Stanley J. Robboy, MD
August 2013—Many people don’t know what we pathologists do. This is concerning, especially when some of the same people are responsible for determining levels and allocation of funding for graduate medical education, keeping our training programs open, or encouraging careers in pathology. I hope this column ignites a sense of urgency around funding for pathology training and recruiting a strong workforce, for without both our patients will suffer an indefensible loss.
Pathology has a relatively low profile, in part because there aren’t many of us—fewer than 18,000 at last count, in 2010, which is 5.7 pathologists per 100,000 population. We anticipate that number could drop precipitously in the next two decades, to 3.7 per 100,000, while the variety and complexity of pathology services continue to increase. It looks like we will need 14 percent more pathologists than we are projected to have in 2020—and far more will be needed than we expect to have in 2030.
Those data come to you courtesy of a just-completed comprehensive, evidence-based assessment conducted by our CAP Workforce Project Work Group and published in Archives of Pathology & Laboratory Medicine (www.archivesof pathology.org/doi/pdf/10.5858/arpa.2013-0200-OA). (The paper reports on supply-side findings; a series of papers on the projections of demand for pathologist services is in development.)
The workforce analysis project came about as we realized that medicine was changing and we needed a plan that anticipated training and workforce needs. To that end, we built an integrated modeling tool that enabled us to project the supply of pathologists through 2030—incorporating market conditions, population demographics, disease incidence, subspecialization, new technologies, and the role of informatics.
Pathology is one of the smaller specialties, and our demographic skews older than most. Only 21 percent of active pathologists are 35 to 44 years of age while 33 percent are ages 45 to 54 and 41 percent are 55 years or older. This is obviously upside down. If the pathologist population were in equilibrium, we would have more practitioners earlier in practice, but our numbers show the reverse. And the picture has been further complicated recently by trend lines reflecting later retirement and postponed entry to the workplace by graduates electing to take one or more fellowships.
Even without the demand-side analysis, we know the general population is aging, which will increase health care needs and costs. And we know that pathology is also moving into new areas, such as genomic medicine, bioinformatics, in vivo microscopy, biorepository management, and preventive health management. Each opportunity is welcome, but staffing could become a conundrum, because beginning in 2015 we expect to begin experiencing a net outflow of pathologists. The long-anticipated “retirement cliff” is about to begin, underscoring the importance of our training pipeline.
To put this in context, it is important to understand that federal Medicare funding for residency training in all specialties was capped in 1997, a persistent frustration made worse by new pressures to create more primary care training slots. No one doubts we need more primary care physicians; our challenge is explaining to policymakers that those primary care physicians, and the nurse practitioners who are taking on expanded roles, will very much need their pathologists.
Our relatively low profile makes it that much more important that each of us educate colleagues and legislators about pathology’s unique workforce needs. To that end, it is always helpful to have a “news hook”—something to get the conversation started. The recent Supreme Court decision on gene patents gives us that news hook, one indirectly tied to the pressures on our workforce pipeline.
On June 13, the U.S. Supreme Court announced its unanimous decision in Association for Molecular Pathology, et al v. Myriad Genetics. I like a 9–0 vote, especially when it favors our position, and the College was a co-plaintiff in the lawsuit. The justices invalidated many claims within the patents held by Myriad Genetics on the BRCA1 and BRCA2 genes and their naturally occurring mutations. The underlying principle the court cited—that human genes cannot be patented because they are products of nature—is fundamental to the important research that drives genomic medicine.
This Supreme Court decision has renewed excitement around the development of promising new genetic tests and companion diagnostics for targeted therapeutics. Media coverage of the court case drew attention to the importance of genetics and, by extension, pathologists, who manage clinical testing that enables diagnosis and enlightens treatment choices. As these new technologies emerge, we will need more pathologists who are trained in their use, but that training will not be funded if its value is not understood.
Genomic medicine, already moving from the research setting to clinical relevance, has the potential to become a cornerstone of medical testing, treatment, and clinical integration. Getting there will require an integrated understanding of genomic variants and sharing of data from many other sources, such as clinical labs, outcomes research, and population studies, which are expensive but extremely useful. This is why we continue to press for fair payment for not only well-established molecular services but also clinical tests using next-generation sequencing.
Three bills pending in Congress would expand funding for graduate medical education for demonstrated shortage specialties as well as primary care. Two bills are before the House: H.R. 1190, The Resident Physician Shortage Reduction Act of 2013, introduced by Rep. Joe Crowley (D-NY), and H.R. 1201, Training Tomorrow’s Doctors Today Act, introduced by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.). Senators Bill Nelson (D-Fla.) and Charles Schumer (D-NY) and senate majority leader Harry Reid (D-Nev.) have introduced similar legislation, S. 577, Resident Physician Shortage Reduction Act of 2013. Please contact your legislators and ask them to support these bills. Tell them that the federal Health Resources and Services Administration has designated pathology as a shortage specialty. Describe the impending retirement cliff in the context of exploding developments in promising technologies and the continuing need to meet our traditional responsibilities in service to all patients and medical specialties. Then ask them to support these bills.
Dr. Robboy welcomes communication from CAP members. Send your letters to him at president@cap.org.