US Pathologist Supply Down Relative to Diagnostic Demands

Nicola M. Parry, DVM

May 31, 2019

The number of pathologists in the United States decreased by 17.53% from 2007 to 2017, despite a corresponding 41.73% rise in diagnostic workload per pathologist, a study published online May 31 in JAMA Network Open shows.

"Adjusted for population, the US pathologist workforce is now smaller relative to other countries that have experienced major adverse events in clinical laboratory quality and delays in diagnosis," write David M. Metter, MD, University of Texas Southwestern Medical Center, Dallas, and colleagues.

In most medical specialties, patients can directly experience the consequences of staff shortages via delays in physician scheduling. In contrast, patients typically do not become aware of shortages in the pathologist workforce until significant events, such as diagnostic errors or long diagnostic delays, occur.

Indeed, pathology workforce shortages in Canada and the United Kingdom have resulted in critical events that have negatively affected patient care.

To analyze trends in the US pathologist workforce, Metter and colleagues conducted a cross-sectional study to examine trends in the US pathologist workforce from 2007 to 2017 and compared them with trends in the Canadian pathologist workforce during the same time frame.

The investigators used the Association of American Medical Colleges (AAMC) Physician Specialty Data Books (2008 – 2018) and annual survey findings from the Canadian Medical Association as their main sources of data.

From 2007 to 2017, the number of active US pathologists fell 17.53% (from 15,568 to 12,839), despite a 16.61% growth in the overall US physician workforce (from 765,88 to 892,856).

Among all US physicians, the percentage of pathologists dropped from 2.03% in 2007 to just 1.43% in 2017, the authors say.

In contrast, the number of Canadian pathologists rose 20.45% (from 1467 to 1767) during the same period.

The number of pathologists dropped from 5.16 to 3.94 per 100,000 population in the United States and rose from 4.46 to 4.81 per 100,000 population in Canada.

This 10-year decline in the number of US pathologists is the largest among all physician specialties tracked by the AAMC workforce survey, the authors say.

The gap between the US and Canadian workforces continues to widen, they stress.

"In 2017 there were only 3.94 US pathologists per 100,000 population compared with Canada's 4.81 per 100,000 population," they state.

Metter and colleagues also examined numbers of pathologists at the state level for the years 2012 and 2016. They found wide variations per 100,000 population; Idaho had the fewest pathologists (1.37), and the District of Columbia had the most (15.71).

The change in the number of pathologists from 2012 to 2016 was mostly negative, ranging from −1.75% in Hawaii to −30.30% in Idaho.

According to the investigators, the estimated number of new cancer cases in the United States rose by 16.88% (from 1,444,920 to 1,688,780) from 2007 to 2017. After adjusting these data with respect to the number of US pathologists in each year, the diagnostic workload per pathologist rose by 41.73% (from 92.81 to 131.54) during this 10-year time frame.

In contrast, the Canadian diagnostic workload increased by 7.06% (from 109.00 to 116.69) from 2007 to 2017.

The authors acknowledge the discrepancy between the findings regarding the steady decline in the US pathology workforce in their study and the lack of an increase in open positions or salaries for pathologists.

"While the decreasing number of pathologists would be expected to cause widespread workforce deficits or position vacancies, a recent job market survey from the College of American Pathologists Graduate Medical Education Committee found that new trainees had difficulty finding jobs, but otherwise the pathologist job market was stable," they note.

Physician salary surveys from 2011 through 2017 indicate that average salaries for pathologists rose by 29%, compared with 27% for radiologists and 25% for anesthesiologists.

"We hypothesize that the 17.53% decrease in active pathologists has been absorbed by increased efficiency, or at least increased elasticity in pathologist work tolerance," they explain.

Because pathologists cannot limit their workload, care is needed to avoid overwork and burnout.

The authors cite key findings from other studies that show that pathologist fatigue and burnout contribute to diagnostic errors and that patient safety is affected when pathologists work more than 39 hours per week.

Policy makers, healthcare delivery systems, insurers, and physicians should all work to identify the cause of the declining US pathologist workforce, they say.

"Because the Canadian pathologist workforce has increased during this period of a shrinking US workforce, lessons from the Canadian experience may provide valuable insights into further action in the United States," Metter and colleagues conclude.

In an accompanying commentary, George D. Lundberg, MD, from the Lundberg Institute, Los Gatos, California, describes the findings of this study as "profoundly disquieting."

He underscores the need for the pathology community to reverse this workforce decline by adapting to current opportunities.

"[T]here is a place for the skill and knowledge of a trained pathologist at every interface with a need of a living or dead patient as represented by the board certification subspecialties," he writes.

Identifying opportunities to help counter the fall in the number of pathologists, Lundberg highlights the National Academy of Medicine's 2015 report on improving diagnosis in healthcare. This report urged that autopsy be revived as a diagnostic error-reduction tool, he says. He also discusses the need for pathology-led diagnostic management teams to help improve diagnosis.

The growth of precision medicine, with its molecular diagnostic focus, also offers promise of opportunities for pathologists, he notes.

There remains an unmet need for pathologists to educate clinicians about concepts such as selecting the right test for the right patient at the right time, Lundberg adds, followed by correct interpretation, clinical action, and effects.

"Many physicians do not understand the basic concepts of sensitivity and specificity and that predictive value of lab results is dependent on the prevalence of the disease in a tested population," he writes.

The potential opportunities for pathologists in research are endless, says Lundberg, and there are always shortages in forensic pathology.

"The work that pathologists offer to perform must become more highly valued," he concludes.

"But it will not just happen naturally. It will need to be earned."

One author has received personal fees from Miraca Holdings outside the submitted work. Lundberg is a life fellow at the College of American Pathologists, master and former president at the American Society for Clinical Pathology, and a member of the Association for Molecular Pathology. The remaining authors have disclosed no relevant financial relationships.

JAMA Netw Open. Published online May 31, 2019. Full text, Commentary

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