In histology labs, backs against
  the wall

September 2001
Cover Story

Karen Titus

If vendors of automated histology instruments ever need a prompt to pick up the pace on product development, they’ll need to look no further than their own "help wanted" ads. That’s because when it comes to hiring histotechnologists, vendors as well as their clients often go hurting.

"We’d been trying to fill some positions in our customer/product support department, and it was quite difficult to get qualified people," says Elise Green, marketing manager at Sakura Finetek.

Of course, no vendor truly needs reminding that automation is in high demand. Even if Green and her industry colleagues weren’t feeling their customers’ pain, they certainly hear about it. "When labs lose a histotech, it’s traumatic," she says. Customers who call for technical assistance, for example, more often than not are seeking help for a problem that just occurred; understaffed and overworked, they no longer have time to troubleshoot. "They call the company and need as quick a response as they can get," Green says.

That they may be calling another understaffed group of histotechs is just one of many Escher-like oddities confounding histology these days, all of which spring from the same problem: too few histotechnologists to go around, and too few new ones on the way. Which puts labs and vendors in the same boat—one that’s headed for even rougher seas.

The shortage is hardly new—it’s been years in the making. Ditto for the automation designed to help histology laboratories cope with the drought. "The same time we first started seeing the techs disappear, 10 to 15 years ago, the companies started seriously developing automation," says Catherine Locallo, BA, HT, HTL(ASCP), director of the Technical Assistance Center at Leica Microsystems.

What is new is the severity and complexity of the problem. And while automation is making impressive inroads into the histology laboratory—learning, in part, from the automation of the clinical chemistry lab—it still lags behind the shortage. Even with automation, labs can barely keep their heads above water.

It’s little wonder they feel like they’re drowning. The American Society of Clinical Pathologists reports that the overall vacancy rate for histotechnologists nearly doubled between 1998 and 2000, when it reached 22.2 percent; that’s quadruple the rate in 1996. Broken down by categories, the numbers reveal another shocker: The average vacancy rate for hospitals was a whopping 37.7 percent last year, with hospitals of all sizes affected almost equally.

Vacancies for histologic technicians reached 16.1 percent in 2000, up from 12.9 percent in 1998. Only histology supervisor vacancy rates remained steady between 1998 and 2000, though that bit of relative good news is tempered by the high rate—20 percent, twice what it was in 1996.

Numbers convey only part of the story. More telling are the tales drifting up from the trenches—or, more accurately, from the forgotten corners of the basement labs where histologists have traditionally been relegated.

•  At Rush-Presbyterian-St. Luke’s Medical Center, Chicago, Kathleen Clodfelter, BS, MBA, recently filled a histotech position—after it had been open for a year. The new hire, though familiar with the lab’s equipment thanks to research experience, was not a trained histotechnologist; nevertheless, Clodfelter, who is supervisor of immunohistochemistry in the Department of Pathology, views the matter with relief. "I found a great candidate—I got lucky," she says.

  Sometimes Clodfelter has to do battle with her own human resources department. "Because it takes so long to fill these spots, they say it’s too costly to keep running an ad in the paper," she says. "Which of course makes it even more difficult to find someone."

•  Lorraine Smallwood, M.Ed., BB(ASCP)HT, MT(AMT), CLS(NCA), supervises the histology lab and blood bank at Phoebe Putney Memorial Hospital, Albany, Ga. During a restructuring of the histology lab several years ago, all three members of the histology staff quit within three months, and Smallwood has had to make do with a series of temporary workers and histotechs-in-training. Even after her trainees become certified, however, Smallwood won’t be able to breathe easy. "I have an evening position open right now, and we just can’t find anybody to fill it," she says. She’ll also need to request another FTE in the next budget year. "Our workload is growing at an enormous rate," she says. "I don’t see how we’re going to keep up."

•  Peggy Wenk, BA, BS, HTL(ASCP), is used to hearing about vacancy woes—she’s program director of the schools of histotechnology at Beaumont Hospital, Royal Oak, Mich. But even she sounds a bit startled by the calls she now receives. "Two years ago, labs would call me, and they were already desperate," she recalls. "They were short one histotech, and were so overworked they didn’t have time to train anyone on the job. So if they couldn’t hire a student, they weren’t going to hire anybody."

  Now she’s hearing back from these same people. Now they’re two or three people short. "Now they’re in tears," Wenk says.

•  One of Heather Diamond’s laboratory clients recently signed a histotechnologist who hadn’t worked in the field in three years. "They thought this was the best thing that ever happened to them," says Diamond, owner and senior recruiter of HDSR, a Florida-based recruiter specializing in histology. "That’s how desperate people are." Another of her laboratory clients is so short-staffed, she says, it may soon close down.

  “I am absolutely floored by the number of histotech positions open in this country,” she adds.

•  Christopher N. Otis, MD, reports that competition for histotechnologists has grown so intense, "We’ve had, for the first time, episodes of predatory activity from other medical centers." Shortly after being hired by his institution, several histotechnologists were lured away by nearby facilities offering $5,000 more, says Dr. Otis, who’s associate professor of pathology at Tufts University School of Medicine and director of surgical pathology at Baystate Medical Center, Springfield, Mass.

How did things get so bad? Get ready to point more than a few fingers.

Many blame the advent of DRGs and CLIA ’88. Trying to cut costs, hospitals trimmed staffs to skeleton crews. As these workers have grown older, many are moving into supervisory or education roles, leaving labs for higher paying jobs in industry, or retiring. "I certainly don’t want to stay in this field forever," says one histology supervisor.

Histology also has been cloaked in invisibility, which has not served the profession well. "Our main problem is nobody knows about us," says Glenda F. Hoye, BS, HT(ASCP). "We are a hidden group of people, very important, but not visible at all."

It’s not a matter of assuaging fragile egos. How can the profession fill its thinning ranks if no one is aware the field exists? "If you talked to a hundred practicing histotechs, you’d probably hear about 99 stories about how they just fell into the laboratory," says Hoye, who is histotechnology program director at the Indiana University School of Allied Health Sciences, Indianapolis.

Indeed, that’s how Sherri Young, HT(ASCP), jokes about it when asked how she began her histology career 23 years ago. "I fell into the trap," says Young, supervisor of laboratory operations at Rush-Presbyterian-St. Luke’s, Chicago. Brief internships, a casual suggestion, a chance encounter—all are typical routes into the profession. But that’s not going to solve the current, let alone future, crisis.

When histotechs do come to the attention of others, they still come up short. "Even when we toot our own horns, it hasn’t always been enough to earn the respect among other laboratory professionals," Hoye says.

Far too often in the past, "pathologists felt they could train anybody to do this job, and it wasn’t uncommon for secretaries to be taught to do histology," Leica’s Locallo says.

"In the days when our hospitals were community or local, the physicians always figured they could get a local high school girl to come in and do histology," adds Alton Floyd, PhD, who has spent more than 30 years in the histology field as an educator and consultant. That belief, he says, has "gone on and on and on."

That, in turn, has fostered rather lax attitudes about retaining and rewarding histotechnologists, who traditionally have been among the lowest paid of all allied health professionals. It hasn’t been uncommon for histotechs to be paid less than phlebotomists, or even the janitorial staff.

"Salaries have to rise, and they are," says recruiter Diamond. "I don’t even bother with labs that won’t pay what histotechs deserve, or pay relocation costs. If they’re not willing to face the current reality, I need to move on, because there are plenty of companies and hospitals who are willing to pay." In fact, signing bonuses and relocation expenses are becoming
the norm.

Those who haven’t mustered out of the field are feeling the squeeze as they try to keep pace with exploding workloads. It’s not unusual for histotechnologists to cut well over a hundred blocks a day. "And that’s just the cutting part," says Dr. Floyd.

As surgical pathology becomes more sophisticated, notes Dr. Otis, "We’re requested and required to do more and more and more and more with the material, everything from straight morphology to immunohistochemistry to in situ hybridizations." Workloads will only increase, he says, as emerging molecular pathology techniques make their way into histology labs.

The growth in so-called companion diagnostics will push loads up even higher, predicts Kirk Kimler, vice president of marketing and business development at Ventana Medical Systems. Herceptin and its monitoring tests are just the tip of the iceberg—some 200 new cancer drugs are in the pipeline, he estimates. "It’s going to drive tremendous growth in the histology lab. It’s the equivalent of PSA when it arrived in the clinical chemistry immunoassay arena in the early 1990s." Further growth will come, he says, from the overlap of histology and cytology. HPV, which can be tested using a liquid-based cytology sample but run through an automated stainer, is a prime example.

As histology grows more complex, so do the demands on histotechs’ knowledge. Ironically, however, few have time to learn the theory behind the methods anymore. And pathologists, who used to be the primary resource for troubleshooting and training, can rarely supply that expertise these days. Many histotech supervisors, in fact, report having to take time to train residents as well as histotechs in the finer nuances of certain procedures. Despite expanded curriculums and longer residency programs, basic histology training has fallen by the wayside. This, in turn, undermines histotechs’ abilities to troubleshoot when things do go wrong in the lab.

And when that happens, watch out. "Any little glitch will cause havoc in my day," Young says. "Nothing needs to ever break down."

Once you start poking around, there seems to be no end to the problems bubbling up in histology labs.

"People don’t get breaks anymore," says Rush’s Clodfelter. "The stress is incredible. We’re working around the clock, and there’s never
any downtime."

Instead of supervising, Clodfelter often joins her colleagues in the lab to make sure the work gets done. While that may help with the day’s output, it doesn’t give her time to troubleshoot, train, plan ahead, pursue hiring, or perform any of the myriad other duties that keep a laboratory running efficiently.

Though there’s little room for cutting corners, it does happen in subtle ways. Errors in labeling that might normally be caught early on, for example, may go undetected until the mislabeled slide reaches a resident, says one histology supervisor. "We just don’t always have time to catch them anymore, we’re so busy cutting blocks," she says.

The frantic pace in most labs, not surprisingly, does little to lure prospective hires. When the rare applicant at Rush learns how many blocks a day they’ll be cutting, says Young, "Everybody says, ’Oh, no, I’m not interested.’ Even if the pay is good, they’re not interested, because we do a ton of work." Her histotechs may cut from 80 to 100 blocks a day, in addition to handling all the other routine work and ongoing special projects. "We have a sentinel node project that requires us to make 80 slides on one block, and we run as many as six sentinel node blocks a day."

Young uses temporary, "rent-a-tech" histotechnologists to fill in for vacationing staffers. "But usually these are techs that we can get in for only a short time, or they can work only part time, because they’re actually working somewhere else full time," she says. "So we take a couple hours here or there, whatever we’re able to get from them." Certainly that doesn’t solve her larger problem—she’s had two positions open for more than
a year.

"There’s very few applicants," she says. "And the ones that you do get, they’re leaving from somewhere else. These are not people who are sitting at home who suddenly decide to look for a job in histology."

Or, as Wenk puts it: "We’re stealing from each other."

In more ways than one. Moonlighting is becoming commonplace, says Lena T. Spencer, MA, HT, HTL(ASCP), QIHC, president of the National Society for Histotechnology.

One supervisor reports that two of her histotechs, on early morning shifts at her institution, head to a nearby university lab to do more work once their shifts end; another employee works Saturdays and some evenings at another hospital close by. Even the supervisor works Saturdays at a second lab.

While the boost in income is a plus to individual histotechs, it’s hardly a long-term solution to the shortage. "At some point you’re going to do a burn-out," Young concedes. "And that means even more suffering for the labs." As if they weren’t suffering enough already.

Labs lucky enough to find qualified candidates aren’t always home free. Baystate’s Dr. Otis isn’t alone in having to fend off competitors. When Catherine Locallo worked at the University of Chicago as the technical director of anatomic pathology, she made what she calls "very, very good salary offers" to two histotechnologists. "Both of them turned us down because two other nearby places could pay even more." Six months later, she managed to hire another histotech, who soon left to pursue another, better offer.

Even labs that are fully staffed have their troubles. When Locallo was at UC, one of her histotechs had 35 years of experience—a boon until vacation time rolled around. By dint of her lengthy tenure, she accumulated six weeks off a year. "So every six months she had to be off three weeks at a time," Locallo says. "So even fully staffed, I sometimes had five people cutting 900 blocks or more a day."

But what scares people the most isn’t the current situation—it’s the future. "The real crunch, in my mind, is yet to come," says Jeannie Fisher, HT, HTL(ASCP), histology specialist at St. Luke’s Hospital of Kansas City (Mo.). With the majority of current histotechnologists in their 40s and 50s, "What’s going to happen when they retire?" she asks. As things stand now, nowhere near the needed number of new histotechs are entering the field. "Everybody in the country needs to be training histotechs," she says.

At first blush, this would seem to be a straightforward proposition. After all, the number of histotechnology schools in the country has held relatively steady in recent years—about two dozen.

But those numbers are deceiving. "We’ll add a school, but drop another one," says Beaumont’s Wenk. Furthermore, she notes, the schools that are closing tend to be hospital-based, while the new ones are part of junior colleges or technical schools. This means students receive less lab-based training. "Traditionally, students spent a whole year at a hospital learning about the theory behind special stains, and knife-sharpening, and so on. Now, they’re only getting two, four, six months at a hospital."

Most community colleges simply aren’t familiar with histology, she adds, which makes it even more difficult to launch new schools. As is so often the case in histology, serendipity typically saves the day.

She recounts a recent example when representatives from a community college were scheduled to discuss an MLT affiliation with a local hospital. "They got lost on their way to the meeting and wound up in the histology lab instead," Wenk says. "The histotechs told them, ’No, no, you have to talk to us first.’ And that’s how they got interested in developing a
histology program."

Histotech training will soon take another twist. Starting in January 2005, histologic technicians will have one less route for obtaining the ASCP Board of Registry HT certification; candidates with only a high school degree and on-the-job training will no longer be eligible for the exam. Candidates will instead either need to complete a NAACLS-accredited HT program or have an associate’s degree or 60 semester hours from a college/university (including coursework in biology and chemistry) and at least one year of experience working in a histopathology lab.

The pros of this higher standard would appear considerable. Spencer suggests the new requirement "may draw that science-based group of people that we so desperately need." The added educational cachet may also help persuade HR departments to boost histotechnologists’ salaries, and it may garner respect from those who still feel histotechnologists are a dime a dozen.

On the other hand, the more stringent requirements could shrink the pool of histotechs, at least short term. Given the field’s long reliance on luck and high school graduates to fill the ranks, closing off one avenue of training may not be wise, especially if no real efforts are made to promote histology as a career at the college and university level. "You tell somebody you’re a histologist, and they say, ’Well, what is that? You study history?’" says Young. "No one knows about histology, and until you change that, we’ll just be stuck in the same spot." Or worse.

Wenk doesn’t buy into those arguments. Those with only high school diplomas often lack even the most basic biology and chemistry backgrounds, a disadvantage when working in labs that grow more complex each year. Furthermore, she says, the HT certification exam pass rate for applicants with high school diplomas/OTJ training is only 40 percent. "For those who say we’re cutting down on the pool of people, my answer is, You’re cutting out a pool of people of which 60 percent can’t pass the basic minimum requirement to be a certified tech with minimal competency."

Not that she’s knocking those who’ve trained on the job. They’ve come through the hard way, she says. But they’ve also had plenty of years to reach their current level of expertise, while those now entering the field have to cram their education into one year. "We have to look at what’s realistic now, and what’s realistic now is we can’t keep doing things the way we’ve been doing them."

In fact, says St. Luke’s Fisher, the higher standards may not be high enough. "It will only be of small help at this point. Until it goes to an even higher level, histotechs won’t be paid in the range the cytotechs and med techs are, which is where they need to be."

With no immediate relief in sight, some institutions are giving serious thought to opening—or, in some cases, reopening—their own histotechnology school.

What would it take?

Students, for starters. Unfortunately, these days potential students are a rare species, too, and histotechnology schools in recent years have seen a decline in numbers and quality of applicants.

"Young people just don’t want to come into this field. They don’t want to work in hospitals," Wenk says, starting a litany. "They don’t want to work with diseases, and they don’t want to study that hard. They want to work with computers, they want to work out of their own home, they want to work their own hours; they don’t want to work weekends, they don’t want to work midnights, they don’t want to work holidays." And they likely want to earn more money than the field traditionally pays.

Plucking students from the ranks of failed medical technology school applicants is one possibility. Fisher says if St. Luke’s decides to start its own school, it would look to students who applied to, but were not accepted at, the institution’s CLS school. Other options include recruiting employees from other areas of the lab.

Then there’s the little matter of putting together a curriculum. Wenk says she’s inundated with requests that she offer night classes or put her lectures on the Web. "They might have time to teach students how to do something in the lab, but they have zero time to teach them the theory behind it," she says. But it’s that theory, of course, "that they
desperately need."

They can get it at one institution, at least—Glenda Hoye’s innovative program at Indiana, which offers an unusual blend of distance learning and hands-on training.

Students enrolled in the program receive didactic training via a two-hour lecture, delivered by Hoye in a weekly phone teleconference. They learn technical skills in their own laboratories, where they are already employed. Though the students are from all over the country, they are registered as IU students and pay in-state tuition, which runs an affordable $126 per credit hour, plus fees and books. At the end of the 10-month program, students will have earned 24 academic credits and are eligible for the ASCP exam.

For laboratories that want to "grow their own" histotechs, Hoye’s program is nothing short of a miracle. Fisher, who has used the program to train one histotechnologist and has enrolled another for the current school year, says it prepares histotechs to function in the real-world, high-volume laboratory, something that even traditional HT schools—let alone strict on-the-job training—sometimes fall short on.

"The program is wonderful. It’s push-button education for us," she says.

This year’s class has 46 students enrolled, the largest to date. Currently the campus telephone bridge can accommodate only 23 labs, which meant that Hoye had to turn down some qualified applicants. "Next year we hope to offer two sections," she says. "I don’t think we’ll have a problem
finding students."

Given that the problems of the histology lab have been years in the making, no one expects any quick resolutions. Except, perhaps, on the automation front.

"Histology automation was moving at 60 miles per hour, but within the past few years it’s approached the speed of light," says Ventana’s Kimler. As automation nears third- and fourth-generation platforms, many envision a histology lab where linked instruments smoothly process tissue in a rapid, continual flow.

Even current automation, fragmented as it is, has been a godsend. "If it wasn’t for automation, we’d all be in a lot more trouble," says Young.

But only the most naive observers would suggest that automation is a remedy for all the ills now plaguing histology labs. Unless the histotech shortage abates—and no one expects that to happen anytime soon—automation will, at best, keep labs afloat. Breakdowns and glitches will always be part of any automated setting, which means no lab will ever lose its need for histotechs who are steeped in theory as well as experience. And a slide will never be a number. Histology, its practitioners say proudly, will always be somewhat of an art, requiring the delicate touch of a skilled human being.

Some other considerations: Automation may not be affordable for all labs; as with clinical chemistry, some predict, it may be best suited to larger institutions. Automated special stains, in particular, have yet to prove their cost-worthiness, Locallo says. "An institution must be reimbursed for work done. Is the reimbursement going to cover the costs of reagents and instrument plus tech time?" she asks.

Likewise, not every aspect of the histology lab may be amenable to automation. Microtomy springs to just about everyone’s mind—it simply requires too much human judgment to make it a shoo-in candidate for automation. Moreover, histotechs appear to be less than enchanted with the idea. "It’s like driving a stick shift car," says Young. "I need that control. And you just don’t get that with the automated microtome."

Then again, says Green, of Sakura Finetek, "Almost anything is possible. It’s just going to take more time and research and money."

In fact, insist many observers, much of the technology for improved automation already exists. The real hurdle, they say, is resistance to change. "It’s a matter of changing the workflow within the institution, which will always create problems and tension," says Doug Sweet, vice president of marketing and sales at Dako.

He predicts a growing split in histology labs as automation evolves, similar to what has occurred in the clinical chemistry laboratory. "There are some technologists who will feel empowered by technology and automation, and others who will feel totally threatened by it. That’s natural in any difficult transition," he says. "But there will be room for both in the future—some procedures will always be more suited to manual methods."

Some suggest automation will make the histotechnologist’s job more attractive. "I hope it will," Dr. Otis says. Perhaps automation will absorb the rote, mind-numbing procedures, freeing histotechs to concentrate on the more challenging aspects of the job, such as manual cutting of difficult specimens, hands-on IHC and in situ hybridization work, and special neuromuscular biopsies.

Others see potential downsides. "Does automation mean people will be staying at the microtome longer? I see that happening now," Wenk says. "We’re cutting more and more, and hopping up and down less to do the staining and coverslipping. That could mean more carpal tunnel syndrome. It could also make for a more boring job."

Dr. Floyd points to another interesting twist, noting that increasing reliance on automation diminishes histotechs’ ability to troubleshoot—at a time when they need it most.

Not that anyone is preaching Luddite values. In this day and age, automation is not optional.

But it is additive, as Steve A. McClain, MD, points out. "Now that we have MRI, did CT scanners go away? Did ultrasound go away?" says Dr. McClain, director of dermatopathology and director of pathology informatics at Albert Einstein College of Medicine at Montefiore Medical Center, Bronx, NY. The real issue, he says, is figuring out how to manage added complexity.

Yes, automation is helpful, he says, and standardization is important. Indeed, his lab is implementing a near fail-safe identification system using bar-code-labeled bottles and slides for acquisition of gross and
microscopic images.

But in other ways, he says, his laboratory has learned when to step back. "We found that automated stainers are not necessarily faster, nor do they stain more consistently, necessarily," he says. "We’ve found manual methods yield more precise H&E staining by adjusting or extending staining times to counterbalance stain depletion."

Just as important as linking machines to one another, he says, is learning how to link people to technology, and to each other. "We don’t ask our histotechs to push our current technology beyond its limits." Nor does he expect his pathologists to push histotechs beyond what is reasonable. "Yes, we expect histotechs to do their jobs well, and to work hard, and we want our slides to look perfect," he acknowledges. "But that obliges us, as pathologists, to treat them with respect, to listen to them, and to make adjustments when we’re wrong."

In his lab, special requests are kept to a minimum and batched whenever possible, and fixation is under the pathologist’s direct control. Consistently well-fixed tissues, he notes, make the work of histologic slide preparation far easier.

"Pathologists have to protect their histotechs," he says. "These employees are gold."

Karen Titus is CAP TODAY contributing editor and co-managing editor.