http://www.ipetitions.com/petition/oversupply-of-pathologists-in-the-us
https://www.facebook.com/pages/Oversupply-of-Pathologists-in-the-US/1548366392082748
[email protected]
THE GLUT OF PATHOLOGISTS IN THE USA
A) WHO ARE WE:
We are a group of US anatomic and clinical Pathologists who are concerned about the surplus of qualified physicians in our field. This surfeit has existed for at least a quarter century and is becoming worse every year.
B) CAUSES OF THE SURPLUS:
1. Mergers and acquisitions have increased the workload per Pathologist and reduced the total number of Pathology positions needed in the US.
Ten to twenty years ago, the Pathologist, on average, signed out about 2,000 surgical cases per year. On many occasions, the companies which owned one hospital bought out several others nearby hospitals. Each time the company bought a hospital, it would merge half of their Pathologists into the existing group and lay off the other half. As a result, the workload for each remaining Pathologist increased exponentially with each new acquisition. Despite the undesirable work environment, there were no other positions available in the area because the parent company had purchased most or all of the other local hospitals. On average, the workload doubled (increased to about 4,000 surgical cases per Pathologist per year; not to mention the increasing number of cytology slides).
2. Due to reimbursement cuts and refusals for payment for Clinical Pathology services by insurance companies engaging in cost saving purpose, more and more hospital and Pathology groups are replacing board-certified, full-time clinical Pathologist with Ph. D. scientists and non-MD administrative and technical staff. The result is a dramatic reduction in the demand for professionally trained clinical Pathologists. However, clinical Pathology certificates account for at least half of the general certificates issued by the American Board of Pathology.
3. Recent predictions of the job market by the College of American Pathologists (CAP) are seriously distorted by indicating the normal retirement age of Pathologists as being 65 year of age. In truth, a far higher percentage of Pathologists over age 70 are remaining in their positions and not retiring. In many groups, it is not difficult to find Pathologists working well into their late 70s. This phenomenon further limits Pathology positions available to new graduates.
4. Even with all the above factors, the main reason for the glut of Pathologists is the fact that teaching hospitals keep cranking out large numbers of freshly minted Pathologists, regardless of the market needs. The number of residents in training for Pathology has remained the same over the years, even though the job market has deteriorated badly, while the institutions that train Pathologist continue to recruit students aggressively. Residency Program Directors should have been aware of this situation as far back as 1993, when the job market started shrinking. Yet, teaching hospitals continue to promote the vocation of Pathology despite the growing surfeit. Ironically, this condition benefits such teaching hospitals because when the new Pathology graduates cannot find positions in their chosen field, they are likely to continue working for the same institutions at relatively low wages during "fellowships".
Shortening residency programs from 5 to 4 years in the year 2006 also added stress on what was already a very tight job market. As a consequence of this change, the number of Pathology residency training graduates in the US doubled in 2010. Very few of them were able to find permanent formal jobs upon graduation. Instead, they had to remain on fellowships (two to three fellowships for many of them) while searching for jobs. All Pathologists in the field have experienced further deteriorating job market in terms of the number of available positions and starting salaries since 2010. The job market simply could not accommodate and digest this abrupt increase of new Pathologists.
So why, then, train people who may never find jobs?
Because of the high tuition revenues involved. Medicare provides Indirect Medical Education (IME) and Direct Medical Education (DME) reimbursements to hospitals that train residents, regardless of what the job market is. This is a considerable amount of money. Medicare subsidies for GME total about $10.1 billion annually, an average 112,642 per resident. Residents in Pathology also represent a very cheap, but highly skilled, labor group that is relatively inexpensive for what it does. The value of a ''total package'' (value of GME subsidies and value of services) for one resident calculates to about $150K per year if the resident also performs the full time duties of a Physician Assistant (PA), such as during rotations in Surgical Pathology. Rather than employ a PA, whose annual salary might average $100K, the hospital instead will require a resident to perform similar tasks for only $60K, saving the difference. Teaching hospitals are motivated to seek these government tuition payments while exploiting their residents. Our group, the working Pathologists, must use our clout and force such hospitals to cease claims of the existence of a shortage of Pathologists and assuring Pathology students there will be an abundance of open positions upon graduation.
Residents in Pathology are mainly assigned to doing surgical Pathology gross exams and autopsies. According to the Medicare Rules for Reimbursement, residents and fellows are not allowed to sign out cases. Another factor at play is that some hospitals have a hard time attracting Pathology assistants, morgue attendants, and other related positions. As a result, they use Pathology residents to do this level of work for a fraction of prevailing cost. Residency programs are intended for training, but in many instances, they are being used for manpower. As a result, there are far too many residents in training relative to the number of attending level positions available. New Pathologists graduating in the next five years are likely to have only a 50-50 chance of ever finding an attending level position in Pathology.
Another contributing factor is due the lack of uncompromising advocacy for individual pathologists (a guild). The CAP makes money through the sales of accreditation products and would love to see the glut worsen for the sake of their margins.
C) CONSEQUENCES OF OVERSUPPLY:
There are more residency programs and Pathologists in the market than are needed, and we can see the consequences of this glut in the following questions and answers:
1) Why can other physicians, but not Pathologists, direct bill? There are too many Pathologists competing for a limited number of specimens.
2) Why can hospitals relentlessly reduce compensation to Pathologists for Part A reimbursement? Because the hospitals can easily find cheaper alternatives to cover the service.
3) Why do commercial laboratories dominate the outpatient Anatomic Pathology specimen market? They can hire at a lower wage.
4) Why do many graduates do second and third fellowships? There are too few jobs for them.
5) Why is our locum tenens pay rate only half that of the Radiologists? More Pathologists than Radiologists are available for this type of work.
6) Why are Pathologists at the very bottom of the pecking order in most work settings? Because it is well-known that Pathologists can be easily replaced by more subservient job-seekers needing employment under any conditions.
7) Why do clinicians who open pod labs keep the entire technical component and more than ¾ of the professional component per slide? They can do this only because of the oversupply of Pathologists.
8) Why are Pathologists treated as servants by many of their colleague physicians, regardless of how good they are? Because there are so are many unemployed Pathologists waiting to replace them.
9) Why do administrators, even with no knowledge of medicine, usually side with clinicians? Because they know how easy it is to replace a Pathologist.
D) THE ROLE OF TEACHING HOSPITALS, COLLEGE OF AMERICAN PATHOLOGISTS (CAP) and its POLITICAL ACTION COMMITTEE (PATHPAC)
Decades ago, Political Action Committees representing dermatologists, ENT doctors, neurosurgeons and urologists protected their fellow practicing colleagues from oversupply by decreasing the number of training spots. Unfortunately, our “leaders” today are doing just the opposite: they are pulling the rug from under our feet by lobbying hard to increase the number of training spots. Pathologists in academia and CAP represent the interests of teaching hospitals and commercial laboratories, and not general Pathologists, by trying to increase the number of training spots as much as possible. Below are just a few examples (If link does not work, please go to the Facebook page and see the documents under the photos: https://www.facebook.com/pages/Oversupply-of-Pathologists-in-the-US/1548366392082748
1) Barbara J McKenna, MD, the past President of USCP, predicted in 2008 an impending perfect storm due to Pathology and laboratory workforce under-supply. Her predictions, as is true with all other predictions created by academia, never materialized:
http://s3.amazonaws.com/zanran_storage/www.pathology.ecu.edu/ContentPages/2486963008.pdf
2) Priscila Markwood, CAE, Executive Director of Association of Pathology Chairs and Director of Scientific Affairs at American Society for Investigative Pathology, wrote an impassioned letter to the Institute of Medicine / National Academy of Sciences, a think tank involved with the looming debate about the future of GME, asking them to add Pathology to the list of medical specialties in shortage:
http://www.cap.org/apps/docs/statline/gme_funding_coalition_letter_1220.pdf
3) Stanley Robboy, MD and other members of the Workforce Project Work Group very recently published a study in which they predict that Pathologist numbers will decline steadily beginning in 2015. Anticipated population growth in general and increases in disease incidence owing to the aging population would – according to their study - lead to a net deficit in excess of more than 5,700 Pathologists. According to them, in order to reach the projected number of Pathologists that will be needed, there would have to be an increase of approximately 8.1% more residency positions. Dr. Robboy and other members of the Group grimly warn that a Pathologist shortage would negatively impact both patient access to laboratory services and health care providers' abilities to deliver more effective health care to their patient populations. It should be noted that all members of the Group work in academia.
Abstract:
http://www.ncbi.nlm.nih.gov/pubmed/23738764
Entire article PDF:
http://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&ved=0CB4QFjAA&url=http%3A%2F%2Fwww.archivesofpathology.org%2Fdoi%2Fpdf%2F10.5858%2Farpa.2013-0200-OA&ei=sT7EVJHzE4KbNr-vg_AC&usg=AFQjCNGNim4zbc6l_u-zu260iXBlJIb9Rw&sig2=23GxLUzACXpGK4ZfuP5ewQ
4) The inter-society Council for Pathology Information is using the Dr. Robboy's study to lure more students into Pathology residency programs lying to them that “the job marked for Pathologists is EXCELLENT”, please see page 8:
http://www.ucdmc.ucdavis.edu/pathology/resource/PDF/ICPI_Why_Choose_Pathology_PPT_2013.pdf
5) The 2013 Pathology Workforce Summit, sponsored by ASCP, the College of American Pathologists (CAP), the Association of Pathology Chairs (APC), and the United States & Canada Academy of Pathology (USCAP), convened to consider how the profession will adjust to an unprecedented demand for services claiming that “the present number of training positions is insufficient to maintain the present ratio of practitioners to population” (please see propositions 1 and 3 on pages 2 and 3):
http://www.cap.org/apps/docs/statline/pdf/pathology_workforce_summit_propositions.pdf
6) PATHPAC (Political action committee of College of American Pathologists) has been actively lobbying for the increase of Pathology PGY1 positions for years. According to CAP: “The increased funding for GME has been more of a rhetorical priority for members of Congress than real issue; GME is expensive and it’s not yet become a priority for most members. Additionally, not all residency slots have been used, which makes arguing for an increase more challenging. Nevertheless, PATHPAC will continue to pursue an increase in Pathology residency slots”.
http://www.cap.org/apps/docs/advocacy/advocacy_issues/gme.pdf
7) Donald Karcher, MD, FCAP, Chair of Pathology at George Washington University and President-Elect of the Association of Pathology Chairs (APC) spoke on behalf of the CAP and the Association of Pathology Chairs (APC) on September 9 to the members of the federal Council on Graduate Medical Education (COGME) and told us that “The country faces a significant shortage of Pathologists in the near future at a time when Pathologists will play essential roles in new care delivery paradigms”. He is also coauthor of another paper showing shortage of Pathologists in the US which will be coming out in Archives later this year.
http://www.cap.org/apps//cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=statline%2Fstat091213.html&_state=maximized&_pageLabel=cntvwr#Story3
8) Stephen Black-Schaffer, MD, FCAP, told us during the 2013 CAP Policy Meeting that there is an imminent Pathologist shortage which will cause potentially disruptive changes in the current patterns of practice unless we increase the number of Pathologist in training. He revealed that CAP is fighting for increased GME funding that would allow full funding of all Pathology residency positions. Please see pages 10, 18-20:
http://www.cap.org/apps/docs/advocacy/policy_meeting/gme_3.pdf
E) OUR MISSION:
Our mission is to use our influence in this democratic society to bring to light the current, and growing, surfeit of professional Pathologists to maintain the integrity of the profession, its training institutions and ultimately, benefit the patient population. What can we do?
1) The most important action is to sign the petition. We will be mailing the petition to appropriate organizations and persons at an appropriate time.
http://www.ipetitions.com/petition/oversupply-of-pathologists-in-the-us
2) Send your own personalized message to the email addresses listed in 2a. If you do not have time to write your own message, you can use the text of our petition listed in 2b. Names of institutions and names of individuals corresponding to emails as they appear in 2a are listed in section 2c:
3) Contact Medicare Commission members. They should be aware that their money is being used to increase available manpower in the field of Pathology where there is already a surplus instead of supporting education involving specialties in demand and where there are legitimate shortages.
http://medicare.commission.gov/medicare/members.html
4) If this is not effective, we should consider hiring our own lobbyist. We have more funds than - and are greater in number than - our colleagues in academia. If we act together and unite, we will certainly win this fight, as did our colleagues in other clinical fields such as ENT, dermatology urology and others.
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2a. Emails:
[email protected], [email protected], [email protected], [email protected],
S[email protected], [email protected], [email protected], [email protected],
mesobel@tmo.blackberry.net, [email protected], [email protected]
[email protected], [email protected]
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2 b. Text of petition:
I am an Anatomical / Clinical Pathologist (resident or fellow) from the USA and I am concerned about the severe oversupply of Pathologists in our country. The glut is a consequence of mergers and acquisitions, the relegating of administrative and clinical Pathology duties to a non-MD staff, the trend of older Pathologists to remain on the job and retire at later ages, and most of all, the overproduction of new Pathologists by teaching hospitals that keep cranking out large numbers of freshly-minted Pathologists, regardless of the market needs. We understand that teaching hospitals need federal funds; however, these should not be obtained by training physicians for positions that do not exist.
We respectfully demand that the training of new Pathologists be cut by at least one-half. The foreseeable future will not require more than 300 new Pathologists per year. This means that no more than 300 PGY1 positions should be allocated to Pathology residencies. The remaining 300 PGY1 positions currently reserved for Pathologists should be given to specialties where a shortage actually does exist and is not made up for the purpose of obtaining Medicare funds and cheap labor of residents.
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2 c: Institutions and Individuals: (feel free to copy and paste email test as linked in item 2a above):
PATHPAC, (Political Action Committee of College of American Pathologists):
Email addresses: pathpac@cap.org, [email protected], [email protected].
Institute of Medicine / National Academy of Sciences. Emails:
Donald M. Berwick, M.D., Co-Chair and Gail R. Wilensky, Ph.D., Co-Chair: [email protected]
Deborah E. Powell, M.D., IOM Committee Member: [email protected]
Chelsea Frakes, IOM Committee Staff: [email protected]
American Society for Investigative Pathology (ASIP):
Mark E Sobel: [email protected], [email protected]
Tel: 240-643-7103(cell), 301-634-7130 (office)
Association of Pathology Chairs (APCPRODS)
Priscila Markwood: [email protected]
Tel: 301-634-7408
The Intersociety Council for Pathology Information, Inc(ICPI)
Email: [email protected], [email protected]
Tel: 240-643-7103(cell), 301-634-7130 (office)
Dr Stanley Robboy. Email: [email protected], tel (919) 684-3656 (office)
Dr Donald Karcher, President, Association of Pathology Chairs, email: [email protected], tel: 202-715-4665 (office)
Dr Stephen Black-Schaffer, MD, FCAP, emails: [email protected], [email protected]
F) COMMENTS:
WHY ARE STUDIES PREDICTING A PATHOLOGIST SHORTAGE WRONG?
We have been reading and listening to glowing reports about the wonderful job prospects for those in the profession of Pathology for decades; yet, such predictions never materialized. Why?
1) All such studies are self-serving since they were all conducted by academia and not by community hospitals. Pathologists in academia have plenty of time to compose what is to their advantage. They have vested interests in training as many future Pathologists as ACGME would allow them due to money subsidies and cheap labor that residents represent.
2) These studies do not take into account new trends in the job market that differ significantly from the past. For example, Pathologists of today are much more efficient than Pathologists of yesterday. Due to increased pressure, Pathologists of today are in most cases signing out twice as many cases they were only a decade or two ago.
Dr. Robboy says in his article on page 1724 (Model of Supply Analysis Chosen): “their model estimates future work supply from analysis of relationships between historical supply….. and assumes that the future algebratic impact of these factors would not differ from that of the past”. This is wrong, because, as stated previously, Pathologists of today sign out many more cases than in the past. Dr. Robby also blames delayed workforce entry on required additional fellowship training and that such extra training delays new Pathologists from entering the job market, resulting in fewer practicing Pathologists. Yet, this circumstance, rather reflecting a shortage, is in fact a manifestation of oversupply since most residents choose one, two or more fellowships only because they cannot find positions in the tight market and therefore elect to continue their education.
In addition, Dr. Robboy mentions a 9% drop-out from fellowship training across the 4- year training period. He credits the high drop-out rates as being due to dismissal, withdrawal etc. but he neglects to mention that most of residents who drop out do so because during training, they realize that the jobs are not out there waiting for them.
3) Many studies claim that aging baby boomers potentially represent a goldmine for Pathologists. Such studies ignore the interplay of technology. Thyroid nodules, for example, only get a fine needle aspiration (FNA) biopsy, and not a lobectomy. Pancreatic masses also get an FNA and if cancer is present, they are followed only by a surgical bypass, not a major surgery. Today, gastrectomies are not performed for ulcer disease, since we treat Helicobacter with antibiotics. There are also very few autopsies, since doctors have concerns about being sued. The specialty is changing: MR and CT scans decrease the need for exploratory laparotomies. Hysteroscopy, colposcopy, laparoscopy, arthroscopy, cauterization of clinically unsuspected skin tags, and many other procedures often no longer generate tissue for histologic examination, but often only carbonized or vaporized tissue. The same is also true for alternative therapies of benign prostatic hyperplasia, where lasers, cryosurgery, balloon dilatation, stents and microwave therapy may not provide tissue.
4) Many studies assume that the Pathologist will retire when qualifying for Social Security. This has never been the case; Pathologists can, and will, work well into their mid- and late-seventies, or even into their eighties, holding onto positions in a market with decreasing openings.
5) Studies ignore the influence of Digital Pathology which is poised to explode over the next seven to eight years. This will happen as medical laboratories acquire and deploy Digital Pathology systems to improve their connectivity with other providers, further improve productivity of Pathologists, and as a tool to reduce costs. Increased productivity due to widespread usage of Digital Pathology will further decrease the need for Pathologists.
http://www.darkdaily.com/financial-experts-predict-sales-of-digital-pathology-systems-will-nearly-triple-in-the-united-states-by-2019#axzz3Q2wKhu4u
THE ROLE OF ACCREDITATION COUNSEL FOR GRADUATE MEDICAL EDUCATION (ACGME):
ACGME accredits Pathologist training programs. However, accreditation status depends only on available resources (number of specimens, number of teaching Pathologists) and not on market needs. In theory, the number of PGY1 spots for Pathology could quadruple and still be approved by ACGME so long as funding and resources, but not jobs, were available.
THE ROLE OF MEDICARE AND CONGRESS:
Congress does not designate slots for Pathology. This is so for a number of reasons. First, Congress does not have the expertise to assess hospital needs. Second, this practice would pit specialties against each other, given that some specialties are facing a shortage. At present, the only actions that would help decrease training in Pathology would be to decrease all training spots for GME. In the end, it is up to hospitals to allot funds to different specialties.
THE ROLE OF THE NEW LEGISLATION:
Teaching hospitals strive from year to year to have members of Congress address the national physician shortage. The obstacles the hospitals face are shortage of funds and the claim, by some, that there is not a severe shortage of physicians. We expect that the new GME bill will be introduced in 2015 and will result in an increase of GME funding for all specialties in 2016.
Our “leaders” in academic Pathology are, however, not content with just a general increase of GME posts, which would increase the number of training spots in Pathology simply due to trickle-down effect. They went a step further, added Pathology to the list of specialties in short supply and will push for additional slots under the new legislation (see Section D2 and THE ROLE OF THE NEW LEGISLATION at the end). The determination of exactly which specialties are in short supply will likely be made by the Institute of Medicine or some other governmental body. PATHPAC and other organizations lobbying for the benefit of academic Pathology departments are using the current study of Dr. Robboy and the soon-to-be published study of Dr. Karcher to persuade the key players that there is in fact a “shortage” of Pathologists (which exists only in their wishful imagination).
Latest update:
- No GME bill was passed during the last Congressional Session (the113th). GME bills had been, however, already introduced by lobbyist of CAP to the below committees, but were not yet scheduled to appear on the floor. Typically, a bill is considered first by the subcommittee and later submitted for full committee consideration. In the House, the committees dealing with new GME bills are the Ways and Means and the Energy and Commerce Committees; in the Senate, the Finance Committee is reviewing the GME bills.
http://waysandmeans.house.gov/subcommittee/health/
http://waysandmeans.house.gov/subcommittee/full-committee/
http://energycommerce.house.gov/subcommittees/health#members
http://energycommerce.house.gov/about/membership
http://www.finance.senate.gov/about/membership/
2. Bills to increase slots for primary care and shortage specialties were reintroduced to the current, 114th Congress Session (January 3, 2015 to January 3, 2017).
3. Pathology continues to be included in the bills with the contention that there is a shortage of trained Pathologists and with references to Pathology as being a "shortage specialty", based upon the HRSA's 2008 workforce report.
4. Initially, three GME bills were introduced, championed by Representatives Schock & Schwartz; Nelson, Schumer & Reid; and Crowley & Grimm. All three bills propose adding 15,000 new residency positions, of which at least one third to one half will be reserved for shortage specialties, such as Pathology. Please see a side by side comparison graph below:
http://www.oakland.edu/upload/docs/Government%20Relations/Web%20Site/AAMC%20grr/4-24-13%20GME%20Side-By-Side%20for%20GRRs.pd
- The Resident Physician Shortage Reduction Act of 2015 (H.R. 2124)
- https://www.aamc.org/download/431122/data/theresidentphysicianshortagereductionactof2015.pdf
- https://www.congress.gov/bill/114th-congress/house-bill/2124
- The Resident Physician Shortage Reduction Act of 2015 (S. 1148)
- https://www.aamc.org/download/431126/data/theresidentphysicianshortagereductionactof2015s.1148.pdf
- https://www.congress.gov/bill/114th-congress/senate-bill/1148/related-bills
- 5. Not everyone at CAP is sold on illusion of a Pathology shortage; however, CAP officially decided to lobby for the increase in GME pathology positions after Robboy’s study came out.
6. Practicing Pathologists can, in addition to signing a petition, signup for AAMC’s action alerts. Another action that would be effective is to organize the physicians in their state or district around this issue, schedule meetings with their Congressional delegations and then ask them to send letters to the various Committee chairs requesting them to hold a mark-up of the bills.
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