In appropriate utilization of laboratory testing has been estimated to range from 10% to 50% of the volume encountered in hospital laboratories. Many strategies to control utilization of laboratory testing have been reported, including redesigning test requisitions, changing standing orders, the use of provider order entry, physician profiling, and educational initiatives. The major motivation to reduce utilization of unnecessary testing is financial, although other benefits also may be observed, such as reducing false-positive results stemming from testing patients in low prevalence populations, eliminating unnecessary follow-up procedures, avoiding iatrogenic anemia, and potentially lowering hospital length of stay resulting from the need to track down the significance of falsely abnormal tests. The majority of utilization control efforts have focused on reducing routine laboratory tests such as chemistry profiles and automated blood counts. In many hospitals novel diagnostic tests, especially in molecular genetics and oncology, are the major driver behind increasing laboratory costs. Traditional methods to control utilization of routine testing are usually ineffective in controlling testing of novel diagnostic methods. In most cases, test requests originate from a small group of physician specialists who typically are more knowledgeable in their area of expertise than is the clinical pathologist. For this reason, a different approach is generally required. It is particularly important to establish an institutional structure authorized to review and approve new laboratory tests. The clinical pathologist usually takes the lead in this effort because laboratory-based physicians are familiar with new tests being requested by physicians across a spectrum of medical specialties. To be successful, the laboratory physician must identify potential utilization issues, acquire and analyze data, function on interdepartmental teams, and develop strategies to satisfy the needs of clinicians while at the same time preventing introduction of inappropriate technologies into the laboratory. This article will give a perspective on approaches to laboratory test utilization and offer specific examples of initiatives we have undertaken in our institution. The examples will illustrate how the pathologist can use knowledge of medicine and the clinical laboratory in conjunction with organizational and team building skills. In the final analysis, the process is more of an art than a science.