The maximum number of residents in all programs collectively was approximately in Approximately 2. This is well in excess of the estimated pathology residents graduating per year.
Selective pathology is the largest group filled ; this includes a host of general surgical pathology fellows or fellows in general pathology with an emphasis on a subspecialty, for example, gastrointestinal pathology. Specific specialties with filled positions are cytopathology fellows , hematopathology fellows , and dermatopathology 84 fellows.
The surplus of available positions is explained in part by the multiplicity of fellowships taken by a substantial minority of graduating residents.
Nearly all fellows, including those in ACGME-accredited programs, will provide some, but variable, degrees of patient care, and very likely, most in non-ACMGE programs will actually function for a portion of the year in a junior staff capacity.
However, the net addition of FTE effort was considered as not significantly affecting the overall available workforce, as the additional FTE effort from this professional pool is likely to remain stable. Their contribution to both supply and demand is presumed to remain as at present. The average age at which pathologists reported they planned to retire is at During recent times, pathologists older than 55 years have reported their planned retirement age will rise by about 4 years from age 67 to 71 years.
After there is some fluctuation in the rates of pathologist retirement, owing in part to the currently older pathologists having completed their retirement, to pathologists between 55 and 64 years of age having largely retired, while with some uncertainty those currently aged 45 to 54 years will just have begun their retirement Figure 4.
From the planned retirement patterns, approximately pathologists will leave the workforce during —; and an additional pathologists, between and With time, women have increasingly chosen careers in pathology.
Maternity leave averaged Once through residency training and in practice, during the childbearing years, the overall average working hours spent by women in the age category of 44 years or younger was slightly lower than for men The variables of family leave and differences of hours worked, being determined as having a low impact on the FTE supply of pathologists, were excluded from the model.
Similar to all specialties constituting medicine, PAs enable pathologists to provide patient care more efficiently. Ninety-six percent of PAs are involved in preparation of smaller pathology specimens and grossing of larger specimens. In AHCs, PAs, by assisting in grossing, also help residents from exceeding their allowable duty hours. Five percent each were at the extremes. The programs leading to certification by the Board of Certification of the ASCP currently graduate a net of about PAs a year, which has been constant for some years, although this may well change in the future.
This number includes the net number leaving the field each year as dropouts or through retirement. The higher counts noted earlier reflect grandfathering of an additional PAs in and PAs in Through , we estimate there are certified PAs. In addition, many PAs are noncertified: some trained before certification began. Others are PAs who have limited responsibilities and have chosen not to become certified. From surveys, we estimate there are slightly more than noncertified PAs, that is, about twice as many as the certified group.
The C4C indicates slightly higher ratios, with 1 PA supporting 3 to 4 pathologists. Based on the C4C survey only, there are PhD holders working in pathology laboratories for a ratio of about 1 PhD holder per 8 pathologists. We are unable to estimate the growth rate of PhD holders. It does not include the anticipated additional numbers needed due to changes in demand, that is, from population growth and other factors see Figure 6.
Working with just the supply side of the model, altered projections can be forecasted from supply-side scenarios. The key variable is funding of US allopathic pathology residency training positions.
The third prediction of our model considers that the demand for pathologist FTE effort will not remain constant over time, but will increase. Filling this gap will require a total of 8. If the goal were simply to maintain the supply of pathologists in at the same level as in , a 5.
These demand-side considerations will be reported in a separate forthcoming article. The gap in pathologist workforce between supply available and numbers needed is widening continuously, in part owing to additional demand factors. Pathologists are central to bringing the understanding of disease and disease mechanisms to bear on patient diagnosis and management.
The CAP, as part of a long-range vision to help transform its specialty and prepare for the future, undertook a comprehensive survey of pathology workforce supply and demands and population needs in the United States, with the goal of developing a dynamic modeling tool that could be easily updated, and be sufficiently flexible to predict pathologist needs in any particular subspecialty area.
With our model, we have been able with some precision to address specific concerns about the workforce. Of the 36 specialty groups tracked by the AAMC, pathologists have the second highest percentage of active practitioners aged 55 or older. The pathology residents trained in the s have practiced for some 40 years and are now beginning to retire; current training programs are insufficient to make up the shortfall. With new technologies and other new areas of endeavors opening, the coming demand for pathologist services will greatly exceed the supply.
There are multiple strengths to this study. Studies of the pathology workforce supply have been projected before, but not at this level of detail. The studies reported earlier, 10 , 11 while large in scope, were unable to comprehensively survey the entire specialty. Our study tried to account for and quantify as many variables as possible that are associated with the pathologist workforce supply, including 1 additions to the workforce in terms of residents, fellows, and IMGs; 2 separations from the workforce in the form of retirement, death, and emigration; and 3 the supply of extenders PAs and PhD holders.
We also were able to identify variables which, while present, were of much more limited influence in particular, work effort as a function of sex or age. Building our model from previously available and primary research allowed us to be explicit in our methodology and made our model more robust. Despite best attempts, there are limitations to this study. Some data gaps outlined below hopefully can be improved in future studies.
Further work is needed to determine if this is an accurate estimate for the United States, and why the rate is this high. Questions include: What numbers represent MD clinicians, most likely board certified in other specialties, who are working in blood banking or transfusion medicine, clinical laboratories, or in other specialized fields of pathology such as microbiology?
What numbers are trained pathologists who never obtained board certifications and are now working in academic health centers or in the research industry in administrative or scientific positions? Of a greater health care concern, are licensed physicians who have failed the ABP certifying examinations practicing as pathologists, possibly in physician-owned in-office laboratories, where the prerequisite of certification could be left to the discretion of the owners of the practice?
Annually, about 34 dermatologists complete their training to become dermatopathologists. We cannot assess what workforce contribution this group brings, without a better understanding of what portion of their effort is subsequently devoted to practice as dermatopathologists, and what percentage of their work is derived from their own or their immediate group's practice as dermatologists.
The more common areas involve dermatopathology, gastrointestinal pathology, and uropathology. While we do know that the pathology services provided for these laboratories are often done by board-certified pathologists, we do not know to what extent. Few practices are willing to reveal details of their operations or finances, but their advertisements indicate clearly they are thriving.
Highly sensitive details needed to relate these practices to the workforce model would include volumes of specimens generated and time spent by pathologists in these practices. International medical graduates comprise a substantial portion of pathology trainees and subsequently the workforce. With current visa rules, it is unclear what proportion of IMGs who come for purposes of residency training are required by law to return to their home countries, and what proportion ultimately return to join the permanent workforce.
With the global economy changing currently, we also do not know how many IMGs in the workforce later decide to permanently leave the United States and seek employment in another country.
Information specific to pathology residency is not captured by the information sources known to us. Availability of information was also limited for international pathologists who completed their residency training in other countries and have migrated to the United States for pathology practice. Our model has a placeholder for this variable. Pathologists' assistants play a critical role in the functioning of today's pathology laboratories and for that reason were included in this analysis of pathologist workforce supply.
While PAs can be seen to some extent as replacing certain work that the pathologist might otherwise do, to a large extent, they extend what pathologists perform, and are essential as the requirements for a comprehensive examination of a specimen become far more complex. For example, in the s, the usual workup of a breast lumpectomy specimen consisted of 1 or 2 slides being prepared from the tumor mass, and possibly a slide or 2 of the nontumorous region and a closest margin.
Today, the same specimen workup routinely incorporates specimen radiographs, gross photographs, extensive inking, detailed correlation maps made of the gross findings and radiologic findings, fixing of the entire specimen in formalin, blocking and mapping the entire specimen for microscopic examination requiring often 25 to 60 blocks , and preparing key areas for the biorepository. All of this requires substantial work. All of these procedures require substantial time and effort, and explains the pathologist—pathologists' assistant partnership in dealing with the new world of complexity.
In this analysis, we have examined the ratio of anatomic pathologists to pathology extenders, but we are unable to measure precisely what work the pathologist does that is actually replaced by the pathology assistant. Clinical scientists with PhD degrees participate integrally in the operation of the laboratory.
A detailed study, like ours done for pathologists, is needed to analyze this segment of the workforce, including its various training programs. As medicine rapidly changes, we see rapidly evolving demands for pathology services. In part, some of the services will be related to a larger population and also to the aging of so-called baby boomers, whose health care needs will significantly add to an already stressed health care system.
Our analysis shows that current numbers of pathologists completing training programs are substantially inadequate to compensate for the numbers of pathologists retiring in the next decade and a half. There is also great concern about the recent closure of several training programs, lack of funding for current seats, and health care reform that might broadly cut financial support for medical education, affecting all specialties including pathology. The model we have developed provides a robust tool to analyze and quantify workforce data from which thoughtful decisions can be made.
The model's supply-side analysis displays the variables that have been considered, which are critical, and how they could be changed to assure sufficiency of the pathologist workforce. The companion report on the demand side will analyze current specialty and subspecialty needs, and explore workforce demand as new testing modalities are introduced and new forms of testing are integrated into patient care. Additional participants in data collection, analysis, or preparation of the manuscript included David A.
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Pathology cut medical care in a different direction. We were all about diagnosis. There was a time when physicians referred to pathologists as the "doctor's doctor. We instructed on the interpretation of tests and helped guide the pursuit of the diagnosis. In an era of increasing specialization focusing on systems and body parts, pathologists were often the only ones who were really aware of all the disease processes that might account for a patient's findings.
I believe that is still a valuable role. Unfortunately, over time laboratories were moved out of the hospital. Test results are divorced from the patient. Not many pathologists are in the laboratory helping to understand results.
The entire practice of medicine changed with shorter visits, essentially, no history and physical and no one who knows the patient. The ability of a knowledgeable clinician to speak with an informed pathologist about an individual was greatly reduced.
The autopsy disappeared because, although the cost was supposedly included in hospital payments for overall function, nothing was paid out to the physician who invested a day or two in each one, and no one wanted to find out about those significant unexpected finding.
At the same time pathologists experienced the same degradation of cognitive work. They were paid for producing the piece work of anatomic pathology diagnosis. Their expertise in the lab was largely neglected, or increasingly over time, never obtained during their residency. The no longer did the very valuable work of "the big biopsy" and bringing the whole story together after an autopsy.
Many happily went along with that and did well for a few years. Although I pine for the good old days, I don't see that either the environment or the current pathology workforce can support their return. Moved on 20 some years ago and have been outside medicine ever since.
I come from the med-legal side of things. Judging by the news reports of delays in the court system related to a tremendous backup in the state ME office, the answer would seem to be, "A heckuva lot more.
Is that going to be in the public's best interest? I'm thinking not.
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