Inside the Lab Industry: Addressing the Coming Pathology Shortage

The United States has been facing a shortage of physicians for at least a decade now, and it is expected to grow more acute in the coming years. However, the shortage of pathologists is expected to grow quite dire over the next 15 years, with the downward slide beginning as early as next year. It could even place pressure on the growing business of molecular assays and personalized medicine. That is the opinion of Health Care Development Specialists Inc. (HCDS), the Florida-based lab and pathology consulting firm. It recently issued a special report to its clients on the shortage, which is available for download at www.hcdsinc.com. That report itself is based in part on a study published late last year in the Archives of Pathology & Laboratory Medicine. That study, which was co-authored by a group of leading pathologists, concluded that the ranks of the nation’s pathologists would be thinned by a large number of retirements starting next year and continuing until 2030. Dramatic Drop Around the Corner By 2030, the rate of practicing pathologists is expected to decline from 18,000 to 14,000, or 3.7 per 100,000 of population. That would be a 32 percent decline from the current rate of 5.7 per 100,000. “We observed that because pathologists play a pivotal role in diagnosing disease, projected shortages pose serious implications for patient care,” HCDS said in an introductory note to the client alert. The situation was serious enough for the College of American Pathologists (CAP) to hold a special summit late last year to discuss the issue. The reasons for the decline are numerous, but it is pegged primarily to the fact that the active chronological age of pathologists is among the oldest of the medical specialties—75 percent are 45 years or older, 41 percent are older than the age of 55, and 12 percent are older than 65. By contrast, only 26 percent of the nation’s pathologists are under the age of 44. And the current average age is around 57, which while not old is not exactly youthful. Moreover, the number of residency programs has shrunk dramatically over the past 50 years, from about 700 in the early 1960s to less than 150 today. CAP President Gene Herbek, M.D., estimates that those programs—which produce about 500 new pathologists per year—is about 150 to 200 short annually of preserving the current workforce levels. Given that few new medical schools have opened in the past decade despite the general overall shortage of physicians, and policymakers are incentivizing the creation of more residency slots for primary care physicians rather than specialists, industry observers do not think the pipeline of newly minted pathologists is expected to expand any time soon. Already Overextended What does such a projected drop in the population of practicing pathologists portend? Barry Portugal, the president of HCDS, believes it could become worse for health care delivery sooner rather than later. He noted that pathologists—particularly those practicing in the hospital setting—are already overextended due to the extra duties they are asked to perform, such as managing utilization and blood supplies, acting as laboratory directors, and other side work. They also perform additional services such as special consultations and special stains. “There’s not even a reference to an additional workload in many studies, and I think because of that the timetable [for the shortage] will be sooner rather than later,” Portugal said. That is definitely the case for Herbek. In addition to his pathology practice, he oversees blood management at Methodist Hospital in Omaha, Neb. He also serves as the laboratory director at Methodist Women’s Hospital and devotes time to developing care guidelines and analyzing test algorithms for clinical appropriateness as part of Methodist’s accountable care initiative. “Those are the kinds of things we’re doing on a more regular basis,” Herbek said, estimating the extra workload to be about 10 hours per week, or about 20 percent above his current workload as a pathologist. Of course, that is completely separate from the work he does on behalf of CAP. Extending Extenders But not all of the scenarios are dark. There is the possibility of adding to the “pre-signouts” job duties to allied staff such as cytopathologists, histotechnologists, pathology assistants (PAs), and doctorate-level clinical scientists. In a report on last year’s workforce summit, CAP recommended using cytopathologists to conduct testing for the human papillomavirus, much in the way they currently conduct much of the work connected to Pap smears. “With their background in biology and genetics, prerequisites for laboratory training programs, cytotechnologists possess the knowledge base required for molecular testing,” the report said. “In response to changes in practice increasing demand for cervical cancer screening utilizing molecular techniques, broader training offered in cytotechnology education programs will provide graduates the relevant broad skills to continue as key health care professionals in women’s health.” Herbek noted that pathologists will have to allocate more duties to extenders in the future. “We will need to rely on them to help us get the job done, particularly in getting the diagnoses and lab testing out in an efficient manner,” he said. Friction regarding scope-of-practice issues is not likely to surface as in primary care or other specialties because the relationships with pathologists and their extenders tends to be collegial, according to Herbek. The HCDS report also recommended the use of extenders to help close gaps in the coming pathologist shortage. It suggested using pathology assistants for a variety of duties, including coding, tissue procurement for research purposes, training of histotechnologists, and other aspects of personnel management. But the report also noted that while using extenders is crucial, so is recruiting them. Portugal observed that PAs and other extenders are in short supply themselves. And while hospital-based pathology practices may have the resources to hire extra personnel to assist the doctors, that is not necessarily the case for independent practices, most of which have 10 doctors or fewer. A PA can command a salary of $90,000 to $140,000 a year; a cytotechnologist, up to $75,000; and a histotechnologist, up to $50,000. Given the current financial environment for pathologists, who have been hit hard by ongoing reimbursement cuts, many may be reluctant to hire additional staff. “In academic settings or in large pathology groups, the use of a PA is something that is widespread. But when you have a preponderance of pathology groups with 10 doctors or less, they may decide not to use PAs because the money may have to come out of their own pocket,” Portugal said. “If you’re already facing substantial reductions in your income, some of them may simply try to work longer hours rather than invest in extenders.” Many pathologists may not have a choice. Herbek noted that the specialty does not require the physical skills—or the physical stresses—of other specialists, such as surgeons. As a result, many could choose to delay their retirements. Currently, CAP’s workforce staff pegs the average retirement age for a pathologist at 71—a half-dozen years beyond qualifying for Social Security and in line with a U.S. labor force that is working years beyond what they had in the past. “And that [retirement age] is pretty conservative,” Herbek said. Takeaway: The pathology community and its advocates will have to find creative ways to stretch the dwindling numbers of newly minted pathologists.