I would agree with the general sentiment that you have to be geographically flexible in our field for job opportunities. If your mentality is, "San Diego or bust!", it might be "bust" for quite awhile...
To put some perspective, remember everything is transient in life; and that goes with jobs as well. This group may not be hiring now, but eventually they will. Even if they have low turnover, somebody is going to leave. I'm not recommending anyone to hold out for any particular job they really want while waiting for a partner to retire/die until there's an opening. But, you have to be flexible and take what you can find that is the best available option other than you're #1 choice. Meanwhile, continue to keep an eye out and touch base with connections for a place you might really like to go down the road. There may not be an opening today; but, one day there will have to be.
As far as openings in big cities for pathologists, as I said above, you have to be geographically flexible. And sometimes, if you or your spouse are set on a big city, the only opportunities that might be available are in undesirable areas or a rural places. However, it depends if you are referring to a specific big city and a specific small town.
For example, let's say there is a quaint small town that you and/or your spouse are in love with. The kind of picture-perfect place with a high standard of living, low crime, and white picket fences that makes postcards and featured on HGTV. Well, if they have a small hospital with a solo pathologist in their 30s-40s who loves their job and got hired after the prior pathologist retired after a 40 yr career there, guess what, you'll probably never get the chance to move there, because people rarely leave good jobs like that and there's only 1 pathologist in that particular town.
On the other hand, take a specific large city like New York City that you and/or your spouse want to move to. You might have trained there, have family ties there, or you want to move there for other reasons. In that particular year/timeframe, there might not be any openings. But if we're strictly speaking of job openings in either Smalltown, USA or NYC, which one statistically is going to have more openings? Obviously, NYC because there's hundreds of pathologists employed there vs the solo pathologist in Smalltown who will probably stay there for the next 30+ yrs.
My point being, you actually have a better chance of getting a job in a
specific large city than a
specific rural area simply because of total number of positions i.e. job openings in the long run in that large city. It might seem kind of obvious, but if someone feels stuck in a job where that part of the country is not their cup of tea, and they want to be in a big city like NYC (or wherever), eventually there will be an opening because of the sheer number of pathologists working in that big city and there's bound to be turnover.