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Falling off the cliff: are we short of pathologists?

I can recall clearly the pathologists coming to lecture our medical school class our second year in 1993.

Most of them felt compelled to tell us, “Pathology is a lot of fun, you can make a good living, but don’t go into it, there aren’t any jobs.”

Once we finished our didactic years and hit the wards and the floors, students were often asked about what speciality they were considering. Without hesitation, I responded “Pathology”. Many of my surgery, medicine, paediatrics and gynaecology attendings were flabbergasted at this. The response was “You’re just going to be replaced by a gene chip in 25 years [which would have been this year now].”

By the time I finished medical school, residency, fellowship and completed my military obligation, there were plenty of jobs in pathology in desirable places. And the gene chip hasn’t replaced me yet.

Sometime longer than I can remember exactly, perhaps in the early 2000s, there was an increasing discussion about pathology falling off a cliff. I think what was meant was that there were a number of pathologists who would be of retirement age leaving us with a shortage of pathologists. That, combined with people living longer thanks to excellent healthcare and cancer and heart disease becoming chronic illnesses rather than death sentences, there was a concern that not enough pathologists would be available to meet the public health demand.

This changed again in 2008. Those pathologists that were supposed to retire, didn’t do so when their 401Ks were no longer worth 401K. A recent article now points out that between 2007 and 2017 there was a loss of pathologists, consistent with workforce projections about lack of pathologists.

The article mentions “The number of active pathologists in the U.S. plummeted between 2007 and 2017 by about 17.5% and puts the country at risk of a shortage in the future, though a smaller workforce is currently handling a bigger load of cases.” according to a study published on May 31 in JAMA Network Open.

This 20% reduction is cited as putting us at risk of shortage with a smaller workforce handling a bigger load of cases.

Certainly, I know of no pathologists who are doing fewer cases in any given day, week, month or year than they did ten or fifteen years ago. As a resident, one of my mentors used to hold afternoon teas with the pathology residents and pathology and oncology fellows. About one hour of “sign-out” was tea and small talk. Another mentor would prepare home-cooked delicacies from his native land and have “liver rounds” on Thursday afternoons while reviewing interesting cases. I remember the hummus and the taramasalata much better than I do any particular case with the exception of some very old examples of yellow fever in the liver.

Those days seem to be over. There isn’t time for afternoon tea and liver rounds pairing taramasalata with the ideal wine while reviewing cases.

But are we really short of pathologists or close to it?

One figure I have never seen published, if it exists, is how many pathologists do you need per 100,000 persons? The medical and surgical subspecialties seem to have this worked out and perhaps shift the numbers from time to time, but the professional societies of vascular surgery and neurosurgery, among others, can tell you how many of them are needed per 100,000 people in a community.

If the College of American Pathologists or other professional societies in the US or elsewhere have a number in mind, I do not think it is well-publicized. As a result, it is not always exactly clear how many residents to train. And we end up on a pendulum with either a glut or a shortage.

The numbers do not seem to be in our favour if we think about fewer pathologists and more patients with more biopsies and surgeries and more cases. The National Health System in the United Kingdom has struggled with this for years with documented longer turnaround times and staffing issues.

But – I think this is a problem that exists if we continue to think we need to work as we have in the past – piles of slides and a microscope and a LIS with voice recognition or dictation system.

We have the technologies now to change not what pathologists do, but how they do it. It has happened in radiology with computer-assisted diagnosis. It will happen in pathology.

When liquid-based cytology (LBC) started to become more commonplace in laboratories by 2000, cytotechnologists and cytotechnology schools feared they would be replaced by machines. It didn’t happen. Certainly, LBC helped with the shortage of cytotechnologists, but it didn’t displace or replace them. There may be fewer cytotechnologists and cytotechnology schools now because of other market forces, but it isn’t because of some automation.

The same will be true in surgical pathology. Machine learning (ML), artificial intelligence (AI), and computer-assisted diagnosis can and will be available to augment what the pathologist does to maintain throughput and accuracy.

If we know with some degree of accuracy that 10.2 pathologists are needed per 100,000 people and there are 100 residencies with 4-6 spots per year and a population of 320 million and a retirement rate of 4.27% per year – then, the goal and challenge need to be on recruiting medical students to the speciality.

Shiny new computers and monitors and fancy user interface tools in comfortable chairs with blue lighting and classical music in the background with handheld devices and apps and instant gratification making a diagnosis would go a long way, much like radiology has seen with its technology and surgery has done with robotic surgery.

Sitting hunched over a microscope in a chair better designed for a tailgate rather than an office and relying upon manual methods and dictation and too many keystrokes and mouse clicks to result in a case isn’t going to cut it. We have shown that.

So, before gene panels replace us, we need to embrace ML/AI and showcase this in medical schools.

And then in ten years when I am teaching medical students I can tell them, “Pathology is a lot of fun, you can make a good living, but don’t go into it, there aren’t any jobs.”

Keith Kaplan, Digital Pathology

 

Keith Kaplan is Chief Medical Officer at Corista, a practising pathologist and author of the Digital Pathology Blog.

 

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