What would a good job market look like?

[Parts Unknown]

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If there were widespread vacancies for newly trained pathologists, what would the ramifications be? Would most groups need to be getting worked to death in order to justify the demand? Would increasing demand on the coasts lead to unsustainable reductions in pathology services in the Midwest secondary to worker migration?

Thoughts and conjecture, please.

 

[Thrombus]

When demand goes up, prices (salaries) go up in any system (even if we are becoming a socialist state).

No one gets worked to death if they do not want to as you could find another job easily if you were in high demand.

 

[Parts Unknown]

No one gets worked to death if they do not want to as you could find another job easily if you were in high demand.

That's not necessarily true. Hypothetically, for a group to hire there either needs to be a retirement with static volume, or an increase in volume. If, for the sake of argument, the vacancies are all due to increased volume, then there would be a lot of short-staffed groups. Not bad if you're a job seeker, but potentially bad if you're a partner picking up slack.

 

[Thrombus]

That's not necessarily true. Hypothetically, for a group to hire there either needs to be a retirement with static volume, or an increase in volume. If, for the sake of argument, the vacancies are all due to increased volume, then there would be a lot of short-staffed groups. Not bad if you're a job seeker, but potentially bad if you're a partner picking up slack.

There is high demand (a shortage of dermatologists) to get an appointment in dermatology. Yet rarely do you find a dermatologists who work long hours in the private world.

If there was a shortage of pathologists, turnaround time would go up.

 

[Parts Unknown]

There is high demand (a shortage of dermatologists) to get an appointment in dermatology. Yet rarely do you find a dermatologists who work long hours in the private world.

Dermatologists can simply choose how many patients to see, and the excess can either wait or go somewhere else. We don't usually have that luxury. The fact that we depend on intermediaries (clinicians) to generate our workload separates us from most other specialties in a very fundamental way.

 

[Pathwrath]

If there were widespread vacancies for newly trained pathologists, what would the ramifications be? Would most groups need to be getting worked to death in order to justify the demand? Would increasing demand on the coasts lead to unsustainable reductions in pathology services in the Midwest secondary to worker migration?

Thoughts and conjecture, please.

I'm not sure I understand your point. One thing that would change is more real partnership jobs, instead of the spurious ones that are becoming more common in pathology. Also, industrial path mills would have a more difficult time recruiting.

Successful groups are doing more for less due to falling compensation. I would argue that the glut of pathologists is the major reason.

 

[Thrombus]

Dermatologists can simply choose how many patients to see, and the excess can either wait or go somewhere else. We don't usually have that luxury. The fact that we depend on intermediaries (clinicians) to generate our workload separates us from most other specialties in a very fundamental way.

We don't have that luxury because there are too many of us.

If there were too few of us, we would have clinicians catering to us instead of us bending over backwards trying to kiss everyone's arse.

(yet another big benefit that would come if there were a shortage of path's)

 

[Thrombus]

Dermatologists can simply choose how many patients to see, and the excess can either wait or go somewhere else. We don't usually have that luxury. The fact that we depend on intermediaries (clinicians) to generate our workload separates us from most other specialties in a very fundamental way.

Unfortunately, you do not understand the dynamics of the marketplace my friend. I realize that you are well-intentioned, but please do some reading on simple supply and demand principles -- it will help you in the future.

Look at fields with high demand -- consultants -- "primary" physicians will make phone calls begging to get a patient in quickly instead of joining the wait list to highly sought after specialists.

The same thing would work for pathology -- we woudl be getting phone calls begging us to try to sign out this stomach biopsy quickly instead of doing so when time allows if there were a shortage of us.

 

[Parts Unknown]

I'm not sure I understand your point.

Not so much a point as a question. Pretend training spots were cut by 75% and 3,000 existing pathologist set sail for Guam. Would this make the job market suddenly good, and what unintended consequences might be foreseen?

I bring this up because after all the bemoaning of the job market and the oversupply of pathologists, I'm trying to imagine what would happen if things change.

 

[Parts Unknown]

Unfortunately, you do not understand the dynamics of the marketplace my friend.

I just don't see them as simplistically as you do.

 

[Parts Unknown]

The same thing would work for pathology -- we woudl be getting phone calls begging us to try to sign out this stomach biopsy quickly instead of doing so when time allows if there were a shortage of us.

I already get these phone calls... all day long. If our signout pace slowed but we couldn't be replaced, the clinicians would eventually have no choice but to restrict the services that generate laboratory specimens. Is this what we are gunning for?

 

[Pathwrath]

Not so much a point as a question. Pretend training spots were cut by 75% and 3,000 existing pathologist set sail for Guam. Would this make the job market suddenly good, and what unintended consequences might be foreseen?

I bring this up because after all the bemoaning of the job market and the oversupply of pathologists, I'm trying to imagine what would happen if things change.

Okay, I'll try to apply that to my own experience in the midwest, supposedly still a wonderland for the profession.

A few years back, our area's gastroenterologists, urologists, and dermatologists began congealing and started setting up in-house path labs in their mills, in order to capture path tech fees and a good chunk of path professional fees. At first, we balked at working for them, but changed our minds once we saw how quickly and easily we were replaced. We had to undersell an underselling in order to regain that business. The experience was informative, because we learned exactly what our services were worth in the current glutted market. So we started doing more--much more--for less in order to maintain our income.

That means that the area currently has less working pathologists than it did even ten years ago. That also means we will not hire until the situation becomes unbearable, and I strongly suspect that once it becomes inevitable, that new hire will be our first non-partner track hire. That's the way it is.

Now, let's assume pathologists were not a dime a dozen. Who would the clinicians hire to staff their in-house labs, and for what price?

Ditto the corporate path labs.

 

[Thrombus]

I already get these phone calls... all day long. If our signout pace slowed but we couldn't be replaced, the clinicians would eventually have no choice but to restrict the services that generate laboratory specimens. Is this what we are gunning for?

Do you bother your most trusted dermatopathologist consultant (the guy whom you want his name on your tough melanocytic case) with phone calls if it is taking him a long time to sign out a case?

Answer: No (if you want to keep him happy)

An expendable pathologist will get hounded by clinicians.

A non-expendable pathologist will be kept happy by clinicians

Unfortunately, you have been groomed (and rightly so with today's poor job market) to do whatever it takes to keep clinicians happy. Today's neurosurgeons/plastic surgeons/dermatologist are not being groomed to keep everyone happy but rather only to be a good physician.

Yes, it is that simple. Get it?

 

[Pathwrath]

An expendable pathologist will get hounded by clinicians...Yes, it is that simple. Get it?

This is certainly true in my experience. There is something seriously wrong when routine pointless gastric biopsies take precedence over cancer diagnoses, but that's the way it is. Clinicians' demands are proportional to your indebtedness to them.

 

[Parts Unknown]

Get it?

Wow, I thought I could posit a thought experiment without people getting bitchy and condescending. Clearly I was mistaken.

When consultation or sendout results are taking an exorbitant amount of time, I will call to check up on them. It's not a matter of keeping anyone happy, it's a matter of professionalism. If I wanted to work in an environment where people can be A-holes because they are entrenched, I would have become a clerk at the DMV.

 

[Parts Unknown]

Now, let's assume pathologists were not a dime a dozen. Who would the clinicians hire to staff their in-house labs, and for what price?

Ditto the corporate path labs.

Let's assume it were extraordinarily difficult to hire any pathologist. What would happen?

I'm thinking more big picture, BTW.

 

[Thrombus]

Let's assume it were extraordinarily difficult to hire any pathologist. What would happen?

I'm thinking more big picture, BTW.

$,$$$,$$$

 

[Pathwrath]

Let's assume it were extraordinarily difficult to hire any pathologist. What would happen?

I'm thinking more big picture, BTW.

I'm afraid you've lost me.

You mean by some act of God, on a different theoretical planet?

Here on earth, there has never been and will never be a shortage of pathologists to that degree. If the ceiling fell on the USCAP convention, the surviving academics would train sufficient replacements in four years.

 

[Pathwrath]

Wow, I thought I could posit a thought experiment without people getting bitchy and condescending. Clearly I was mistaken.

Thought experiment or straw man?

 

[lipomas]

I'm not sure I understand your point. One thing that would change is more real partnership jobs, instead of the spurious ones that are becoming more common in pathology. Also, industrial path mills would have a more difficult time recruiting.

Successful groups are doing more for less due to falling compensation. I would argue that the glut of pathologists is the major reason.

Would it?

I tend to wonder that if there was a shortage of pathologists, that would INCREASE the tendency towards consolidation. More mega labs. More mergers. Fewer pathologists would mean fewer experts, and mega labs could pay more to bring them in, and further consolidate their power. If it's hard to find a local qualified pathologist, what makes you think that clinicians wouldn't just find the easiest way out and go with the mega lab that promises the best turnaround time (and sends people out to their region if they need it)? It may also increase the use of technology such as slide scanning, etc, to make things more efficient and centralized, and increase the tendency to bypass local pathologists.

Of course, this might all be wrong and you may be totally right. But I don't think it's as obvious as you put it. But I fail to see how it is obvious that if there were fewer pathologists, there would be more partnership track jobs. Sure, glut of pathologists means some groups can afford to hire employees instead of partners, but a shortage of pathologist might mean that that group can't competitively bid for the business, which then gets taken over by a larger group (or the larger group pays them to just do what they can, since they can't handle it all).

What the business world shows is that when there are many people doing the same thing (oversupply), mergers tend to happen so that some people can consolidate their efforts and increase their competitive advantage. But when there is a shortage (monopoly), it becomes much harder for the little guy to gain a foothold. The monopoly just steamrolls everyone.

I think the reason pathologists are doing more for less is because of the less - less compensation means people have to work harder to maintain income. This is a direct reason FOR the oversupply of pathologists, not a result OF it.

 

[path19]

Let's assume it were extraordinarily difficult to hire any pathologist. What would happen?

I'm thinking more big picture, BTW.

I think it's very possible that clinicians would learn to read their own slides, especially the quick outpatient biopsies (derm, GI, prostate). I can imagine them arguing that the increased TOT was hurting patient care and being able to get some sort of accreditation to do so (if this is even necessary). Maybe even have clinically trained docs doing fellowships in all areas of path, similar to the way derm has always done it.

This brings up another question...Is it easier for a pathologist to learn to do clinical procedures and open up their own clinic (and convince primary care docs to send them patients) or for a clinican to learn to read the slides in their field of interest?

 

[Pathwrath]

Would it?

I tend to wonder that if there was a shortage of pathologists, that would INCREASE the tendency towards consolidation. More mega labs. More mergers. Fewer pathologists would mean fewer experts, and mega labs could pay more to bring them in, and further consolidate their power. If it's hard to find a local qualified pathologist, what makes you think that clinicians wouldn't just find the easiest way out and go with the mega lab that promises the best turnaround time (and sends people out to their region if they need it)? It may also increase the use of technology such as slide scanning, etc, to make things more efficient and centralized, and increase the tendency to bypass local pathologists.

Of course, this might all be wrong and you may be totally right. But I don't think it's as obvious as you put it. But I fail to see how it is obvious that if there were fewer pathologists, there would be more partnership track jobs. Sure, glut of pathologists means some groups can afford to hire employees instead of partners, but a shortage of pathologist might mean that that group can't competitively bid for the business, which then gets taken over by a larger group (or the larger group pays them to just do what they can, since they can't handle it all).

What the business world shows is that when there are many people doing the same thing (oversupply), mergers tend to happen so that some people can consolidate their efforts and increase their competitive advantage. But when there is a shortage (monopoly), it becomes much harder for the little guy to gain a foothold. The monopoly just steamrolls everyone.

I think the reason pathologists are doing more for less is because of the less - less compensation means people have to work harder to maintain income. This is a direct reason FOR the oversupply of pathologists, not a result OF it.

By your argument, those specialties that are the most tightly regulated in number of trainees should also be the most consolidated and offer the least number of partnership-track jobs. I really don't see this at all. Pathology may be a theoretical unique case, but I seriously doubt it.

When people are resigned to working more for less, they have less incentive to hire, not more. There is less revenue to share with new employees.

 

[Parts Unknown]

Thought experiment or straw man?

 

[Parts Unknown]

When people are resigned to working more for less, they have less incentive to hire, not more. There is less revenue to share with new employees.

Absolutely, and this fact supports my thinking that the lousy job market stems more from reimbursement issues than supply issues (although supply is clearly a factor). I am concerned that without improving reimbursement, attempts to restrict supply will ultimately only make things worse.

The radiology job market has been starting to teeter lately. Perhaps we should be paying closer attention to what happens if payment for imaging gets further gutted with a huge number of trainees coming down the pike.

 

[2121115]

Absolutely, and this fact supports my thinking that the lousy job market stems more from reimbursement issues than supply issues (although supply is clearly a factor). I am concerned that without improving reimbursement, attempts to restrict supply will ultimately only make things worse.

The radiology job market has been starting to teeter lately. Perhaps we should be paying closer attention to what happens if payment for imaging gets further gutted with a huge number of trainees coming down the pike.

It is likely both oversupply and reimbursement. According to some of the older pathologists here though, when reimbursement was a lot higher the pathology job market was still poor right? So oversupply has to have something to do with it. Eventually work load will increase to the point that groups have to hire. Unfortunately, as was posted above, groups will likely be offering non-partnership track jobs, which is insulting to the new hire but I do understand why they are doing it.

I am going to be hunting a community practice job over the next year, but personally I could not come to work everyday and look my peers in the face in a situation where everyone else is partner and I'm the bitch. For a couple of years to pay my dues? Sure. As a long term position? Hell no. At some point it is about self respect and I didn't go to medical school to be the permanent employee of another doctor be it a urologist, gastroenterologist or another pathologist.

 

[Pathwrath]

Absolutely, and this fact supports my thinking that the lousy job market stems more from reimbursement issues than supply issues (although supply is clearly a factor). I am concerned that without improving reimbursement, attempts to restrict supply will ultimately only make things worse.

Oversupply sustains in-house labs, corporate labs, and non-partner track positions. The current salaries paid to the stooges working in these arrangements are set by oversupply, not reimbursement rates. The masters pocket the difference. Even if you argue that falling reimbursement provided the incentive to set up in-house labs, corporate labs, and non-partner track gigs, so what? Unless you had a glut already, you couldn't staff them.

You may be right that now, once the cat is out of the bag and it is clear that pathologists can and will work for peanuts, we'll never go back to classic rates for 88305 biopsies and such. But we got here from oversupply.

 

[Psychopathology]

Oversupply sustains in-house labs, corporate labs, and non-partner track positions.

This makes sense to me. What is our leadership doing to stop this? What can we do as residents, fellows, and young attendings to keep our prospective autonomy and earnings?

 

[Entgegen]

This makes sense to me. What is our leadership doing to stop this? What can we do as residents, fellows, and young attendings to keep our prospective autonomy and earnings?

Large-scale assassination of the old attendings who refuse to retire?

 

[lipomas]

By your argument, those specialties that are the most tightly regulated in number of trainees should also be the most consolidated and offer the least number of partnership-track jobs. I really don't see this at all. Pathology may be a theoretical unique case, but I seriously doubt it.

When people are resigned to working more for less, they have less incentive to hire, not more. There is less revenue to share with new employees.

Pathology is really different from other specialties though. The closest is radiology, but even that doesn't overlap enough to compare directly in this fashion. Most other specialties require you to actually see the patient where the patient is located (or have them come to you). In path, the specimen is the patient, and specimens can be sent by courier or airplane or whatever. The specimen can be taken from the patient and sent anywhere cheaply within several hours. Mega labs have proven that their existence several states away from the actual patient does not affect turnaround time all that much. Pathology is more similar in this fashion to a non-medical area (like sending your watch out for repair, for example) than it is to other medical specialties. Obviously everybody likes things to get done locally, all things being equal. But when all things aren't equal that preference can quickly change. Again, I'm not saying you're wrong in your conclusions, I'm just positing the theory that an undersupply of pathologists may not necessarily lead to the things you say.

I do agree with you that the reason for proliferation of pod labs (in office labs, whatever the hell they want to call them to get around the fact that they should be illegal) is due to oversupply. That I don't think is really an arguable point. Their ability to lower pathologist pay and keep the difference is what keeps these labs in business.

taking these things together, I think there is a fine line between adequate supply and undersupply of pathologists - adequate supply is good for pathologists and doesn't allow proliferation of in office labs, and prevents mega labs from extending their tentacles. Undersupply might not. But I definitely agree with you that oversupply is NOT good for the field, and cannot fathom why national organizations don't grasp this point.

 

[yaah]

I think that's a fascinating point you bring up - whether a shortage of pathologists would damage the field and hurt practicing pathologists. I am not sure either. I think to get to such a shortage that would be harmful it would have to be a pretty dramatic shortage, but with the way pathology keeps tending towards subspecialization it's not that difficult to foresee. It's probably irrelevant since we are not going to get to any such shortage any time soon though.

One of the reasons that major labs like Caris and Dermpath diagnostics have flourished is partly because clinicians want "experts" reviewing their biopsies and the local path group doesn't have such an expert. Bostwick, for example, gets a lot of business by pointing how general pathologists make a lot of mistakes in prostate pathology. Lots of smaller path groups are trying to hire subspecialists precisely because they are losing business to large labs, and local clinicians tell them that if they had an expert, they would be more likely to send their specimens to the group. Although, to be fair, $$$ is probably a bigger (even if unacknowledged by the clinicians) factor in that decision. I tend to agree though that a major shortage of pathologists would not necessarily increase partnership jobs.

The current glut, however, is more damaging. And the presence of in office labs/pod labs is related to that aspect.

 

[JPR22]

This makes sense to me. What is our leadership doing to stop this? What can we do as residents, fellows, and young attendings to keep our prospective autonomy and earnings?

I think this is a pretty good time to just bail on pathology altogether, and try to persue another specialty.

 

[Entgegen]

I think this is a pretty good time to just bail on pathology altogether, and try to persue another specialty.

Yes. Everyone forget about pathology so that each program only gets half their spots filled, or no spots filled at all. We won't need to hope that half the programs just go away, we can effectively cut the output of pathologists in half if we just discourage enough people!

 

[2121115]

I think this is a pretty good time to just bail on pathology altogether, and try to persue another specialty.

You may say this in jest, but it is not as far fetched as you may think. If you left pathology now to do, say, anesthesia in 4 years you would be guaranteed a high paying job in a city located close to where you want to be. Can you really say that about staying in pathology? If you are a first year resident would you rather do 4 more years of pathology training (minimum) and roll the dice on the job market all the while knowing you may have to do an additional one to two years of training just to get a job or do your next 4 years in anesthesia, internal medicine, etc and be assured a good job. Moreover, if you are a 4th year resident with several years of fellowship to go and still no guarantees that everything will work out alright would you be better off switching even then and moving to another field?

As to the other question about how to stop corporate labs etc... You can't stop it. In fact I know several young attendings from my department that left and went to a coporate lab because they were paid better and treated better than they were at our "prestigious" academic medical center. Lots of pathologists are buying into the coporate lab thing because even though the jobs are mill-type jobs they are better than many junior attending academic jobs and non-partnership track private jobs. Hey, we may all be working for Quest, LabCorp, or Caris one of these days so don't knock it quite yet. At least when you work for these labs you don't have to worry about the shady pathology group across town undercutting you.

 

[green mantis]

This brings up another question...Is it easier for a pathologist to learn to do clinical procedures and open up their own clinic (and convince primary care docs to send them patients) or for a clinican to learn to read the slides in their field of interest?

I'd say it's easier for clinicians to read slides in their field of interest because it already happens (dermpath, oral path, ophthalmic path, etc). There's just not enough time to train pathology residents to do procedures to the point where they'd feel comfortable. Most of my co-residents didn't even like doing FNAs or bone marrow biopsies, much less a skin biopsy. A lot of them opted out of the clinical part of the DP rotation.

We'll use DP as an example. At my residency institution, dermatology residents do 2 months of DP every year for a total of 6 months. As pathology residents, we do 1 month of DP for our entire residency unless you choose to do a 2nd month as elective. Who do you think would be better?


----- Antony

 

[Entgegen]

You may say this in jest, but it is not as far fetched as you may think. If you left pathology now to do, say, anesthesia in 4 years you would be guaranteed a high paying job in a city located close to where you want to be. Can you really say that about staying in pathology? If you are a first year resident would you rather do 4 more years of pathology training (minimum) and roll the dice on the job market all the while knowing you may have to do an additional one to two years of training just to get a job or do your next 4 years in anesthesia, internal medicine, etc and be assured a good job. Moreover, if you are a 4th year resident with several years of fellowship to go and still no guarantees that everything will work out alright would you be better off switching even then and moving to another field?

I think here it comes down to what you would rather be doing, and if you see a somewhat uncertain future in your chosen field as being more desirable than a for-sure future in a field you'd otherwise not want to be in. I see lots of posts asking why go into this field when there are guaranteed jobs in, say, IM...but this assumes that to the person they're talking to, all jobs in medicine are equal. Personally though, it doesn't matter how good the internal med job is, I think I would shoot myself before working IM for the rest of my life.

 

[pathstudent]

When I was a second year medical student I "rotated" with a community pathologist whose hospital had a residency program and he told me that pathology was a two-tiered job market with US trained med students getting good jobs. He said only two of his residents (all FMGs) ever got a job and one was in the UK or somewhere in Europe. This was a number of years ago. Is it similar today or are now US trained med students also unable to find good jobs?

 

[BrainPathology]

As to the other question about how to stop corporate labs etc... You can't stop it. In fact I know several young attendings from my department that left and went to a coporate lab because they were paid better and treated better than they were at our "prestigious" academic medical center. Lots of pathologists are buying into the coporate lab thing because even though the jobs are mill-type jobs they are better than many junior attending academic jobs and non-partnership track private jobs. Hey, we may all be working for Quest, LabCorp, or Caris one of these days so don't knock it quite yet. At least when you work for these labs you don't have to worry about the shady pathology group across town undercutting you.

So large corporate labs are paying and treating people better than either acedemics or private practice jobs? So what you're saying is market based large companies do a better job at attracting talent than greedy old men who like screwing over new hires or acedemic institutions who think that just being around med students and the joys of research should be enough to keep you there.

And this is bad. Very very bad for the specialty somehow.

That's really interesting.

 

[HbyHA]

Personally though, it doesn't matter how good the internal med job is, I think I would shoot myself before working IM for the rest of my life.

i was going to write the same thing in reply to that post but you beat me to it😀