India’s courts are slowly addressing scope of practice issues in pathology laboratories
Turf wars among medical laboratory professionals about scope of practice—combined with concerns about price-gouging—resulted in the ransacking of three pathology laboratories in India.
On Thursday, June 21, 2012, members of the regional political party known as Maharashtra Navnirman Sena (MNS) attacked three pathology laboratories, damaging equipment and furniture. The three medical laboratories were located in the Yavatmal District of Maharashtra. Maharashtra is the third largest, the second most populous, and the richest state in India. Its capital is Mumbai.
This news was reported by the The Times of India in its Hagpur edition, The Maharashtra Medical Laboratory Technologists Association (MMLTA) condemned the attacks.
Scope of Practice Controversy in India’s Pathology Laboratory Industry
The violence highlights long-standing tension between pathologists and medical laboratory technologists concerning who should be allowed to operate medical laboratories in India. According to a paper published in the International Journal of Biological & Medical Research, Across India, there are many regions where medical laboratory accreditation is not compulsory. This situation contributes to poor clinical laboratory techniques and practices.
Sanjeev Chaudhry, Chief Executive Officer of Super Religare Laboratories Limited, pointed out in a 2010 Dark Daily e-briefing that there are more than 50,000 pathology and diagnostic testing laboratories in India, but only 200—less than 1%—are accredited. (See Dark Daily, “Consolidation of Pathology and Clinical Laboratory Testing Happening in India”.)
According to the Nagpur Times, there are over 30 pathology labs in the city of Yavatmal. Of those, 13—or about 43%—are run by laboratory technicians. These are individuals who hold the Diploma in Medical Laboratory Technology (DMLT) qualification.
In Maharashtra’s 14 remaining districts, there are only five medical laboratories run by pathologists registered with the Medical Council of India (MCI). The remaining clinical laboratories—which the article states number over 100—are run solely by DMLT-level technologists.
Pathologists in Gujarat Bring Scope of Practice Issue before High Court
For years, pathologists in India have sought to prevent non-pathologists from operating pathology laboratories. [Editor’s note: in India, the term “pathology laboratory” generally describes a medical laboratory that is testing blood, urine, and similar types of specimens. “Histopathology” is the term that describes a laboratory that tests tissue specimens.] “By way of legislation, the government should ban DMLT holders from running labs, as they are not as qualified as the MDs,” stated a source whom Nagpur Times identified only as a “qualified and senior pathologist.” “And, in the absence of such a legislation, nobody can restrict them from doing the business,” observed the unnamed pathologist.
In Maharashtra, there is ongoing public interest litigation that centers upon the scope of practice concerning pathology laboratories. In 2010, the Civil Surgeon of the Maharashtra District Hospital initiated a court case against 13 private pathology lab operators.
According to the Nagpur Times, MMLTA approached the government to stop administrative action that would prevent laboratory technicians from operating pathology laboratories, pending resolution of the issue in the High Court. Subsequently, the government instructed district administrators across the state to hold off any action against DMLT-level technician lab operators, pending a ruling by the High Court.
After the MNS intimidation tactics against the pathology laboratories in Maharashtra, including the ransacking incident, the MMLTA threatened that its members would “wind up” their labs if the state government prohibits DMLT-run laboratories, the Nagpur Times reported.
Ruling by Gujarat High Court Provides Clue to Outcome in Maharashtra
For more than a decade, the association of pathologists in the neighboring state of Gujarat has sought court resolution of the scope of practice controversy, a story in the Ahmedabad edition of The India Times reported.
In 2010, that state’s High Court ruled that medical laboratory technicians could no longer independently run pathology laboratories. Instead, they would have to engage a pathologist registered with the MCI to authenticate all laboratory reports and render diagnoses. Further, the court directed the Gujarat state government to ensure that no pathology laboratory is run by an unqualified person.
Allegations of Pathologist Kickbacks and Price-Gouging Fuel Attacks
Claims that certain medical laboratories may be splitting the revenue from lab test fees with the referring physicians are adding to the tension that provoked the recent attacks. “There is an unbroken nexus between the doctors, medical shop[s] & lab owners,” MNS leader Neeraj Waghmare alleged in the Nagpur Times piece. “It is a well-planned racket [and] the poor patients are being looted,” he declared.
Pathologists and clinical laboratory managers in the United States will remember that similar arrangements involving some type of revenue sharing arrangements between medical laboratories and referring physicians were seen decades ago in this country. The abuses were common enough to bring about Congressional legislation and Medicare regulations that sharply curbed these types of practices.
For medical laboratory scientists in developed nations, what is noteworthy about these developments in India is that the dispute over scope of practice can escalate to such a degree that crowds will attack and ransack medical laboratory facilities. That incident in Maharashtra State is a reminder that there is always a thin line between the rule of law and anarchy. It doesn’t take much to incite people to violence over issues of money and power, even if the issue is something as basic as whether the law will restrict the operation of medical laboratories only to pathologists, or will allow medical laboratory technologists to also run labs.
—Pamela Scherer McLeod