CEO SUMMARY: In Canada, it is known that the supply of pathologists and laboratory physicians has diminished since 1998. Further, a federal program that measures patient wait times for certain surgical and imaging procedures does not measure how long patients wait for anatomic pathology test results. Authors of a recent study point out that—lacking data on patient wait times for laboratory test reports—government funders may be inclined to steer funding to other clinical specialties.
IN MANY DEVELOPED COUNTRIES, the supply of pathologists already falls short of meeting the demand. This situation is expected to become more acute because of cutbacks in medical training positions and as more pathologists reach retirement age.
In Canada, these shortages are exacerbated by disincentives to create attractive positions within the controlled healthcare market. As a consequence, the shortage of pathologists is already severe in some places. For example, Saskatoon, Saskatchewan, has seen reporting delays for anatomic pathology tests due to an inadequate number of pathologists in the region.
Currently, the Saskatoon region has openings for four pathologists, a shortage that caused a backlog of 992 specimens in July and a turnaround time (TAT) of seven days or more. In March, the backlog was 1,300 specimens and the average TAT for reports was 12 days, according to the Canadian Medical Association Journal (CMAJ). The College of American Pathologists says the standard report time should be two days for rush biopsies and five days for complex surgical cases.
Canada’s national government analyzes how long patients wait for certain procedures. However, pathology wait times are not evaluated, said Terence J. Colgan, M.D., Head of Gynaecological Pathology, Pathology & Laboratory Medicine, at Mount Sinai Hospital in Toronto. Recently, Colgan and his colleagues studied the supply of pathologists and laboratory physicians and published their results in an article, “Canadian Laboratory Physician Supply: Falling Behind,” in the Canadian Journal of Pathology.
Researchers determined that, across Canada, the number of pathologists and/or laboratory physicians has diminished in the past decade, relative to the size of the population and also relative to the number of clinical physicians and radiation oncologists in practice. There is also variation in the supply of pathologists and laboratory physicians by province.
More significantly, researchers concluded that the number of pathologists and/or laboratory physicians relative to the number of clinical physicians fell in most provinces. This finding is inauspicious for the future of anatomic pathology services in Canada.
“The study clearly showed, that by the three parameters we used, the supply of pathologists is shrinking,” Colgan said in an interview with THE DARK REPORT. “The reasons are difficult to identify. However, we know that there are two demographic waves occurring simultaneously.
“First, the pathologist population is aging, and we are uncertain whether there are enough new graduates to replace the older ones going out,” explained Colgan. “Second, demographics of our aging population in Canada contribute to an increasing number of cancer cases each year. This means more work in cancer screening, diagnosis, and prognostication—even as the available supply of pathologists and laboratory physicians declines.”
Less Interest In Pathology
Compounding the problem is what Dr. Martin Trotter, Vice President of the Canadian Association of Pathologists, said is low interest in pathology among medical graduates, primarily as a result of changes in medical school curricula in the past decade. In a CMAJ article, Trotter wrote that medical students no longer take second-year pathology courses. Instead, they are expected to choose specialties in their second or third year. Thus, in their second year, these students lack knowledge of pathology and laboratory medicine.
“I concur with Dr. Trotter’s comments that physicians in training are not exposed to pathology and medical laboratory training,” stated Colgan. “Until recent years, pathology was an identified discipline within medicine. But changes in curriculum meant that undergraduate schools in this country tend to teach conceptual courses which don’t identify pathology or lab medicine as a discipline.
Single-Payer Health System
“There is another reason for the potential shortage of pathologists,” he added. “In Canada, the number of physicians available for training—and ultimately the total number of physician positions within the regional health authorities—are controlled by the single-payer health system.
“Under this type of healthcare system, a strong argument can be made that there is a significant disincentive for the regional health authorities and hospitals to create new pathology positions when money is tight and needed in other areas in healthcare,” observed Colgan.
“For example, our federal government, in conjunction with the provinces, established a patient wait-times strategy,” he continued. “They monitor how long it takes to get specific, important procedures done, such as hip replacement, cancer treatment, or an MRI.
“However, currently no laboratory medicine or pathology procedures are on that list,” Colgan said. “Thus, funders have an incentive to spend money to shorten the patient wait-times for certain surgical and radiologic procedures. But funders have no incentive to fund pathology procedures.
“What compounds the negative impact these policies have on anatomic pathology is that Canada does not have accepted national parameters to measure quality in pathology,” observed Colgan. “That leaves us with a health system where funders direct money away from laboratories as a consequence of the waiting-times strategy. And, because we lack a method to measure lab quality, that puts the laboratory testing profession in a very tough spot.”
Colgan is aware of long wait times for pathology reports in Saskatoon. “Cer- tainly in some cases, not having specimens reported out in an appropriate length of time will impair patient care,” he said. “This is particularly true if there is a significant and unexpected finding.
“Also, the decision to do follow-on molecular testing can be made only after an initial pathologist review,” he noted. “However, if the tissue sits in formalin too long, it’s no longer possible to undertake such testing. In either of these situations, the standard of care for the patient is not met.
“The issue of turnaround time is important for other reasons as well,” Colgan continued. “Prolonged TAT indirectly increases clinical costs, but this impact is often not appreciated. Pathology test turnaround time can also serve as the ‘canary in the coal mine.’ Should TAT for a tissue specimen become extended, then often the development and monitoring of other quality parameters may not happen.
Pathology Test TAT
“Similarly, longer turnaround times for pathology testing often detract from the development and introduction of the latest clinical practices in molecular pathology or personalized medicine because the lab is struggling with this single parameter,” observed Colgan. “So, not only should pathology test TAT be of concern by itself, but it can also be a red flag about the actual state of quality in pathology in 2011, compared with where it should be.”
THE DARK REPORT observes that this latest published survey of pathology staffing shortages in certain provinces of Canada can be instructive to both pathologists and health policy makers in other developed countries. How each province in Canada meets the challenges of expanding the supply of pathologists or investing to shorten turnaround times for anatomic pathology testing will teach important lessons.
Pathologist Supply/Demand Experience Varies Across the Different Provinces in Canada
FOR AN ARTICLE IN THE Canadian Journal of Pathology, researchers reviewed physician supply data from 1998 through 2008 from the Canadian Institute for Health Information (CIHI).
The researchers defined and then calculated three measures of laboratory physician or pathologist supply as follows:
- Population-to-laboratory physician ratio and population-to-pathologist ratio;
- Clinical physician-to-laboratory physician ratio; and
- Comparison of population-to-pathologist ratio and population-to-radiation oncologist ratio.
Under each of these parameters, the supply of laboratory physicians or pathologists in Canada has diminished in the past decade, relative to: total population; number of clinical physicians; and number of radiation oncologists, said the researchers. The number of family practitioners and clinical medical specialists in Canada each increased by more than 6% over this 20-year period. By contrast, the number of pathologists and laboratory physicians decreased by 1.4% and 1.8%, respectively. Supply trends varied by province and parameter, but the supply of laboratory physicians relative to clinical physicians fell in most provinces.
The researchers who conducted this study were: Aaron F. Pollett, M.D., and Terence J. Colgan, M.D., of the Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, University of Toronto, in Toronto, Ontario; and Ginette Lajoie, M.D., a member of the Department of Laboratory Medicine, at Brampton Civic Hospital, William Osler Health System, in Brampton, Ontario.
Pollett, Colgan, and Lajoie concluded that if the current trends in staffing of pathologists and laboratory physicians continue into the future, an adverse effect on Canadian healthcare can be expected.