Plaintiffs claim state is criminalizing speaking the truth about their earned advanced degrees
Doctorate of Nursing Practice (DNP) is the highest degree that can be acquired by a nurse practitioner (NP). But can NPs who achieve this degrees call themselves doctors? What about others who hold doctorates, such as PhDs in clinical laboratories?
According to the State of California—which has enacted a law restricting the use of the word “doctor” or the prefix “Dr.” in titles, online, or in business communications solely to physicians and surgeons—the answer is no.
“The word ‘doctor’ doesn’t belong to physicians,” Jacqueline Palmer, DNP, one of the three NPs suing over California’s law restricting non-physician medical providers from using that word, told The Washington Post. Palmer argues that NPs should be able to use the word “doctor” or the prefix “Dr.” when describing themselves much like PhDs and other non-physicians do who hold doctorates. (Photo copyright: Jacqueline Palmer, DNP.)
Section 2054 of the statute states, “Any person who uses in any sign, business card, or letterhead, or, in an advertisement, the words doctor or physician, the letters or prefix Dr., the initials M.D., or any other terms or letters indicating or implying that he or she is a physician and surgeon, physician, surgeon, or practitioner under the terms of this or any other law, or that he or she is entitled to practice hereunder, or who represents or holds himself or herself out as a physician and surgeon, physician, surgeon, or practitioner under the terms of this or any other law, without having at the time of so doing a valid, unrevoked, and unsuspended certificate as a physician and surgeon under this chapter, is guilty of a misdemeanor.”
In their complaint, the three lawsuit plaintiffs state, “Defendants are California state officials charged with enforcing a law that criminalizes the truthful use of the title ‘Dr.’ by any healthcare professional who is not a licensed physician or surgeon. That means veterinarians, dentists, pharmacists, physical therapists, and nurse practitioners are subject to severe penalties if they truthfully refer to themselves as ‘doctor.’ This is true even where the doctor specifies the specific profession in which he or she has obtained his or her doctorate degree. The statute that mandates this regime goes far beyond patient protection and violates the First Amendment rights of doctors to truthfully describe themselves and their credentials.”
California is not the only state that restricts the use of the word “doctor” or “Dr.” but it is the strictest, according to Donna Matias, JD, Pacific Legal Foundation, the attorney representing the three plaintiffs.
“If you read the law literally, it appears to prohibit even PhDs and university professors from using the title,” she told the Post.
Previous Case Led to Stiff Penalties for Nurse Practitioner
In November of 2022, California Nurse Practitioner Sarah Erny, DNP, was fined a total of $22,500 by both the State of California and the State Medical Association for describing herself as a doctor on several professional online platforms without also including that she was a nurse, not a physician.
“While in most instances Ms. Erny indicated that she was a nurse practitioner, she failed to advise the public that she was not a medical doctor and failed to identify her supervising physician. Adding to the lack of clarity caused by referring to herself as ‘Dr. Sarah,’ online search results would list ‘Dr. Sarah Erny,’ without any mention of Ms. Erny’s nurse status,” wrote County of San Luis Obispo District Attorney Dan Dow, JD, in a statement.
Dow went on to say, “All forms of professional medical services advertising, including websites and social media accounts, must be free of deceptive or misleading information and must clearly identify the professional license held by the advertiser. Providing patients upfront with the proper title of our healthcare professionals aids consumers in making a more informed decision about their healthcare.”
Along with the financial penalties, Erny was ordered to “refrain from referring to herself as ‘doctor’ in her role of providing medical treatment to the public. [The judgement] also requires Ms. Erny to identify and make reasonable efforts to correct information on internet sites referring to her as ‘doctor’ or ‘Dr.’” the statement noted.
Speaking Truthfully about Advanced Degrees
Palmer spent 14 years in school pursuing her degrees. She feels her patients are smart enough to know the difference between her and a physician. “It’s not an ego trip; it’s not a power trip,” Palmer told the Post, “It’s just validation that I worked hard to get where I am today.”
The Pacific Legal Foundation argues in favor of the nurses by virtue of their advanced and in-depth training: “[After] years earning their advanced degrees and qualifications … they should be able to speak truthfully about them in their workplaces, on their business cards, the internet, and social media, so long as they clarify that they are nurse practitioners.”
Until the dust settles, NPs in California are taking precautions. Palmer said she has asked her patients to stop calling her “doctor” out of fear of being fined like Erny, a move she also claimed her patients protested against. “They all have said that they know that I worked hard for it,” she told the Post.
Clinical laboratory PhDs and others with advanced degrees may want to investigate their state’s requirements as to how they can legally refer to themselves.
Sales of SARS-CoV-2 tests at other IVD companies, including Roche Diagnostics and Danaher’s lab businesses also report declines in COVID-19 test revenue
Clinical laboratory leaders and pathologists seeking a marker that the COVID-19 pandemic has passed may have it in the plunge in SARS-CoV-2 test revenue during the second quarter at Abbott Laboratories, Abbott Park, Illinois.
COVID-19 test sales in Q2 2023 at Abbott fell a “whopping” 89% as people try to “move on” from the SARS-CoV-2 outbreak, the Chicago Tribune reported.
Developer of the BinaxNOW rapid COVID-19 antigen self-test, Abbott saw its COVID-19 sales revenue decline from $2.3 billion in Q2 2022 to $263 million in the quarter ending June 30, the Chicago Tribune noted.
The decline was expected by Abbott. Nonetheless, the company will likely sell more than $1 billion in COVID-19 tests by the end of this year—business it did not have in 2019.
Abbott lowered its forecast for COVID-19 sales in 2023 to $1.3 billion, down from $1.5 billion, MedTech Dive reported.
“We decided to bring our COVID-19 number down a couple of hundred million dollars, because we’re seeing—as the public health emergency ended—a little bit of a decline in testing,” said Abbott’s Chairman and CEO Robert Ford during an earnings call transcribed by Motley Fool. “So, we’ll see how that’s going to play out in Q4 (2023), the first quarter we will see an endemic respiratory season.” Clinical laboratories that performed high numbers of SARS-CoV-2 test during the pandemic will likely experience similar declines in test volumes. [Photo copyright: Abbott Laboratories.)
Overall, Abbott Has ‘Good Recovery’
COVID-19-related diagnostics was just part of the financial report by Abbott, which also develops other clinical laboratory tests, clinical laboratory analyzers and automation, medical devices, pharmaceuticals, and nutritional products such as infant formula.
Abbott said in a news release that its sales—driven by base business performance—were $10 billion in Q2.
“We have had a really, really good recovery here as the health systems are opening up, and are seeing routine testing come back,” said Abbott’s Chairman and CEO Robert Ford during the earnings call.
Here are diagnostics financial results for Q2 2023 as compared to Q2 2022, according to the news release:
Diagnostic sales fell to $2.3 billion from $4.2 billion.
Core laboratory sales were flat at $1.2 billion.
Molecular sales plunged to $141 million from $212 million.
Rapid diagnostics plummeted to $741 million from $2.7 billion.
As need for COVID-19 testing contracts, Abbott is focusing on research and development of assays that may be “missing on the menus,” Ford said during the earnings call.
“We’ve been working on expanding the menu in molecular and point-of-care. One of the most exciting assays that the team has developed for point-of-care is a rapid test for traumatic brain injury,” he added.
COVID-19 Revenue Falls at Roche, Danaher
Abbott is not the only in vitro diagnostics (IVD) manufacturer to report a recent significant decline in demand for COVID-19 products.
Another sign the major wave of the pandemic has passed is the dramatic fall in COVID-19 product revenue at Roche to 0.4 billion Swiss Francs (CHF) (US$460 million) from 3.1 billion CHF (US$3.5 billion) in the first half of 2022, according to a Roche news release.
The Basel, Switzerland company—reporting on six months of financial results—said its Roche Group base business increased 8% and Diagnostics Division base business rose 6% in 2023, as compared to the first six months last year.
Diagnostics Division sales overall fell 23% to 7 billion CHF (US$8 billion) from 9.9 billion CHF (US$11.3 billion), Roche said.
Here are more first-half of 2023 financial results at Roche as compared to the same period in 2022:
Core lab: 3.9 billion CHF ($US 4.4 billion), up 10% from 3.8 billion CHF (US$4.3 billion).
Molecular lab: 1.1 billion CHF (US$1.2 billion), down 40% from 1.9 billion CHF (US$2.1 billion).
Diabetes care: 723 million CHF (US$831.7 million), down 5% from 832 million CHF (US$957 million).
Pathology lab: 687 million CHF (US$790 million), up 12% from 652 million CHF (US$750 million).
Point of care: 635 million CHF (US$730.6 million), plummeted 74% from 2.6 billion CHF (US$2.9 billion).
“In the first half of 2023, sales in the base business of both of our divisions (diagnostics and pharmaceuticals) grew strongly, largely offsetting the impact of declining demand for COVID-19 products,” said Roche CEO Thomas Schinecker, PhD, in the news release.
COVID-19 May Linger as IVD Companies Refresh Menus
As the COVID-19 pandemic wanes, healthcare providers will continue to test patients for the SARS-CoV-2 coronavirus.
But it also appears that IVD companies are aiming to keep their instruments—which ran full tilt performing COVID-19 testing during the pandemic—of high value to clinical laboratories by developing new tests for possible inclusion on labs’ testing menus.
Strike may delay critical blood testing and cause postponement of many surgical procedures
Medical technicians, phlebotomists, and clinical laboratory scientists in New Zealand are once again going on strike for fairer pay in various areas around the island nation. And their complaints mirror similar complaints by healthcare and clinical laboratory workers in the US.
The latest group of New Zealand medical laboratory workers to strike are in the South Island and Wellington regions. They were scheduled to walk off the job on July 28 after a negotiated agreement was not reached between APEX, a “specialist union representing over 4,000 allied, scientific, and technical health professionals,” according to the union’s website, and Awanui Labs, one of the country’s largest hospital and clinical laboratory services providers.
Medical laboratory workers in New Zealand are among some of the poorest paid healthcare professionals in the country’s medical industry, according to New Zealand Institute of Medical Laboratory Science President Terry Taylor who told the New Zealand Doctor that some workers aren’t making a living wage. “These people worked their butts off during the pandemic, so you’d think [Awanui] would be able to come up with a decent offer for its staff,” Taylor said.
On the picket line, New Zealand phlebotomists and medical laboratory technicians express that they do not feel they are being compensated properly. “Without your blood samples, you don’t get your results, you don’t get your treatments, you don’t get admissions, your hospital appointments, your operations,” a phlebotomist told 1News. Clinical laboratory workers in the US who experienced the enormous pressure during the COVID-19 lockdowns would likely agree. (Photo copyright: Otago Daily Times.)
Phlebotomists and lab workers in an around New Zealand are demanding a pay wage to put them on par with healthcare workers in the public sector. According to The Southland Times this raise would average around 23.5%.
However, to date Awanui has only offered the medical laboratory workers a 5% pay increase. The APEX union says that is far below what is acceptable for them.
“It doesn’t even get them to parity with colleagues from the public hospitals, and with inflation the way it is at the moment, it’s effectively a wage cut. So, it looks like these strikes are continuing,” David Munroe, Apex Union Advocacy Lead, told 1News New Zealand.
Patients in these regions can expect to see delays on blood test results as medical laboratories and phlebotomy collection centers close due to the strike action.
Poorest Paid Health Professionals in New Zealand
Last year, Dark Daily reported on a similar strike of New Zealand’s 10,000 healthcare workers—including its 4,000 medical laboratory scientists and technicians—which was scheduled to take place in March.
That strike was also over low pay and poor working conditions.
This year, unionized workers met with Awanui on May 23, but the company declined to make an offer to prevent the strike. A second day of bargaining was scheduled for May 24, but according to Munroe, Awanui refused to show up for negotiations. However, Vicki McKnight, an Awanui General Manager, claimed the company was willing to come to the table but that “APEX declined,” New Zealand Doctor reported.
“To date, there has only been one day of bargaining and the collective agreement has not yet expired, so we are surprised by the comments on potential industrial action after just one day of negotiations,” McKnight told New Zealand Doctor.
McKnight said the parties were unable to come to an agreement because of a significant gap between the claims the parties brought to the bargaining table.
Awanui Pays Out Dividends in the Millions
In reaction to workers taking to the picket line, Awanui Labs acknowledged the strike. The company’s Chief People Officer Emma Kelly told 1News, “We do value our people, and it’s a difficult position to be in strikes for our people, for our patients, for everyone. So, I just want to go into this situation with empathy and respect for all of those involved.”
However, one of the things the New Zealand clinical laboratory workers took particular issue with, in light of Awanui’s 5% offer, was that in the last financial year Awanui paid out $41 million in dividends to its shareholders. According to Munroe, the workers want the company to invest in them—instead of the shareholders.
“They are the business. You can’t run laboratories without scientists, technicians, and phlebotomists. They know it, and it’s about time the company knows it too,” Munroe told 1News.
The medical laboratory workers plan to remain on the picket line until a deal is made.
Clinical laboratory managers in the US should take heed of what the New Zealand strikers are saying about low pay and poor working conditions—situations mirrored in many nations following the COVID-19 pandemic.
Australian government rules lab employee’s rogue actions jeopardized patient care
In an example of “if something can go wrong in the lab, it will,” a senior histology laboratory worker at Royal North Shore Hospital in Sydney, Australia, has been banned for life from providing health services for allegedly swapping patient tissue samples in an attempt to harm a lab co-worker, according to The Sydney Morning Herald.
Dianne Reader, 61, was a “a senior technical officer at the Anatomical Pathology Laboratory with more than 40 years’ experience,” the Herald noted, adding that Reader “had swapped 20 patient tissue samples, leading to the misdiagnosis of at least one patient.”
Her motivation, the Herald reported, was to “target and discredit her colleague.”
“Ms. Reader repeatedly engaged in conduct that demonstrated a flagrant disregard for patient health and safety” that may have “serious adverse consequences for the patients involved,” Tony Kofkin at Australia’s Health Care Complaints Commission told The Sydney Morning Herald. This is a lesson that clinical laboratory managers can never be too diligent because something unexpected can happen at any moment—and these events have the potential to cause serious patient harm. (Photo copyright: LinkedIn.)
Lab Staff Suspicions Raised
The sample mixups began in 2020, when the targeted employee (employee A) was working specimen “cut-up” duty. After two incidents of sample mixups being found in her work, she was removed from the duty for three weeks. The Herald reported that the employee told a co-worker she believed she was being “framed.” When she returned to cut-up duty, she took photographs of her work as a precautionary measure.
The employee’s photos served as evidence when that day’s work again showed errors, now the third incident of sample mixups. Upon further research, a total of four occasions of swapping samples were discovered between March and June of 2020.
Laboratory records showed that Reader was responsible for unpacking the tissue processor on each of those occasions, the Herald noted.
Lab workers noted a strained working relationship between Reader and the targeted employee. “One co-worker, a hospital scientist, told the [Health Care Complaints Commission] the working relationship between Reader and ‘Employee A’ could be ‘frosty,’” the Herald reported.
Lab staff apparently grew suspicious when a co-worker discovered that Reader “was only looking up gall bladder and appendices samples on the mornings Employee A had been ‘cutting up’ (dissecting and describing samples before placing them into cassettes for processing).” Lab staff also confirmed to the Health Care Complaints Commission that Reader had improperly accessed 43 patient records, adding that “there was no reason for her to have accessed the records when she did,” The Sydney Morning Herald reported.
Reader, according to the Herald, “denied she had ever interchanged specimens or improperly accessed patient files in two recorded interviews in July 2020, and maintains her innocence.”
Nevertheless, Tony Kofkin, the Commission’s complaint operations Executive Director, found that Reader “posed a risk to the health and safety of the public because she was prepared to risk patient safety in order to discredit her colleague.
“Ms. Reader repeatedly engaged in conduct that demonstrated a flagrant disregard for patient health and safety,” he wrote in the Commission’s findings, adding that Reader “had shown no remorse or insight into her conduct ‘despite the overwhelming evidence’ and as such posed a permanent risk to the health and safety of the public,” the Herald reported.
The Health Care Complaints Commission determined that Reader’s actions were “motivated by a desire to target and discredit her colleague.” The Commission’s decision prevents Reader from forever providing healthcare services, including medical, hospital, pharmaceutical, forensic pathology, or health education services, according to the Herald.
Who Was Harmed by the Swapped Samples?
Reader’s alleged actions had significant consequences. One patient’s swapped sample nearly led her to having a hysteroscopy for a glandular polyp, when in fact she was suffering with endometrial hyperplasia. Thankfully, the histology laboratory staff discovered the mistake and quickly contacted the patient’s doctor to ensure the proper surgery was performed, the Herald noted.
Things could have gone much worse for that patient and for others. Clinical laboratory managers should look upon this as a cautionary tale and consider how to ensure similar—and very rare—occurrences do not happen in their own laboratories.
In preparing to deal with outbreaks of three different respiratory viruses, measures include newly approved vaccines for RSV and reformulated COVID-19 shots
Clinical laboratories are the frontline of testing for respiratory infections, and as such, were heavily involved in last winter’s so-called “tripledemic” of Influenza, SARS-CoV-2, and respiratory syncytial virus (RSV). According to a Kaiser Family Foundation (KFF) survey, 38% of US households were affected. Now, federal health officials are taking steps to prevent a repeat tripledemic season, which includes new vaccines for RSV as well as reformulated COVID-19 vaccines.
The big breakthrough this year is the federal Food and Drug Administration’s (FDA) first-ever approval of RSV vaccines in the US. On May 3, the FDA approved GSK’s Arexvy for use in adults 60 years or older. Then, on May 31, the agency approved Pfizer’s Abrysvo for use in the same age group.
“Older adults, in particular those with underlying health conditions such as heart or lung disease or weakened immune systems, are at high risk for severe disease caused by RSV,” said Peter Marks, MD, PhD, Director of the FDA’s Center for Biologics Evaluation and Research (CBER), in an FDA statement announcing approval of the GSK vaccine. “[The] approval of the first RSV vaccine is an important public health achievement to prevent a disease which can be life-threatening and reflects the FDA’s continued commitment to facilitating the development of safe and effective vaccines for use in the United States.”
A GSK press release notes that a clinical trial is underway to evaluate the vaccine for adults aged 50 to 59.
“The number of elders who die of viral infection every winter in our intensive care units, and also sometimes in the summer, is large—it’s in the tens of thousands of individuals,” pediatrician Ofer Levy MD, PhD (above), an advisor to the FDA, told The New York Times. “Each of these vaccines is a huge win.” Clinical laboratories will be looking for these new vaccines to help protect their customers from tripledemic infections. (Photo copyright: Harvard.)
As of early June, XBB lineages accounted for more than 95% of the SARS-CoV-2 variants circulating in the US, noted a recommendation from the VRBPAC committee. The recommendation also noted that the XBB 1.16 and 2.3 variants are on the rise as XBB 1.5 is declining, but “the protein sequences of XBB.1.5, XBB.1.16, and XBB.2.3 spike protein appear similar, with few amino acid differences. Available evidence suggests little to no further immune evasion from these new substitutions in the XBB.1.16 spike protein compared to XBB.1.5.”
The committee recommended a monovalent vaccine composition in contrast to the current bivalent vaccines, which have separate components targeting the original coronavirus strain and the Omicron variant.
Experts Differ on How Best to Administer New Vaccines
One question is whether the three vaccines—COVID-19, RSV, Influenza—should be given in a single visit or spread out. FDA advisor and pediatrician Ofer Levy MD, PhD, told The New York Times that bundling the shots could result in higher rates of immunization. “Plus, you want to get these shots in arms before the viral respiratory season in the winter,” he said. Levy is Director of the Precision Vaccines Program at Boston Children’s Hospital and Professor of Pediatrics at Harvard Medical School.
However, advisors to the federal Centers for Disease Control and Prevention (CDC) have warned that administering the flu and RSV vaccines at the same time could make both less effective. “I would say, when possible, it might be good to spread them out,” Camille Kotton, MD, Clinical Director of Transplant and Immunocompromised Host Infectious Diseases in the Infectious Diseases Division at Massachusetts General Hospital, told The New York Times. “I remain clinically concerned, especially where influenza vaccine doesn’t engender as much protection as we might like,” she said.
Looking Back at Last Winter
Just how bad was the last triple outbreak? In the KFF survey, 38% of respondents said their households were affected by at least one of the three diseases in the previous month:
27% reported someone in their household having the flu,
“Expense pressures—particularly with the cost of labor—outpaced revenues and drove poor performance [in hospitals]. While emergency department visits and operating room minutes increased slightly, hospitals struggled to discharge patients due to internal staffing shortages and shortages at post-acute facilities,” Swanson noted.
Like their parent organizations, hospital and health system-based medical laboratories are dealing with ongoing staffing shortages, which Dark Daily covered extensively in multiple ebriefings.
Non-profit healthcare systems are particularly hard hit, leading to merger/acquisition deals that continue the trend of hospital consolidation.
“Consolidation will continue. Here’s the scary part. The old solutions of jacking up treatment volumes and commercial payment rates aren’t working. Evidence of business model failure abounds. A fiscal storm is raging,” David Johnson, CEO, 4sight Health, wrote in an article for the Healthcare Financial Management Association. The results of these business failures have a direct impact on hospital-based medical laboratories as well as clinical laboratories in surrounding areas that service a health system’s physicians. (Photo copyright: 4sight Health.)
The numbers speak volumes. Looking at financial statements from 2022, Ascension, Cleveland Clinic, CommonSpirit Health, Providence, and Mass General Brigham all posted losses of more than $316 million dollars, the HFMA series noted. Two in that group (CommonSpirit and Providence) posted losses over $1.1 billion. Providence’s losses represented only nine months of data from 2022.
So, what’s the problem? In another HFMA article titled, “The End of Traditional Nonprofit Healthcare Business Models?” Johnson wrote, “Even in the best of times, the nonprofit hospital business model has never been robust. Hospitals are capital-intensive, labor-intensive, highly-regulated, low-margin businesses that require high-cost facilities and highly expert personnel to operate.
“Competing mission and business priorities make running nonprofit hospitals even more difficult,” he added. “The existential question is whether current operating losses at nonprofit health systems are aberrant or indicate a broader collapse of their models. I believe it’s the latter. Structural weaknesses, combined with pernicious macro forces, make this a period of unprecedented challenge for nonprofit providers.”
In his “Cracks in the Foundation” series, Johnson lists five “deeply embedded defects in current nonprofit business models.” They are:
Brittle business models
“Under pressure, health systems are struggling to right the ship, but they are defaulting to old habits,” Johnson wrote. “They’re chasing volume and rates under fee-for-service (FFS) medicine. While this has worked in the past, it is not a viable long-term strategy. Powerful macro forces are aligning against healthcare business practices. Ignoring them won’t make them go away.”
This chart, taken from 4sight Health CEO David Johnson’s HFMA article, shows the five large health systems that showed operating losses in 2022. The numbers displayed are drawn from each health system’s publicly released financial statements for the periods shown, HFMA noted. (Graphic copyright: Healthcare Financial Management Association.)
Deteriorating Outlook for Health Systems
Increased expenses for labor and supplies paired with inflation is what a 2022 Fitch Ratings report cited as contributing to a “‘deteriorating’ outlook for systems,” Healthcare Dive reported.
“Labor will remain the largest hurdle for hospitals this year even as they struggle with inflation and spiking COVID-19 admissions that can dent revenue. The labor story just dwarfs the inflation story,” financial analyst Kevin Holloran, Senior Director and Sector Leader USPF Healthcare at Fitch Ratings, told Healthcare Dive.
Holloran has worked for Fitch since 2017, joining after 14 years at S/P Global Ratings. He has 20-years experience in the healthcare sector.
Nonprofit hospitals that posted COVID-19-related operating losses are struggling with higher costs for labor and supplies while navigating declining and neutral admission volumes, Healthcare Dive noted, citing that healthcare systems have turned to staffing agencies and contracted labor to counter the loss of burned-out employees who go on strike or who leave healthcare entirely. On a positive note, Holloran sees contract labor use decreasing in the future.
There’s a steep road ahead for nonprofits but Holloran see positive changes. “We are beginning to come out of the worst of it,” he told Healthcare Dive. However, he added, “Hospitals should not expect to ‘grow [their] way out’ of soaring labor expenses by raising revenues or increasing hospital admissions.”
Like Johnson, Holloran stressed the importance of looking for long-term solutions. With rising expenses, declining revenues, and increased labor costs projected to continue for years, “hospitals are putting recruiting and retention efforts ‘on steroids’ amid challenges,” he noted.
One coming improvement is that hospitals “can look toward commercial payer contracts to ease high expenses,” Holloran predicted.
“Payer contracts fall in the approximately 25% to 30% of non-fixed revenue that hospitals have the ability to control. … The ratings agency [Fitch] now expects to see a shift from long-term contracts to single-year contracts as nonprofits attempt to ease expenses,” Healthcare Dive noted.
It appears that, for the foreseeable future, clinical laboratories will continue to feel the pressures brought on by mergers and acquisitions as the healthcare industry struggles to find solutions to the economic downturn and loss of qualified staff following the COVID-19 pandemic.