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Invited Commentary
Pathology and Laboratory Medicine
May 31, 2019

How Many Pathologists Does the United States Need?

Author Affiliations
  • 1Cancer Commons, Los Altos, California
  • 2Cureus, San Francisco, California
  • 3Medscape from WebMD, New York, New York
  • 4Uinversity of Alabama, Birmingham
  • 5Feinberg School of Medicine, Northwestern University, Chicago, Illinois
JAMA Netw Open. 2019;2(5):e194308. doi:10.1001/jamanetworkopen.2019.4308

Pathology is the study of disease. The practice of pathology in the United States is the application of all laboratory sciences to the prevention, diagnosis, treatment, and follow-up of disease. If that expansive vision is true, how can it be that the workforce of US pathologists has declined approximately 17% from 2007 to 2017, from 2.03% to 1.43% of all US physicians, while the number of physicians and the population overall continued to increase, as reported by Metter et al?1 Is this a blip or a trend? Is it serious or trivial?

It is not a blip, and it is serious, but predicting workforce needs is tricky. Various databases of the College of American Pathologists (CAP) indicate that fully trained graduating pathologists often have difficulty finding jobs. However, another recent study reported the job market to be fairly stable, with 67% to 75% of pathologists graduating from residency programs finding satisfactory positions within several months.2 The article by Metter et al1 is profoundly disquieting to an experienced pathologist like me, who really believes in the field. I began working in a clinical lab while in premed, finished medical school in 1957, and (after a rotating clinical internship) finished my 4-year pathology residency in 1962, becoming boarded in anatomic and clinical pathology the same year. We always used to say that about 3% of graduating American medical students entered pathology. In 2019, the National Resident Matching Program reported 569 incoming first-year pathology residents, or 3.2% of 17 763 total residents matched. However, only 201 of those were US graduates, filling only 33.4% of all available positions—the lowest, by far, of all specialties with more than 100 graduates entering a comprehensive program. This is all about supply and demand.

What does a pathologist do? Pathologists can be trained in bewilderingly large and diverse knowledge bases and skill sets that match the breadth of the field described in the first paragraph. A former president of the CAP (James Barger) once said that “pathology is what a pathologist does.” The field of human pathology, broadly writ, is eternal, as long as humans and disease exist. But the practice of pathology is variable, depending on a host of environmental, social, and economic issues and the specialty’s response thereto. Separate certification is available by examination of the American Board of Pathology in anatomic pathology, clinical pathology (also known as laboratory medicine), blood banking/transfusion medicine, chemical pathology, clinical informatics, cytopathology, dermatopathology, forensic pathology, hematopathology, medical microbiology, molecular genetic pathology, neuropathology, and pediatric pathology. Each of these fields has 1 or more membership organizations. Clinicians, by definition, practice with individual patients, while clinical pathologists are often characterized as caring for groups of patients. However, there 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.

All of the fields listed are legitimate endeavors for a pathologist. However, in almost all of them, there are substantial numbers of nonphysician medical professionals who are trained to do many of the same things pathologists (can) do, and for lower wages. Examples abound, from pathologists’ assistants in autopsy and surgical pathology, PhD clinical chemists and medical microbiologists, medical technologist laboratory managers, cytotechnologists, medical geneticists, information scientists, and many other laboratory professionals. This is historically understandable; in fact, the system was developed largely by usually scarce pathologists who developed useful colleagues of many stripes. In the modern US medical business, absent major pushback, a job will go to the lower-paid person. That, plus automation of more and more laboratory procedures, often displaces, or even replaces, humans in pathology and laboratory medicine, as in many other fields.

Two historical trends have had great impact on the pathology workplace and workforce. In the late 1960s into the 1970s, as a forerunner of the “medical industrial complex,” for-profit corporations entered the clinical laboratory field. They used modern industrial management techniques and aggressive sales strategies to wrest away huge numbers and varieties of clinical lab tests from pathologist-directed hospital laboratories, pathologist-owned private laboratories, and physician office labs. Second, the hospital autopsy, historically the centerpiece of pathology, underwent a sharp decline beginning in the 1960s and has not rebounded, instead almost vanishing in nonteaching hospitals.3

Where is the good news that could help to reverse the decline in pathologists? Following its landmark book about therapeutic errors in medicine in 1999, the National Academy of Medicine (formerly the Institute of Medicine) published another landmark book4 about errors in diagnosis in 2015. This report calls for a reinvigoration of the autopsy as a major tool for improved diagnosis and patient safety. It also calls for the creation of diagnostic management teams, headed by pathologists, as a key way to improve diagnosis.5

Another obvious place for growth of pathology work is in precision medicine, which relies heavily on diagnostic genetics, and is booming. One more opportunity responds to an old need that is still unmet. Pathologists have always been teachers, often the best at explaining disease processes to medical students and fellow physicians. They should help clinicians to select the right test on the right person at the right time 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. Modern pathologists should be paid for performing fewer rather than more laboratory tests, using the correct tests that make a difference in outcomes.

The potential workforce size of pathologists in research is endless, simply dependent on funding for studies of promising nature. There are always shortages in forensic pathology, a highly specialized field in which salary levels tend to lag below market value because they are usually civil service positions in county or city governments.

Who pays whom how much for what? The Medscape Physician Income Surveys report that the median annual income for pathologists was $239 000 in 2013, ranking seventeenth of 25 physician categories in 2013,6 and by 2018 was eighteenth of 29 specialties at $286 000 per year.7 Someone has determined that the work pathologists do is still worth finding the money to pay for it. Credit the awesome continuing effort of the CAP for much of that.

I say that it is up to the community of pathologists to again adapt to the opportunities of the new scientific and economic world and turn the slump of the 2010s into a justified rise in the 2020s. The work that pathologists offer to perform must become more highly valued. But it will not just happen naturally. It will need to be earned.

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Article Information

Published: May 31, 2019. doi:10.1001/jamanetworkopen.2019.4308

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Lundberg GD. JAMA Network Open.

Corresponding Author: George D. Lundberg, MD, The Lundberg Institute, 104 Altura Vista, Los Gatos, CA 95032(gdlundberg@gmail.com).

Conflict of Interest Disclosures: Dr 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.

Metter  DM, Colgan  TJ, Leung  ST, Timmons  CF, Park  JY.  Trends in the US and Canadian pathologist workforces from 2007 to 2017.  JAMA Netw Open. 2019;2(5):e194337. doi:10.1001/jamanetworkopen.2019.4337Google Scholar
Gratzinger  D, Johnson  KA, Brissette  MD,  et al.  The recent pathology residency graduate job search experience: a synthesis of 5 years of College of American Pathologists job market surveys.  Arch Pathol Lab Med. 2018;142(4):490-495. doi:10.5858/arpa.2017-0207-CPPubMedGoogle ScholarCrossref
Lundberg  GD.  Low-tech autopsies in the era of high-tech medicine: continued value for quality assurance and patient safety.  JAMA. 1998;280(14):1273-1274. doi:10.1001/jama.280.14.1273PubMedGoogle ScholarCrossref
National Academies of Sciences, Engineering, and Medicine. Improving diagnosis in health care. http://www.nationalacademies.org/hmd/Reports/2015/Improving-Diagnosis-in-Healthcare.aspx. Published September 22, 2015. Accessed April 25, 2019.
Dark Daily. Innovative pathologists and clinical laboratory scientists use diagnostic management teams to support physicians with more accurate, faster diagnoses. https://www.darkdaily.com/innovative-pathologists-and-clinical-laboratory-scientists-use-diagnostic-management-teams-to-support-physicians-with-more-accurate-faster-diagnoses/. Published January 11, 2018. Accessed April 25, 2019.
Peckham C. Medscape pathologist compensation report 2014. https://www.medscape.com/features/slideshow/compensation/2014/pathology#2. Published April 15, 2014. Accessed April 25, 2019.
Peckham C. Medscape pathologist compensation report 2018. https://www.medscape.com/slideshow/2018-compensation-pathologist-6009668#2. Published April 18, 2018. Accessed April 25, 2019.
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    2 Comments for this article
    Whither pathology
    Bruce Bender, MD, MS | retired/disabled, former Director Network Consolidated Lab VANEngland
    Pathology cut medical care in a different direction. We were all about diagnosis. There was a time when physicians referred to pathologists as the "doctor's doctor." We used all the laboratory, including anatomic pathology, resources to diagnose and spent a lot of time with clinicians helping on individual cases. We instructed on the interpretation of tests and helped guide the pursuit of the diagnosis. In an era of increasing specialization focusing on systems and body parts, pathologists were often the only ones who were really aware of all the disease processes that might account for a patient's findings. Autopsies were done on meaningful patients and revealed a significant unexpected finding 10% or more of the time, a result that never changed. I believe that is still a valuable role.

    Unfortunately, over time laboratories were moved out of the hospital. Test results are divorced from the patient. Not many pathologists are in the laboratory helping to understand results. The entire practice of medicine changed with shorter visits, essentially, no history and physical and no one who knows the patient. The ability of a knowledgeable clinician to speak with an informed pathologist about an individual was greatly reduced. The autopsy disappeared because, although the cost was supposedly included in hospital payments for overall function, nothing was paid out to the physician who invested a day or two in each one, and no one wanted to find out about those significant unexpected finding.

    At the same time pathologists experienced the same degradation of cognitive work. They were paid for producing the piece work of anatomic pathology diagnosis. Their expertise in the lab was largely neglected, or increasingly over time, never obtained during their residency. The no longer did the very valuable work of "the big biopsy" and bringing the whole story together after an autopsy. Many happily went along with that and did well for a few years.

    Although I pine for the good old days, I don't see that either the environment or the current pathology workforce can support their return.

    Moved on 20 some years ago and have been outside medicine ever since.
    How many pathologists do we need?
    Wendie Howland, MN | Howland Health Consulting, legal nurse consulting and life care planning
    I come from the med-legal side of things. Judging by the news reports of delays in the court system related to a tremendous backup in the state ME office, the answer would seem to be, "A heckuva lot more." Either that, or the standard of practice for doing real posts on all deaths outside of medical care, specifically, the huge number of overdose deaths, is going to need radical loosening. Is that going to be in the public's best interest? I'm thinking not. Accident victims, dead children, rape victims with kits sitting on shelves, potential homicides, suicides, ODs, ... these people's families (and the courts) deserve better than months of waiting for an answer. And we're not even scratching the surface for advanced needs re brain injury, genetics, pharmacology, and risk management.

    I have had at least one med-legal case where medical records were, shall we say charitably, incomplete. Fortunately, a pathologist examined the extremely unfortunate deceased immediately after death, in the hospital, delivered right from the OR, had all the hospital records, and quoted from them liberally. This path report was critical to understanding the reason he died, which wasn't really clear from the records the hospital released to my attorney client months later. I found myself saying, "Wait, what was that? Where is that documented? I don't have that..." many times. Justice would not have been done had the body gone out to a state lab with overworked staff and incomplete records, and taken the physician's word for the (moderately plausible) cause of death as charted in the final note.
    How many? A five-year-old would spread her arms and say "THIS many!!!" Seems pretty obvious.