Is Pathology Workforce Stable or Shrinking?

Questions raised after JAMA study identified a 17.5% decline in pathologists from 2007 to 2017

CEO SUMMARY: After publishing research in JAMA Network Open showing a coming shortage of pathologists in the United States, the researchers heard from pathologists whose experience in the job market did not match what the researchers found. Anecdotal evidence indicates that the demand for pathologists may vary widely from region to region and in urban versus rural practice settings. Still, there is general agreement that pathologists today work harder and get paid less.

PUBLICATION OF A RESEARCH STUDY into how the pathology workforce in the United States and Canada changed between 2007 and 2017 triggered a wide range of opinions and comments from pathologists in the United States.

On May 31, JAMA Network Open published online the research study, “Trends in the US and Canadian Pathologist Workforces from 2007 to 2017.”

In their study, Dallas pathologists Jason Y. Park, MD, PhD, and David M. Metter, MD, and colleagues reported that from 2007 through 2017 there was a 17.5% decrease in the number of pathologists in the workforce of the United States.

There also was a population-adjusted decrease in the number of pathologists working in the United States over the same 11-year period. (See “JAMA Study: 17% Fewer Pathologists Since 2007,” TDR, June 10.)

As a trend, these findings suggested that the number of pathologists in the United States may have entered into a shortage.

“The JAMA Network Open article does not present evidence of a shortage, but rather it presents a number of pathologists per capita that is consistent with shortages in other countries,” Park explained.

The reaction among some pathologists who read their study in JAMA Network Open suggests that it may not be possible to characterize the market for anatomic pathologists based on a single average national statistic. Pathologists in urban areas may have one view of the job market, while pathologists in rural areas may have a markedly different experience.

Or, it could be that the job market may reflect a shortage of pathologists in the coming years, but there is not a current shortage in the job market, as Park, Metter, and colleagues suggested in their research study.

Comments from Pathologists

In an interview with The Dark Report, Park and Metter said that, following the publication of their research online, they heard from pathologists in a variety of settings who generally disagreed with their findings. In e-mail messages, pathologists who read the study expressed skepticism about the results, saying their individual experiences did not match the research findings.

One such comment from a middle-aged pathologist who is board certified in anatomic and clinical pathology, and in cytopathology, is titled, “One Pathologist Discusses a Different View of His Experience Versus Study Findings.”

Many of the comments were from pathologists whose experience contradicted what the researchers found, said Park, an associate professor, and David M. Metter, MD, a pediatric pathology fellow, both at the University of Texas Southwestern Medical Center.

Findings Prompt a Response

“Some of the feedback we got came from people who were quite upset with our findings,” Park said. “David and I are sympathetic to these comments because we understand what they are going through. Unlike most other physician specialties, the pathology profession has been hammered for almost 20 years as reimbursement shrank and narrow networks caused pathologists to lose access to a growing proportion of patients.

“Many comments seemed to suggest that we were misrepresenting what these pathologists have experienced,” he added. “That’s because—in their daily life and in the job market in their communities—they feel like they’re being treated as a commodity.”

One reason pathologists are commenting on the research findings in the journal article is that their experience of the job market has been negative—at least in part. Shortages among physician specialists have created opportunities for frequent movement from one job to another and increased pay at each new opportunity, Park said.

But in pathology, health insurers and health systems offer take-it-or-leave-it contracts to pathologists quite often, he added. What’s more, the workload of each pathologist has increased significantly in recent years.

“Many pathologists feel that if they don’t accept the contracts as offered, then the hospital or health system will find other clinicians who will do the job,” Park commented.

Such anecdotal comments appear to contradict the findings Park, Metter, and colleagues published in JAMA Network Open. However, the article only identified the downward trend in pathologist numbers in the United States. It did not specifically identify a workforce shortage.

In April 2018, the Archives of Pathology and Laboratory Medicine (APLM) published an article in which researchers reported on five years of job-market surveys from the College of American Pathologists. That article, “The Recent Pathology Residency Graduate Job Search Experience: A Synthesis of Five Years of College of American Pathologists Job Market Surveys,” was based on surveys of recent graduates of pathology programs in the United States.

Difficulty Finding Jobs

In the APLM article, researchers reported that job-market indicators—including job interviews, job offers, positions accepted, and job satisfaction—remained stable over the five years of the survey. Most survey respondents who applied for at least one position had accepted a position at the time of the survey, and most applicants who had accepted a position were satisfied or very satisfied, the researchers reported.

Park commented that the APLM article may be consistent with a shortage because one of its findings indicated the majority of recent graduates had difficulty finding jobs.

Park and Metter said the APLM article focused specifically on the job market for those pathologists just entering the workforce after fellowship training. But the article did not match Park and Metter’s experience, nor that of many of their colleagues who have years of experience.

“Our initial reaction to the APLM article was that we didn’t think it was possible that the market for pathologists’ services was remaining stable,” said Park. “Based on our own experience, that didn’t seem right. We actually thought there was an oversupply of pathologists.”

Before starting the research that resulted in the publication in JAMA Network Open, Park and Metter hypothesized that there was an oversupply of pathologists making it difficult for new graduates to find work. Park and Metter began research into the pathologist workforce and enlisted additional researchers Terence J. Colgan, MD, who is the Head of the Sections of Gynecological and Cytopathology at Mount Sinai Hospital, Toronto, and a Professor in the Department of Laboratory Medicine and Pathobiology at the University of Toronto; Stanley T. Leung, MD, JD, an anatomic and clinical pathologist with Incyte Diagnostics in Bellevue, Wash.; and Charles F. Timmons, MD, PhD, a professor in the Department of Pathology at UT Southwestern.

Pathology Market Paradox?

While the number of pathologists is falling relative to the number in practice in 2007, Park and Metter said the data do not confirm that this is a shortage of pathologists, especially given that the APLM research suggests jobs are available for new graduates.

“To those of us involved in the JAMA Network Open publication, it certainly doesn’t feel like a shortage,” Park said. “So, we have a paradox where there is a decreasing number of pathologists, which has been unabated for 10 years. But David and I had anecdotal evidence and personal experience for over 10 years where the pathology market has been very tight. Therefore, ‘stable’ would be a very generous term to use. We have a significant decrease in the supply of pathologists without an apparent increase in demand.”

Metter explained what typically happens for new graduates. “From my experience, I would say that new graduates apply to a lot of places all across the country but may only get a few interviews,” he said.

Few Offers Forthcoming

“New graduates are not inundated with job offers,” he added. “This paucity of job offers in our experience was the reason for our pre-study hypothesis of a possible oversupply of pathologists.”

But then the data in the JAMA Network Open study did not show an oversupply or a shortage. “It shows that there is a decrease in the number of active pathologists,” Park said. “The data also suggest that there could be a shortage at some point. If you’re decreasing the number of pathologists by almost 20% every 10 years, you’re going to hit a wall eventually. That said, we don’t think we are there quite yet.

“Logically, you assume that as the number of active pathologists declines, both salaries and the number of positions should increase accordingly,” Park added. “But when I talk to my colleagues in the pathology community, that’s not what’s happening.”

Both Park and Metter warned against relying on data from recruiters, not because their numbers are inaccurate, but that they might not be parsed sufficiently to reflect the characteristics of each physician specialty. “Most of my friends who are practicing surgeons or in primary care easily get 20 offers a month,” Park said.

Specialists Heavily Recruited

“And when they were just coming out of training, they were heavily recruited. I don’t think you could find many pathologists who would ever say they had a point in their career where they were weighing multiple job offers.”

Park offered a summary of the current literature. “If we can tie everything together, maybe we can say that, yes, there is a dramatic decrease in the number of pathologists. But there aren’t many job opportunities and, as the APLM article suggests, the job market is somewhat stable.

“The problem is that pathology is an outlier specialty in medicine, because in other specialties there are usually more job openings than physicians to fill them,” he added. “In pathology, we have a paradox: There is an unabated decrease in the number of pathologists over the past decade, but pathologists don’t have a lot of opportunities.”

One Pathologist Discusses a Different View Using His Experience versus Study Findings

AFTER JAMA NETWORK OPEN PUBLISHED A STUDY on the pathologist workforce in the United States and Canada on May 31, a reader wrote to comment that the article was much different from his experience.

“I am a middle-aged pathologist certified in AP/CP and cytopathology,” he wrote. “My experience is that the job market for pathologists in the United States is dismal, despite all reports from academia claiming just the opposite.

“I work in a middle-sized community hospital,” he continued. “Our hospital frequently had problems attracting qualified physicians and had to hire expensive firms to attract good doctors. However, when we advertised for an open position for a pathologist via [an online service] our secretary received 85 CVs in only five days.

“My young colleague will finish his pathology residency and fellowship in July this year,” the commenter wrote. “While his wife, an internist, got 30 job offers, he only recently got a single offer, after nine months of searching.”

This pathologist next asked why academic researchers appeared to be inaccurate. “Why do calculations from academic centers always get it wrong?” he asked.

“People in academia live in special environments and have no idea or interest to see what is going on in the real world,” he wrote. “Since academic departments of pathology have incentive to train as many pathologists as possible (cheap labor and government subsidies), they choose to see reality as it suits them the most. They do calculations based on previous years and fail to see (intentionally or due to ignorance) the major shift which happened [to the pathology profession] in last 20 years.

“In the last 20 years, the workload for most pathologists working outside academia at least doubled, if not tripled,” he wrote. “What caused this sudden increase in workload? It is primarily due to the acquisitions of individually-owned laboratories by large corporations (Quest, LabCorp, HCA, and others).

‘Fire Half the Pathologists’

“To increase profit margins, raise stock valuations, and ensure that CEOs are awarded lucrative stock options, corporations have merged many smaller labs into large conglomerates,” explained this pathologist. “In most situations, a new corporate entity will fire half of the existing pathology staff and increase work expectations for the remaining employees far beyond the prior norm.

“And how did academia respond to the overall cosmic change?” he asked. “Teaching hospitals—in their quest for more federal money and cheaper labor (in the form of residents)—almost doubled the number of [first-year] positions for pathologists in the same time period—from 335 in 2000 to 605 in 2015. Seeking even more profit, these teaching hospitals recently added pathology to the list of specialties in ‘short supply,’ enabling them to push for additional slots (and funds) under new legislation.”

Contact Jason Park, MD, at jason.park@childrens.com.

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