Pathology Leadership

[Inez2000]

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From CAP connect: A blog entry from Dr. Robboy


Posted by Stanley J Robboy| January 2, 2014
Many thanks to all who sent comments on the workforce blogs (Parts 1 & 2). By way of background, the College began planning some years ago for what became the “Transformation Project”. Looking out at the horizon, all of us, i.e., the leadership and members, saw storm clouds gathering and correctly assessed that something major was soon to change American healthcare, even though we knew not what would be its structure or how it would play out (Accountable Healthcare Act and other “reforms”). Healthcare had to change as rising costs were not sustainable, and also care was far less effective and universal than desired.

In launching our Case-for-Change (C4C) in 2010, we desired evidence-based data upon which recommendations would later be based. The strategy was to divide the assessment into four areas: 1) workforce (supply and demand), 2) new and expanded pathologist roles and services, 3) practice models, and 4) emerging technologies.

Workforce, especially the demand side, is complex. The supply side is in reality far easier to appraise. It assesses how many are currently in the field, how many will enter and how many will leave. It says nothing whether the need for numbers actually in the field now or in the future is actually warranted. In the 1960s and 70s, there were approximately 3,500 residents in training at any one time, having dropped currently by more than a thousand. The earlier trainees are now beginning to retire, from which comes “the retirement cliff”.

Simultaneously the U.S. population is expanding and the number of people reaching senior years is rising even faster. Our supply paper determined that currently there are 5.7 pathologists / 100,000 population. If this ratio is to be maintained, a drastic pathologist shortage will ensue.

Many of the comments question whether the assumptions about demand and the ratio is correct, which in reality anticipates the next series of works we plan. I agree wholeheartedly with everybody’s general comments. We all agree that it is terribly difficult to make predictions, especially about the future. It is exceedingly fallacious to say that because something has been in the past, it needs to be or even should be maintained so in the future. This denies technological advances and needs for change.

So how many people do we need? That is the focus of the coming demand papers during the next several months, and also from CAP’s Policy Roundtable.

Additional thoughts:

• Dynamic markets dislike deficiencies and surpluses. Should excesses develop, people will leave pathology or avoid coming into the field in the first place. If real shortages truly develop, other groups will come forward with disruptive ingenuity and fill or even replace entirely the void. Our goal at CAP is to estimate future needs and then help the profession ramp up. Also, from our work, we hope medical school chairs will think through what fellowships are needed to advance the future and which might be truncated. Just one month ago, 24 pathology organizations met to discuss workforce issues, with the hope reevaluations might begin that would be more relevant to modern times.

• Subspecialization has advantages and also dangers. This is a big area upon which more will be written. Given the volume in my department, specializing in one area has let me develop better comprehension of the field and made my life far more enjoyable. But if I were in a much smaller institution with a much lower volume, why would I or anyone wish to specialize if my skills would be not used much?

• New technologies: If we are as a specialty to be wanted and successful, we must look out at the horizon and ask what best utilizes our skills both as physicians and pathologists and how does that better advance patient care and help other clinicians in the House of Medicine. The introduction of immunostains lets me provide a whole new level of precision about the type of tumor present. Pathologists used to have a commanding role in informatics back in the 1970’s. This is a natural area for future professional growth, plus a technology that has made my life simpler and let me be much more efficient. Search engines, database software, spread sheets and word processing reduced to unpleasant organization time that could be used professionally examining specimens and doing professional and rewarding aspects of research. The same was true for the change from dictabelts for dictation and secretarial transcription to automated speech transcription.

• Digital pathology will be another area important to pathology and pathologists. I suspect some cases will be outsourced, but more will be in-sourced. And imagine how much easier it will be to send a case in consultation to a colleague in your group who works in another hospital, or to ask for help with the unusual frozen section. The potential for scope (pun intended) is great.

• Several items mentioned are of great import, but are not critical to workforce issues. We need as pathologists to ensure we receive appropriate part A payment. We need to abolish the in-office ancillary exception that clinicians use to disadvantage us and their patients.

• Ed Uthman predicts good jobs will fill up fast and problematic ones will experience shortages. I wholeheartedly agree, but believe this a truism for every profession. The best jobs and the ones most satisfying or glamorous usually fill quickly.

Please continue this discussion. This exchange is useful to me personally. Many threads begun here will appear later in coming papers about our demand side of the workforce.

And best wishes for the New Year.

 

[Inez2000]

Posted by Stanley J Robboy| December 30, 2013
Last week, I blogged about the recent Archives article, Pathologist Workforce in the United States, in which a group of colleagues and I found that beginning next year, the net outflow (largely from retirement) will exceed pathologists entering the field.

In many respects, it doesn’t matter how we got to this current workforce state. You can blame lack of understanding of the vital nature of pathology, training program closures, lack of funding for pathology seats, or even health care reform. The fact remains: the 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. We have a solid understanding of the size and nature of the workforce problem. What remains to be seen is how pathology will respond.

Through our advocacy efforts, CAP has already been fighting for funding the National Health Care Workforce Commission. We have also been working to secure increased GME funding that allows full funding of all pathology residency positions and increased visibility, so pathologists are “at the table” when healthcare workforce issues are addressed.

But is this enough? Are we doing our part to protect the future of our profession? And in fact what do we think our profession should and will be doing 20 years from now?

The issue of demands that the house of medicine and the public will place on us in the future is what a number of us interested in workforce issues are currently grappling with, and I’d appreciate some insight from my CAP colleagues here on CAPconnect. There’s no doubt medicine is changing (stay tuned, more to come on this issue), and we must adapt. Of great consequence to us all is the growing importance of providing value, which I like to think will occur through newly-emerging roles, and how we demonstrate that value to administrators, payers, policymakers, and patients.

Equally important is for us to look at the functions we have been performing and determine what we might transfer to other, less costly healthcare professionals. This is similar to when we began having cytotechnologists screen smears and pathology assistants aiding in grossing specimens, thus freeing up the pathologist to examine the materials requiring diagnostic and medical judgment. What do we now might remain core to our profession in the future? What might not?

With medicine becoming ever more complex, more effort will be needed in the clinical laboratory to enhance the goals generally ascribed to why Accountable Care Organizations are being developed, which is all about achieving greater value driven results. How do we change to adapt? There are so many facets to this question. With new technologies materializing, how do we best deploy our medical expertise in the most effective way? What we see as threats in pathology is playing out nationally throughout all of medicine. I would appreciate your thoughts.

 

[Inez2000]

Posted by Stanley J Robboy| December 23, 2013
Over the last few years there has been much talk about the pathology workforce. Conferences, studies and dialogues have all attempted to both define the current state and future needs for pathologists, both in the U.S. and Australia and New Zealand. Earlier this month a group of colleagues and I published an article in Archives of Pathology & Laboratory Medicine: Pathologist Workforce in the United States. What we found may surprise you (or confirm what you already know): the workforce shortage is about to become a reality; it’s impact will be significant and far reaching.


(Click to enlarge) Net changes to pathologist workforce (headcount), based on year-to-year additions to the workforce less withdrawals/retirements. It does
not include the anticipated additional numbers needed due to changes in demand, that is, from population growth and other factors

Beginning next year, the net outflow (largely from retirement) will exceed pathologists entering the field. Exactly when the workplace will ease for finding jobs remains certain.

Through 2010, there were approximately 18,000 actively practicing pathologists in the United States, about 93% of who were board certified. The numbers of practicing pathologists will decrease to approximately 14,000 full-time equivalent (FTE) pathologists in the next 20 years.

Starting in 2015, the numbers of pathologists retiring will increase and will peak by 2021. Without changes in workforce entry or exit rates, we can expect to see the number of pathologists to continue to decrease through 2030. This decrease—when combined with expected growth in the U.S. population, and increases in disease incidence from our aging population—means there will be a net deficit of more than 5,700 FTE pathologists.


(Click to enlarge) The gap in pathologist workforce between supply available
and numbers needed is widening continuously, in part owing to
additional demand factors.

Without an increase in the pathologists in training, patients and their clinicians will experience potentially disruptive changes in current patterns of practice.

A substantial shortage of pathologists could impair patient access to needed care. It could also prevent pathology from leading in emerging areas of practice such as informatics, genomic medicine and new delivery systems such as coordinated care. This leaves the door open for others to take on roles best filled by pathologists.

I welcome your feedback on these findings. Also, how do you see this shortage impacting you? Other pathologists at various career stages?

Next week, Part 2 of my blog will focus on how pathologists (and CAP) should respond.

 

[turtle1966]

Wordy chat, GIGANTIC OBSFUSCATION !

What our Specialty needs is a steady application of simple hardy business principles!

 

[AFM]

There is no reason for CAP to post this connect stuff behind a login wall. And to make that login different than the main cap.org site.

 

[deleted314957]

There is no reason for CAP to post this connect stuff behind a login wall. And to make that login different than the main cap.org site.

Robboy's blogs totally ignore the fact that most pathologists don't s/o more than 6000 accessions/year. they could easily double that.

 

[oldfatman]

We had an opening recently. 90 applicants for one job. Took six months to fill. Most of the applicants couldn't speak English or had minimal communication skills. We don't need more pathologists, we need better academic programs, that produce better quality pathologists. More resources need to be spent regulating pathology residency programs so they actually do what they are being paid to do.

 

[turtle1966]

We had an opening recently. 90 applicants for one job. Took six months to fill. Most of the applicants couldn't speak English or had minimal communication skills. We don't need more pathologists, we need better academic programs, that produce better quality pathologists. More resources need to be spent regulating pathology residency programs so they actually do what they are being paid to do.

Jeremiad!! Jeremiad!! Jeremiad!!

In my city, internal medicine PAs are stampeding diseases and dermatology PAs are psoriasis specialists; this with an average intellect, 2 years of post college education, without a debt and without having to move (to find a job).

In pathology, top notch intellect, 4 years of med school plus 4 years of residency plus 2 years of fellowship plus huge debt plus the thrill of getting to live in a never heard of place, in order to be able to sign out an appendicitis!!

This is a self-inflicted and self-engendered situation!

Pathologists wake up! wake up! wake up! Drink no more of this Kool-Aid dispensed by our incompetent, obfuscating and unethical leaders!

 

[path24]

90 apps for 1 job. Shortage starting next year.....haha. Run people run from this field.

FMGs are the hot ticket around here and other places also apparently, after talking to other path friends. Offers are 100k, yearly contract, no partner. No one wants AMG, they get turned away....they expect to much.

 

[Pathwrath]

It appears that CAP is not about to sit idle while our profession is steadily destroyed from the outside.

I guess if we're going down, CAP might as well be the one driving us off the cliff.

 

[turtle1966]

90 apps for 1 job. Shortage starting next year.....haha. Run people run from this field.

FMGs are the hot ticket around here and other places also apparently, after talking to other path friends. Offers are 100k, yearly contract, no partner. No one wants AMG, they get turned away....they expect to much.

PRICE OF PASSIVITY:

First they came for the Socialists, and I did not speak out--
Because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out--
Because I was not a Trade Unionist.

Then they came for the Jews, and I did not speak out--
Because I was not a Jew.

Then they came for me--and there was no one left to speak for me.

Martin Niemöller (1892-1984), a prominent Protestant pastor and an outspoken public foe of Adolf Hitler who spent the last seven years of Nazi rule in concentration camps.

 

[Johnny Sunshine]

1. Just because they are reaching "retirement age" does not mean there is an upcoming shortage of pathologists. If anything, pathologists are less likely to retire than many other professions.
2. Even if the supply of newly trained pathologists cannot keep up with the numbers leaving, that does not mean there will be a shortage. Technology and changes in the healthcare system are, in my opinion, dramatically reducing the number of pathologists necessary. Hell, all some company has to do is create a computer algorithm to scan MPO-stained appy slides for PMN tissue invasion, and we will likely lose a huge part of the professional component for 250,000 specimens a year in the US. Basing your expectations for the future on decades-old per capita data is simply stupid. How about you actually look at what people are experiencing today?
3. Even if all of their prognostications turn out to be correct, are we really supposed to be massively expanding pathologist training now...in order to prepare for something which may or may not happen in 10-15 years? What are these backup pathologists supposed to do for 15 years? I mean, aside from screw up the market and make pathologists cheaper to hire than PAs?

I could go on, but then I'd just get angry.

 

[Path or bust]

I suspect that surgical pathology will slowly go the way of the hospital autopsy.