Reduce Residency Slots In Pathology!!!

[106174]

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Based on the posts on the thread "Pathology: Is It Worth It?," it seems that a lot of us recognize the fact that we are producing way too many Pathologists, making the job market in Pathology the worst in all of medicine.

Being the future leaders of our specialty, why don't we all start a movement to reduce the number of residency slots in Pathology? Let us start making the officials concerned (for example, Rebecca Johnson of the ACGME and Betsy Bennett of the ABP) know that all of us residents and fellows are aware of this problem and that we are going to push for change to happen. We need to make our voices heard. I plan to bring this issue up at the CAP RF Town Hall Meeting in San Diego in September.

Let us protect our specialty and our future as Pathologists!!!

 

[Path or bust]

Based on the posts on the thread "Pathology: Is It Worth It?," it seems that a lot of us recognize the fact that we are producing way too many Pathologists, making the job market in Pathology the worst in all of medicine.

Being the future leaders of our specialty, why don't we all start a movement to reduce the number of residency slots in Pathology? Let us start making the officials concerned (for example, Rebecca Johnson of the ACGME and Betsy Bennett of the ABP) know that all of us residents and fellows are aware of this problem and that we are going to push for change to happen. We need to make our voices heard. I plan to bring this issue up at the CAP RF Town Hall Meeting in San Diego in September.

Let us protect our specialty and our future as Pathologists!!!

Is the ACGME the organization who could limit residency spots rather than the CAP or is a consensus required? These people are going to want facts/figures that counter their data (even though we all know it's nothing more than a wild concocted fabrication). The CAP is putting out reports every year that supports opening even more positions. If we go and give our "opinions" they are not going to take the issue seriously. I will be a resident then and will happily collaborate on this issue.

Perhaps the great and powerful Yaah with all his new and fancy admin powah can start some kind of private path subforum like that of anesthesia and podiatry?? This quorum could be a place to pool our resources/ideas together from now until then?

 

[yaah]

Why do we need a subforum? Unnecessary. You can pool your resources/ideas in the existing forum. There really aren't any secrets. No one is going to shut you down if you post controversial information provided it isn't slanderous or wildly inaccurate.

I agree with Path or bust though, you are going to get nowhere without data. Whether it is a "wild concocted fabrication" or not, just saying it is doesn't make it so. Basically, all I have seen on the forums is a bunch of speculation about how people assume there are too many residency trainees because they assume that the job market is bad. We have had a couple of people post their experiences with the job market, which is much appreciated, but to be honest the majority of experiences have been good ones, not bad ones. And those with bad experiences are often more likely to post, it's basic psychology 101. As I said, that isn't evidence that the job market is good, but it hurts your argument. As I have posted many times, not everyone feels that way - specifically people with the power to change things. Personally, I agree the job market is bad (or at least less than stellar), but mostly bad for certain people, not for everyone. I do agree that if the market is bad for a large portion of people (as it seems to be) then that directly impacts and hurts the rest of the field. That is where you should focus on. The problem is, I also think that pathology is a growing field. Those with the power to change things look more for the future and how we are going to need more pathologists with better training.

The problem with speculation is that it becomes somewhat conspiratorial at some point. If enough people say something, others start to believe it, and it becomes a "consensus" without any actual reason for it.

But I am glad you are willing to bring up these issues, I am trying as well, if only to hear different perspectives on the matter.

Thus, you are going to have to do some more work on just WHY you think the job market is oversaturated. Anecdotal evidence is not going to cut it. As I said, here is how your argument is presented:

1) There are no good jobs. Evidence: Anecdotal as well as an interpretation of data from surveys that has been interpreted otherwise by major organizations (correctly or incorrectly). Saying, "I know a few pathologists who can't find jobs" is not evidence. Saying, "Salaries are less than what they used to be" is also not evidence. You have to demonstrate that QUALIFIED people are not finding jobs they are trained for and that they are actually looking for. Pathology is not a big field relative to others.

2) Reducing residency spots will solve this problem. How? You have many reasons which on the surface sound appropriate (reduce supply, increase demand, basic economics etc) but are they realistic? Is reducing the # of residency spots the real answer? Or is it something else? Medicine as a profession is kind of headed into the toilet everywhere except in superficial (cosmetic) fields or those who can somehow make money off of discounting their services (i.e. administrators of mega labs or people who offshore certain services).

Part of the "evidence" I have seen that residency spots need to be reduced is that residency training programs are cash cows and make money off of trainees. Provide the real evidence, not the speculation. There are tons of private hospitals and labs where the pathology department makes far more money than academic institutions, and they do this without residents. Residents bring in money, but are also expensive.

So I applaud your efforts but you have to do a bit more work. Asking the questions is a good first step, but how will you respond when they answer your questions (as you know they will) with the same data and with impressions of a growing field with increasing complexity, etc? You can't respond to data with conspiracy theories or speculation, unfortunately, and expect to get anywhere. They will answer anecdotal evidence with either facts or more compelling and widespread anecdotal evidence (becausae they have more information).

As I said above, focusing on the proliferation of "bad" jobs (i.e. podlabs and megalabs) is probably a better tactic from a resident perspective. Megalabs have tons of money so you are unlikely to get that far, but these jobs hurt the field in many ways, particular when there are many graduates willing or forced to accept them.

 

[Path or bust]

Why do we need a subforum?

Cause it will make us feel 'special', of course! 🙂

Well one good reason is that this issue is obviously very important to many individuals on this forum. This issue historically spins off into many directions and never accomplishes anything but a spout of whining from various folk. We see many examples of this on the main page and I don't expect to see them end in the near future. Perhaps it's time to try something new? Now if we have a subforum (pvt or not) we can at least get experienced, focused issues addressed by those who are wanting to network with other interested members. This gives the issue more organization, without having every thought process torn down by every lurker who is unfamiliar with the issues. When the group and viewers are limited people are more willing to share their experiences and offer their help/advice. It's just an idea.

However, we can always start a yahoo group or something which can accomplish the same end without having to add extra stuff to the path forum.

 

[exPCM]

Based on the posts on the thread "Pathology: Is It Worth It?," it seems that a lot of us recognize the fact that we are producing way too many Pathologists, making the job market in Pathology the worst in all of medicine.

Being the future leaders of our specialty, why don't we all start a movement to reduce the number of residency slots in Pathology? Let us start making the officials concerned (for example, Rebecca Johnson of the ACGME and Betsy Bennett of the ABP) know that all of us residents and fellows are aware of this problem and that we are going to push for change to happen. We need to make our voices heard. I plan to bring this issue up at the CAP RF Town Hall Meeting in San Diego in September.

Let us protect our specialty and our future as Pathologists!!!

I think the above post is an excellent idea.

I am concerned about the responsiveness of the ABP. There is absolutely no good reason that the CP board exam could not be done at multiple sites and cities yet the ABP has refused to consider this in the past, insisting that everyone go to Tampa for the CP exam. The vast majority of other specialties including radiology (which administers their written exam at Pearson VUE test centers) have gone to multiple site testing for board certification. My opinion of the ABP is that they are completely unresponsive to ideas to make things better/easier for candidates in terms of exam/travel costs and convenience.

I have previously posted information from a pathology recruiting firm:
http://www.americanlabstaffing.com/recruiting.html
"PATHOLOGY JOB MARKET
The job market for pathologists today has improved only slightly since 1998
The number of pathologists looking for jobs still outpaces the number of opportunities available"

Here is more interesting reading from a physician recruiting firm:
http://www.thedoctorjob.com/blog/

HOW TO FIND PHYSICIAN JOBS FOR TWO SPOUSES WITH DIFFERENT SPECIALTIES
The best way for two doctors to find jobs in the same town if the spouses have different specialties is to start with the most difficult specialty.

For example, if the husband is a pathologist and the wife is a family practice physician, start by securing a job for the pathologist. Once the doctors have been able to secure a pathology job, the family practice physician will know exactly what locations to focus her job search in.

The chances of both physicians finding a job in the same city as their spouses is much better when the doctors start with the more difficult specialty, commit to a location, and then begin the other spouse’s job search. This method is especially practical if the couple is using a service that can guarantee a doctor job in an exact location. (Again, a service like The Doctor Job may offer discounts for physician couples with two career searches in the same location - even if they aren’t done at the same time. Remember to ask about all of your career marketing options.)

It is possible to find two physician jobs in the same location - even if the spouses do not have the same specialty. The key is to be smart about your planning and take a strategic approach to both doctors’ career search."

From Merritt Hawkins:
http://www.merritthawkins.com/pdf/2007_Review_of_Physician_and_CRNA_Recruiting_Incentives.pdf
Top 20 Physician Searches by Medical Specialty and CRNA Searches
2006/07 2005/06 2004/05 2003/04
Family Practice* 303 257 166 165
Internal Medicine 273 274 188 124
Hospitalist 194 112 62 82
Radiology 187 237 218 202
Orthopedic Surgery 172 207 210 210
Cardiology 163 174 231 181
OB/GYN 159 111 83 103
General Surgery 121 165 116 112
Emergency Medicine 91 91 47 42
Psychiatry 81 69 80 54
Gastroenterology 78 105 94 105
Urology 63 75 59 94
Pediatrics 63 41 48 52
CRNA 61 117 102 82
HEM/ONC 59 45 n/a n/a
Neurology 58 69 56 60
Otolaryngology 56 57 54 52
Anesthesiology 46 70 64 98
Dermatology 45 39 N/A N/A
Neuro Surgery 41 50 61 52

As you can see, fields that are much smaller in terms of number of residents or fellows such as dermatology, hem/onc, gastroenterology, ENT, urology, and neurosurgery are in the top 20, whereas pathology with a now bloated count of 2316 residents is not.
(see: http://www.acgme.org/adspublic/reports/2006-07_CMS_EndOfYear_Totals_bySpecialty_Report_1.pdf)

It is also interesting that the Merritt Hawkins data show that signing bonuses averaging $20,000 are now standard. Of course, this is not the case in pathology due to the glut of pathologists

Of course, the Fred Silvas of the world will continue to sing a different tune based on ??????

 

[deschutes]

I think part of the problem with not having enough information to prove or disprove this issue of overtraining is, a lot of the decision-making information is not easily available to trainees.

I agree with BigD: I think it needs to get brought up at the CAP RF. The Town Hall is one way to start, but that strikes me mostly as a Q&A session. I wonder if it is not more effective to submit a proposal for the RF to make the information on the method of determining number of residency spots available, and then go over it with a critical eye and see what conclusions can be drawn.

 

[Arctic Char]

reduce the number of slots . . . cool with me, just don't do it until next year's match is over 😉

 

[danaphosaurus]

I am at a small program with 10 resident spots and 50,000 specimens- We have 1 PA and a pour through person- We did the work with 9 residents this year and that was pusing it- I don't think we could trim more-
I am interested to hear what other people think they could trim from their program-

 

[106174]

I am at a small program with 10 resident spots and 50,000 specimens- We have 1 PA and a pour through person- We did the work with 9 residents this year and that was pusing it- I don't think we could trim more-
I am interested to hear what other people think they could trim from their program-

The solution obviously is to hire more PAs and not Pathology residents. Residents are used as cheap labor in most programs. I think that a Pathology residency program can survive even with very few residents, as long as there are PAs. We do not do service work in CP rotations so coverage is not a problem there.

Unfortunately, I heard that there are only 6 certified PA schools in the country. The ASCP needs to do something about this.

 

[Path or bust]

I am at a small program with 10 resident spots and 50,000 specimens- We have 1 PA and a pour through person- We did the work with 9 residents this year and that was pusing it- I don't think we could trim more-
I am interested to hear what other people think they could trim from their program-

I don't think that the purpose of graduate medical "education" is to meet the workforce demands by supplying more residents for hospitals that have more work. But this is how departments think of it. "Oh we have more work so we are going to need more residents", Ummm...no.

As to the above with ExPCM, that stuff is very good. Playing odds here, just because the job market for path is not as good as other specialties, is this a reason to limit the spots? If you say that the job market has improved 'only a little' since 1998 and almost twice the number of spots have been added since then, perhaps we should maybe freeze the number of spots at 600-700 and see what happens afterall, there is a projected need for pathologists in the future so this could all change according to the CAP.

So far the only reasons I see that people have given to reduce positions is for monetary reasons. Pathologists have alot to benefit from reducing the spots. Now, I have an idea....as a result of so many spots open, are residents filling these new spots properly being trained. Many have posted that we need to shutdown path programs because of the horrible training. What is horrible about it? Residents are still passing their boards.


Again I am just countering to get some good debate going. I am totally on your side of course but making the job market the sole and primary issue is a good way to lose the debate quickly.

 

[106174]

I agree with Path or bust though, you are going to get nowhere without data.

That is exactly the reason why we need to start making noise about this issue so that we can encourage each other to work together to gather concrete and solid evidence to support the hypothesis that we are producing way too many Pathologists.

Like I have said many times, this is very doable, using Dermatology as a model. They have a task force that is dedicated to studying this issue.

So, where do we start? Should we formulate a CAP RF resolution to get things moving? Should we talk to Anna Moran (ASCP Resident Council Chair)? Or perhaps we should talk to Bruce Alexander at UAB who, based on his publications, seems to be deeply invested in issues pertaining to resident education?

 

[trent05]

So far the only reasons I see that people have given to reduce positions is for monetary reasons. Pathologists have alot to benefit from reducing the spots. Now, I have an idea....as a result of so many spots open, are residents filling these new spots properly being trained. Many have posted that we need to shutdown path programs because of the horrible training. What is horrible about it? Residents are still passing their boards.


Again I am just countering to get some good debate going. I am totally on your side of course but making the job market the sole and primary issue is a good way to lose the debate quickly.

Remember, medicare is funding these residency spots to supply a need for trained physicians.

 

[trent05]

So, where do we start? Should we formulate a CAP RF resolution to get things moving? Should we talk to Anna Moran (ASCP Resident Council Chair)? Or perhaps we should talk to Bruce Alexander at UAB who, based on his publications, seems to be deeply invested in issues pertaining to resident education?

All of those are good ideas. A CAP RF resolution seems like a good place to start. 👍

 

[LADoc00]

Yaah I guess Im not seeing it: we have tons of data. FFS We have MASSIVE amounts of job data. I reviewed spread sheet after sheet of it 4 years ago when I began digging into the CompHealth database.

In 2004, there were 17 OPEN RADIOLOGY JOBS IN THE STATE OF CALIFORNIA FOR EVERY 1 PATH OPENING.

There is no where near 17x more radiologists trained than pathologists in the state. Its simple math.

And the situation is only getting worse.

Do people think I have some hidden agenda Im making all this up?? I own my own business FFS...but I hate seeing the whole speciality capsize due to stupidity.

Residency programs in Pathology have completely and utterly failed, even and in some cases especially top rated ones. I can not think of another speciality where trainees are so utterly unprepared to really handle the day to day other than Path.

If Academia wants to just state it trains MDs only to work in Ameripath and Kaiser or other Academic centers, fine. I would have read that disclaimer and walked away to Rads or Gas with smile on my face.

If Academia wants to overtrain by 50% then they should have the courage to tell people they likely wont have jobs or at best crappy ones.

But what people dont need is this "George Bush-the Economy is Grrrreatttt" B.S. that Im hearing from the ABP, CAP and ACGME.

 

[Nilf]

As I said above, focusing on the proliferation of "bad" jobs (i.e. podlabs and megalabs) is probably a better tactic from a resident perspective. Megalabs have tons of money so you are unlikely to get that far, but these jobs hurt the field in many ways, particular when there are many graduates willing or forced to accept them.

These 'bad jobs' would not exist if it wasn't for oversupply of pathology workforce.

 

[LADoc00]

These 'bad jobs' would not exist if it wasn't for oversupply of pathology workforce.

Of course. POD labs are a CREATION of the training oversupply, not vice versa. People need to understand the cause and affect: when you oversupply a field you make it vulnerable to exploitation.

Why is this so hard for intelligent people to understand?

 

[trent05]

These 'bad jobs' would not exist if it wasn't for oversupply of pathology workforce.

True.

 

[LADoc00]

Right. If there was not an oversupply, then pathologists would have options and a Pod lab would not be able to undercut the pathologists who are happy just to have a job. Many of these Uro and GI groups are using a type of Pod lab model where they send their biopsies to an independant histo lab (or even an academic hospital path department!), and the slides are then returned to the group office, where they have a microscope set up for their part time pathologist who comes in to read the slides. The independant histolab gets the technical component and the Uro/GI group bills for the professional compent, giving the pathologist pennies on the dollar for their professional component. If a pathologist had good job opportunities they would refuse to work under these conditions or they would want a much higher cut of their professional component which would end up making these arrangements much less attractive for the Uro/GI groups. Just wait until digital pathology makes these arrangements even easier, the Pod lab won't even have to send the slides back to the clinicans office.

Yep, one of my big projects in the works is setting up E-pods, where I can use online images to completely sign out slides que'd for me. Will deep six alot of pathology groups that are tech unfriendly.

 

[Adrian Cocot]

So, where do we start?

Bring it up at the town hall, and it will be politicked to death with verbose, 10-minute long answers that are more trite than Clinton explaining her policies.

Bring it up as a resolution, and you're likely to get a bunch of confused stares as people will be thinking more about fellowship applications or CP training. Then it'll get referred to the RFEC for "reworking."

Bruce Alexander doesn't care about this issue as much as he does fellowships -- Horowitz at UCSD is a better bet. Talk to any of the residents on the RF executive committee. They meet multiple times throughout the year and can discuss the issue, possibly devoting some actual time to it in San Diego instead of some presentation about high-impact communications skills.

Or hell, bring it up on the CAP's online forum, where you'll likely get more information than you would at an entire RF meeting.

 

[yaah]

Yaah I guess Im not seeing it: we have tons of data. FFS We have MASSIVE amounts of job data. I reviewed spread sheet after sheet of it 4 years ago when I began digging into the CompHealth database.

I'm not saying there isn't data. I'm just saying that people (on here, anyway) aren't giving convincing data other than anecdotal evidence and spinning data that supposedly says the opposite thing. I am not really disagreeing with anyone here, I am just trying to get people to move beyond the "this is obviously the case, why doesn't anyone see this?" to a more concrete, "Here is why this is the case and why this is harmful to the field." Posting website links that say "the job market is bad" isn't helpful. Anyone who wants to ignore it or refute it would have a field day if your argument depends on that.

I am not the one that anyone has to convince. I am merely a peon. I hold next to no clout. I have already said I think megalabs are bad things for the field, podlabs are even worse. I have already said multiple times that these things are bad and I agree that part of the reason for their proliferation is a ready supply of people willing to take the jobs. That is not hard to understand.

In my view, which is partly why this is so confusing to me, it really does the CAP, ABP, other professional organizations, etc, very little good to marginalize or dismiss bad signs in order to claim everything is wonderful. Why would these organizations want to create conditions that are harmful to the future of the field itself? It can't be about greed and keeping membership numbers up, can it? That makes no sense. While I am sure that mega labs have a lot of clout and power, the main power in these organizations comes from its membership, correct? Individual pathologists in unison. Perhaps I'm wrong.

exPCM your post was interesting and helpful. The part about pathology and family practice isn't that helpful, given that there are infinitely more opportunities for family practice anyway - an average community needs far more of them than they do pathologists. Additionally, the part about signing bonuses is wrong from what graduating residents here (who got signing bonuses) have told me.

As far as danaphosaurus' point about trimming residents - I suspect the solution is not trimming residents from each program but eliminating residents all together from poorly performing programs. Make programs compete for residents, that would make them provide more training opportunities. There are a lot of residency programs out there that are not doing a good job training residents - if they had any real pressure on them perhaps they would improve.

I agree though - try introducing a resolution, see what response you get. It can't hurt.

 

[green mantis]

The solution obviously is to hire more PAs and not Pathology residents. Residents are used as cheap labor in most programs. I think that a Pathology residency program can survive even with very few residents, as long as there are PAs.

At my residency, we rotated a 3 hospitals, one of which was a large private hospital. The impression I got from the people running the pathology group was that it was cheaper to pay for a resident than a PA. If they hired more PA's, they would need to provide them w/ benefits (health, dental, vacation, sick, etc.); something they didn't need to do w/ residents. It was my feeling that they were just giving the home institution a flat rate per resident. Maybe someone on this board can clarify?


----- Antony

 

[exPCM]

It amazes me still how little knowledge many residents seem to have about GME funding.
http://www.amsa.org/pdf/Medicare_GME.pdf
http://jama.ama-assn.org/cgi/reprint/281/20/1958-a.pdf

Older article from NY Times:
Still true today
http://query.nytimes.com/gst/fullpage.html?res=9905EFD61130F93BA35750C0A961958260

Medicine IS now big business. The main reason hospitals have residency programs is due to the money. Hospitals overtrain residents because residents are funded through Medicare and PAs are not. They do not care if the residents have to face a lousy job market as long as they can keep that GME money flowing in.

 

[KeratinPearls]

Of course. POD labs are a CREATION of the training oversupply, not vice versa. People need to understand the cause and affect: when you oversupply a field you make it vulnerable to exploitation.

Why is this so hard for intelligent people to understand?

Question: How prevalent are these pod labs? I say all of us should go after them...you know like one huge posse with bats. How come legislation hasn't been enacted to prevent such exploitation? What are the higher ups in path society doing about this?

 

[yaah]

Question: How prevalent are these pod labs? I say all of us should go after them...you know like one huge posse with bats. How come legislation hasn't been enacted to prevent such exploitation? What are the higher ups in path society doing about this?

They are fighting pod labs. - from ascp.org - I am sure the sleaze will find a way to stay in business or keep taking money though. They'll just devise a slightly different scheme which skirts the rules. But the organizations are paying attention to this issue.

ASCP Succeeds in Stopping Pod Labs
ASCP has succeeded in its efforts to shut down pod labs. After extensive lobbying by the Society, the Centers for Medicare and Medicaid Services (CMS) implemented the anti-markup provisions it proposed as part of its 2008 physician fee services, at least for pathology services.

Initially, CMS planned to apply the anti-markup provisions to all physician services. Days before the rule was to go into effect, CMS responded to pressure from opponents of the anti-markup rule who urged the agency to delay implementation. ASCP had waged an 11th hour campaign to shield anatomic pathology services from the delay. In the end, the Agency delayed until January 1, 2009, application of the new anti-markup rules to services other than anatomic pathology services.

The development is a big victory for ASCP and its members, who sent thousands of letters to CMS and Congress as part of ASCP's Stop Pod Labs Now campaign. The rule bars physician practices or suppliers from marking up the cost of the technical or professional components of a Medicare-reimbursed diagnostic test if the service is purchased from an outside supplier or performed at a site other than the "same building" of the billing practice or supplier.

The new rules seek to prevent clinicians from using the centralized building criterion of the Stark law's in-office ancillary exception to markup the cost of anatomic pathology services. The mark ups of anatomic pathology and other services were causing a host of problems, such as overutilization of diagnostic services, increased costs, and declining revenue for clinical laboratories and pathologists.

 

[Gyric]

I support reducing the number of spots for a number of reasons.

In my opinion you will get little traction with organized pathology if you tell them you want fewer resident slots in order to increase the job prospects of newly trained residents (drive up signing bonuses etc).

What if you instead made the argument that 4 years of training is currently less than ideal for newly trained pathologists to be ready for independent general sign out, especially given the increasing complexity of our specialty, and add to that the fact that many programs used a fifth year of training for increased surgical pathology exposure (and not credentialing), which was recently removed. I know some prominent academic surgical pathologists have the opinion that, on average, 4 years of AP/CP is insufficient time to train a surgical pathologist (I think some may have even published that) and increased training would play into CAP surveys showing that employers are often not satisfied with level of competence of their new employees.

That would at least buy us time until our generation can get into leadership positions and champion these changes.

I know pathology spots took a nosedive a few decades ago, anyone have insight into why that happened, can that be repeated?

 

[Gut Shot]

Historically, pathology craters every 10 years. It did so in 1980, 1990 and 2000. We're approaching 2010 and it looks like it's headed back down the tubes.

While I completely support limiting training slots, I have to wonder: how much of this is a reimbursement issue? Let's face it, if an 88305 paid a million bucks, the field could support a lot more people. Frankly, the whole setup resembles rads back in the late 1990's: people doing more and more work in the face of declining pay. Perhaps what we should be doing is getting some new, heavily reimbursed diagnostic technology going so we can extract some fat coding and stay ahead of the game.

 

[yaah]

Yeah, I think what is happening is that existing pathologists are working harder and signing out more cases. So while the field has grown in terms of cases and other tasks to do, the # of jobs has not. I don't think I have talked to anybody out there who says they are doing less work than they were 5 years ago.