What is Going On in Pathology?

As a second-year medical student, the chairman of pathology at my medical school came to lecture us on inflammation and repair. Among the first chapters in the hallowed Robbins textbook of pathology (which he contributed to both from his published research and direct writing of chapters). He was the MD PhD research pathologist who was tasked with maintaining academic activities, getting research funding, top researchers and the like while making sure there were enough others wearing blue scrubs to do the daily work of grossing, signing out, autopsies, FNAs and writing and signing SOPs. I hadn’t considered pathology up to this point as a career. This seemed to be wise as the chairman of pathology introduced himself saying “The hospital is the temple, and the pathologist is the priest” and going on to say, “Pathology is a lot of fun, the most interesting cases end up under the microscope, you can make a good living, but don’t go into it, there aren’t any jobs.”

These statements were wrong on two levels. First, watch what happens when a hospital system loses a surgery group or anesthesia group and/or interventional cardiologists and see who the proverbial priests are in the proverbial temple and who contributes the most to the proverbial basket or hat going around. Secondly, by the time I finished medical school, internship, residency, fellowship and military pay back, there were plenty of jobs. Where I wanted to live. Ok, maybe not plenty, but enough.

Since then, in practice, there has seemed to be a constant flow of folks who retire and are quickly replaced by another recent graduate or someone who has “been out a few years”. Finding qualified applicants who fit into the group wasn’t really a mystery. Most of the time the process worked. Medical schools, residencies and fellowships did their jobs, the candidates were willing to work and became trusted colleagues.

I recently heard from a recent pathology resident applicant that there are 3,000 applicants for 700 spots. I really don’t know if either number is true. The 700 spots seems to be in the ballpark from what I remember going through the books in the mid-90s. Seems like a lot of applicants for the number of medical schools and students considering there were usually 1-2% or less of us going into pathology (there were 3 of us out of a class of 180; all three practice today in some capacity). Anesthesia had even fewer. They were probably told there were no jobs as well. Apparently, as I was told, the 3,000 are looking at lifestyle, not internal medicine, family practice or surgery!

As studies by the College of American Pathologists suggested in 2012, we would have a shortage of pathologists by 2020. They nailed it. And the public health crisis aggravated it. Some passed away, some left and never came back, some have opted for part-time or remote only. And the scheduled retirements. They are not sitting in the room adjacent to the OR any longer getting tissue passed through the window for frozen sections. They are not covering tumor boards, call or daily sign out. Autopsies are nearly non-existent in most community hospitals.

As there were “no jobs”, pathology residencies went unfilled. Often times folks who trained overseas that were termed “foreign medical graduates” or “FMGs” filled those spots and practiced in the US. Changes in educational and work visas have really apparently changed this dynamic.

Automated pre-screening of pap smears, molecular techniques, next-generation sequencing, digital pathology and now artificial intelligence were all going to replace us.

Now the hope is that it will enable us to be more efficient. Practice more “seamlessly”, and be “more productive”, perhaps 20% “more efficient” or “more productive”. The hope is that the 20% gain will make up for the 20% in not having another guy or gal with their own stack of cardboard trays full of slides.

I do not see it happening having practiced for the past 18 months with digital pathology, voice recognition, some IA and AI. It is more clicks and steps than ever before.

Hopefully these 700 residents a year will fill the voids across the country, in small towns and large cities. Just look at the number of jobs today.

Welcome to Pathology! It is a lot of fun, the most interesting cases end up under the microscope, you can make a good living and there are plenty of jobs! With a lot of clicks!