I would like to explore what I think are three (of the many) possible reasons for the pathology job market. I'm disheartened like many of us. While this is a relatively large number of words, my goal is to be brief and free of nonsense. I do not wish to rehash the usual claims. I will not treat it as a given that the market is excellent or terrible. The truth is somewhere in the middle, but it is likely that it has gotten worse. I will also not rehash the usual rationalizations such as pathology is a small specialty (so is dermatology) or the retirement boom will dramatically improve the market (maybe, but how did the market become such that people are reassuring others that it will be rescued by the alleged retirement boom?) or that there are no jobs or the sky is falling. While the numbers game is very useful and necessary, I think the level of analysis should go beyond the claim, too many pathologists are being trained, so we should cut supply and/or increase demand...somehow. That is probably a very useful way to improve the market, but it is not something the average pathologist can readily address (e.g. cutting resident/fellowship slots, closing programs, or enacting/repealing laws to change the economics of medicine and pathology billing are complex issues and could only be accomplished over the very long-term, if at all). Besides, if there was a poll, I speculate that most people would agree that too many pathologists are being trained, and the reasons are relatively transparent and obvious (and not the subject of this post). Then why exactly does it continue? Related to this question, my aims are to ask the questions, where are we and how did we get here? before even entertaining the questions, what do we keep and what do we change? I don't claim that any of this qualifies as news or particularly insightful. At worst, it will serve to inform potential pathology residents and those outside the field of some things to consider. I have no arguments or agenda other than, let's improve pathology *for the long term*. I'm more interested in the ideas of others than I am in having these ideas read. Please contribute in any way you can, both in this forum and in other ways. NOTE: As an understatement, the cause of the current market is multifactorial, and I do not claim that any one factor dwarfs all others.
1. A disproportionally lower maximum allowable level of responsibility exists in pathology programs compared to most other specialties. Unlike trainees in the vast majority of other medical specialties, pathology trainees cannot perform the most common main task of an attending pathologist (i.e. signing out pathology reports). Because of Medicare rules (related to reason #3 below), a pathology trainee cannot sign out a report and bill for it without an attending signing it also. In contrast, a surgery resident approaching graduation (while still unable to bill on paper) has proven she can perform surgery to at least a minimum level of competency, usually with an attending merely "stopping by" during a case or, at the very least, taking a back seat to the trainee. Sure, one may argue that a medical or surgical resident must have an attending sign-off for billing purposes just like a pathology resident. However, in many instances the medical or surgical resident has already taken substantial action and done the meat of the work that an attending would do (usually in the form of a significant patient intervention--something that is rare in pathology outside transfusion medicine) well before the attending signs-off. In short, you simply cannot prove yourself as a pathologist-in-training (at least in most areas in which your main task to sign out pathology reports) anywhere near the degree to which you can prove yourself as, say, an internist- or surgeon-in-training. This limitation can, in fact, be largely overcome, as many good programs have figured out a way to do it. While not much can be done to eliminate this limitation altogether, this lack of "acting as much like an attending as possible" is minimized in good programs (see #2).
2. Many pathology training programs fail to maximize the responsibility given to trainees even within this already reduced maximum allowable level. This is the most important topic I want to address, as there is a wide variety of success and failure in achieving this and it is predominantly but not entirely a matter of will by the department's leadership. There appears to be two groups of training programsresident-centric and attending-centric. The resident-centric may be loosely defined as residents do as much as the attendings as legally possible, including writing and dictating *final* diagnosis reports, taking the first call, intervening, and attaining a level of competency upon graduation that would allow them to perform the *most common* (not necessarily all of) *core* duties of the attending *without additional training*. A benchmark for resident-centric status may be the following: say a resident is doing the final rotation of a certain area of pathology, an emergency occurs and no attending is able to cover that service for a five day work week, and the resident is able to perform the majority (not all) of that attending's *core* (not all) duties. The exact percentage that constitutes the majority and the exact list of what are the core duties are important questions, but I think that the apparent difficulty of answering these questions (never mind the time, effort, and difficulty of properly training residents to do these tasks) should not cause us to conclude that it is inherently impossible to train a resident to be a competent general pathologist.
To be more concrete, some common sights that are seen in resident-centric programs are:
- Residents write/dictate final pathology reports that the attending then signs with, ultimately, little to no substantial revision. Since reports are the most common main work product of the pathologist, the importance of this specific competency (i.e. going beyond the step of saying/writing what I would call it if I were writing the report) cannot be overstated. There is a huge difference between the report I *would* write and the report I wrote even if I didn't press the sign out button. In neither case can the resident sign it out, but the resident can and should do as much as the attending does as possible just short of this sign out limitation. The degree to which residents practice this task during residency is usually highly correlated to the degree to which they are competent to perform this task upon finishing residency.
- At least one resident is rotating on every service all the time for continuity. Relatively lesser-effort rotations can be merged successfully regardless of any offense that attendings in those areas may take for implicitly calling their rotations lesser-effort. This also gives attendings incentives to make their rotations greater-effort and to give residents more responsibility on those rotations. While it is neither a guarantee of improvement nor a sufficient improvement by itself, much educational reform and increased resident interaction can often result from merely proposing to combine rotations either because of the increased responsibility or because truly lesser-effort services are combined.
- Service pagers for each service and on-call pagers for each night/weekend call type with constant dedicated phone numbers that allow residents to be incorporated into the services. That is, they are contacted first instead of routinely bypassing the resident and going straight to the attending the *majority* of the time. Exceptions occur, but residents should get the first call and be in the loop and involved even when they are not called first in an exceptional case.
- Relatively strict separation of rotations so residents can focus and be reliably incorporated into the service. In other words, eliminate or severely limit to rare exceptions any directly conflicting simultaneous required duties elsewhere such as grossing, autopsies, or clerical work while not on those corresponding rotations. Less obviously, this may include minimizing the number of required all residents stop what you're doing and attend conferences during usual work hours and putting them early in the day (say, at 7 or 7:30 AM) instead of between 8 & 5. The theme of this point is to minimize distractions and conflicts, as real conflicts only lead to poorly attended conferences and/or missing residents from the service. It is axiomatic that frequent or even daily 7 AM or 5 PM conferences may not be immediately popular among residents and attendings alike.
- Adequate resources. Some obvious resource questions are: Do residents have a truly adequate quantity and quality of microscopes, gross dictation resources, final report dictation resources, computers, electronic medical records, IT support (i.e. minimizing menial workarounds), and clerical support (i.e. the percentage of time residents spend in transporting, retrieving, labeling, accessioning, collating, cleaning, requesting outside materials, faxing, photocopying, scanning, etc)? Does each service have the resources to realistically handle residents acting like attendings as much as legally possible? If not, can any incremental improvements be made to any extents?
These and many other structural characteristics are largely a question of how the resident is viewed. Is the resident primarily an apprentice attending that, with some training, will contribute increasingly more over time to make the service run more smoothly. Or is the resident primarily an observer who is a drain on time and resources and is therefore not trained adequately nor permitted to contribute substantially to the service. A common mantra of many attendings in an attending-centric program is, I have to do the work anyway. Residents just slow me down. The antidote mantra may be, Train them, and they will contribute. In other words, *delegate* tasks (both chores and more glamorous work) to a level appropriate to the resident as *requirements* that cannot be relinquished without consequences (the program director's stick), train them over time (the service attending's carrot), and you will reap the benefits of increased free time from a more efficient service.
As a side note and as a warning to gung ho residents who find themselves in attending-centric programs, in my experience it often comes a shock to each of the two groups of trainees from both types of program (resident vs attending-centric) that the other type of program could even exist. Those from resident-centric programs often can not imagine what exactly residents (and attendings) are doing at programs where residents graduate without dictating or writing all (or most or any!) pathology reports (including surgical pathology, cytology, apheresis orders, patient notes, and clinical pathology reportsbasically anything and everything that is then signed by attending pathologist) other than gross descriptions, autopsies, and rare token reports. Residents from attending-centric programs can not imagine how exactly to implement such changes into their programs that would permit them to perform such tasks, as the organizational inertia is too entrenched to overcome. Many well-intentioned residents have gone as far as they could go even at risk to their own careers trying to improve their programs both at the time they were in training and after graduating, and I wish I could say that they were uniformly successful in helping to effect real changes. Many residents have been ostracized, punished, blacklisted, labeled as a complainer or troublemaker or non-team player, asked to leave, and given negative evaluations and reference letters. The leadership of a program that does not adequately train their residents for whatever reasons are, because of those very same reasons, extremely unlikely to radically change the program. While small measures and incremental changes are possible, I cannot give a blanket recommendation that a trainee should attempt to change their program from an attending-centric one to a resident-centric one. I know of no examples of residents effecting such changes themselves. I know of many examples of it backfiring. The changes can only truly come from the department leadership, usually the chair and, to a much lesser extent, the residency program director. I don't claim it is entirely on the leadership, but there is no possibility of trainees effecting the change themselves without leadership from the alleged leadership.
3. Finally, increasing government control and influence of medicine and medical insurance has caused more than some non-specific uncertainty about the future, on the contrary it has caused more certainty that a greater percentage of physicians will be forced (not asked, and with no alternative) to do a larger percentage of their work for less money. This is not specific to only pathology but rather to all of medicine. This did not start recently, but it was recently accelerated. That's not the primary focus of this post. I can not add anything to the analysis in the link below. Even if you disagree with the viewpoints in the second half of article, the summary of historical facts in the first half are educational:
http://www.theobjectivestandard.com/issues/2007-winter/moral-vs-universal-health-care.asp