests offered. Although the growth of laboratory testing and reliance on testing is vastly different today, much of what Dr. McNamara wrote in 1922 remains current. One hundred years later, we still face under- and overutilization, and routine orders have become order sets. We must still educate the medical community about the role of the laboratory and the rapid proliferation of new tests. Lastly, just as Dr. McNamara stated in 1922 regarding the Finley laboratory, we should all be proud of what has been accomplished in laboratory medicine over the past 100 years. 

Dedicated to Dr. F.P. McNamara and the Finley Hospital laboratory, which has been serving Dubuque, Iowa, for 100 years.  

Dr. Francis Patrick McNamara was born in Fitchburg, Massachusetts, in 1883, and joined Finley Hospital as a pathologist in 1921. A prominent member of the medical community, he served as president of the hospital medical staff, founded the hospital’s Clinicopathological Conference, authored nearly 100 articles and coauthored the Iowa State Medical Society’s Cancer Manual, served in various leadership capacities for medical and professional societies, and received an award from the American Medical Association for his exhibit of pathologic specimens. He died in 1944.8 

Andrew Fletcher

Medical Director