Pathology practice: a moving target
Donald S. Karcher, MD
January 2025—If a much younger version of me could time-travel from the 1980s to today, that young man with his full head of hair would be hard-pressed to recognize modern pathology practice. Forty years ago, I was the junior member in a private practice group in New Orleans. There were five of us in the group, covering three hospitals, with four of us based at the largest facility and one pathologist at the second hospital. And one of us would occasionally travel to the third facility, a 60-bed small-town hospital about 80 miles away, to do prescheduled frozen sections. (Can you guess who got that responsibility? I became very familiar with long-distance driving at 6:00 AM.)
While it was a bit unusual at the time for a single practice to span three hospitals, by most measures our group was very characteristic of how pathology was practiced back then. Small groups of pathologists worked together, usually in one hospital, in a practice they owned. Staffing was loosely based on a calculation of one pathologist for every hundred beds, and every pathologist in the group would cover both anatomic and clinical pathology.
It’s amazing how much pathology practice has changed since then. The CAP has been charting those changes for many years with its annual member surveys, keeping tabs on the evolution of how we practice—and how that affects our ability to provide excellent care for our patients.
We have seen several themes in the evolution of pathology practice, and I imagine they will resonate with many of you. The most common is the ever-increasing size of our practice groups and the patient populations we serve. Gone are the days when a four- or five-person group was the norm; today, there might be 10 or 20 or more pathologists in a standard practice. CAP Practice Characteristics Surveys over the past decade and a half have shown a steady increase in the average size of practices. The fastest-growing practice size during this period has been practices with more than 25 pathologists, increasing from 13 percent to 26 percent of pathologists practicing in groups of this size. There can definitely be advantages to these larger teams. For example, when groups reach a certain critical mass, it opens up the opportunity for pathologists to focus on their subspecialty rather than serve as generalists.
These larger pathology groups often serve entire hospital networks, with responsibility for many different health care facilities in a broad geographic region. The ongoing consolidation of hospitals into hospital systems has accelerated this trend. Larger hospital networks are increasingly centralizing many laboratory services, including histology services. In this scenario, anatomic pathology specimens and microscopic slides are often moved by courier, although a number of practices are turning to digitizing slides, making remote sign-out of cases within the network easier, faster, and more efficient.
The way we work has changed—and will no doubt continue to change—and the way we’re connected to our practices has changed too. While it used to be common to have pathologist-owned practices, pathologists are increasingly likely to be employees of the health system rather than part of an independent practice contracted by the hospital or system. Over the past five years, CAP surveys have shown a dramatic increase in employed pathologists, from 11 percent to 35 percent in private community hospitals and up to 60 percent in community hospitals affiliated with academic medical centers. The shift from owner to employee often feels inevitable, especially for pathologists serving in large hospital networks.
Another theme is contributing to the move to employee status, and that is the dramatically increasing presence of for-profit entities owned by private equity. Private equity ownership has been spreading to many physician practices—we see it in dermatology, ophthalmology, emergency medicine, anesthesiology, oncology, and many other specialty areas—and pathology has certainly been no exception. A growing number of pathology groups have chosen to sell their practices to private equity-backed firms, often receiving a nice one-time payday for group partners plus a contract to continue working as employees.
If you practice with a group that’s considering this kind of private equity buyout, or you’re considering an employment opportunity in such a group, it’s worth looking into how much independence you’ll have in decision-making, how hospitals served by the group will be staffed with pathologists from your practice, and other important practice-related factors. There are clearly pros and cons to private equity ownership, and either way it’s important to enter an agreement with eyes wide open.
One thing is certain about the way we practice pathology: It will definitely continue to evolve. As always, the CAP will monitor trends closely and advocate for what’s best for pathologists and our patients.
Dr. Karcher welcomes communication from CAP members. Write to him at president@cap.org.