AMERICAN MEDICINE AND PATHOLOGY: PAST, PRESENT AND FUTURE. VCUHS Grand Rounds Presentation by Dr. Fred G. Silva September 17, 2004
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1 AMERICAN MEDICINE AND PATHOLOGY: PAST, PRESENT AND FUTURE VCUHS Grand Rounds Presentation by Dr. Fred G. Silva September 17, 2004
2 Medical Schools: Goals, Applications, Curriculum
3 GOALS OF PROGRESSIVE MEDICAL EDUCATION (U.S. MEDICAL SCHOOLS-LAST 100 YEARS) 1) Active participation 2) Problem-solving 3) Self-learning 4) Critical thinking
4 U.S.A. MEDCAL SCHOOLS: IMPORTANCE TO MEDICAL PRACTICE 1) Education of Nation s physicians/medical researchers (Teaching) 2) Generation of new medical knowledge (Research) 3) Introduction and evaluation of innovative Clinical Practices 4) Provision of the most sophisticated medical care (Specialized Patient care such as AIDS, burns, extensive trauma, difficult cases, etc.) 5) Care of poor/uninsured persons (6% of hospital beds vs. 50% of the indigent care)
5 MEDICAL SCHOOL TUITION Steadily rising: Private schools: : median tuition $18, : median tuition $32,107 In-state residents/public schools: : $6, : $12,411 (103% increase)
6 MEDICAL STUDENT DEBT (2003) Average Debt Burden: faster than inflation for over 20 years $104,000 for the 81% of 2003 graduates who carried debt AAMC: Suggests costs $40,000- $50,000/student/year to train
7 National Resident Matching: Residencies in Medicine Overall and Pathology
8 US MEDICAL SCHOOL GRADUATES The number of students graduating with MD degrees in US remained fairly steady for 20 years In 2002, 15,640 students graduate with the 124 accredited MD-granting medical schools (cf. 15,985 graduates from 123 schools in 1982) In recent years, number of DO graduates risen (from 1532 in 1992 to 2534 in 2002; number of schools increased from 15 to 20)
9 NATIONAL RESIDENT MATCHING PROGRAM ,192 FIRST-YEAR RESIDENCY POSITIONS OFFERED IN MATCH 19,392 (91.5%) MATCHED TO FIRST YEAR POSITION 477 positions offered in Pathology 438 positions in Pathology filled: 292 USMG (67% in Path cf. 70% Overall) An 8% overall increase in Pathology from last year (5%, 8%, 20%, yrs before)
10 Number and Percentage of Programs in Pathology by Year
11 Changes in Pathology Programs and Program Directorships, 1994 Through 2000 No. of Program AP/CP No. of Program Subspecialty AP/CP Director % Specialty Director % Year Programs Changes Changed Programs Changes Changed % % % % % % % % % % % % % %
12 The Academic Pathology Faculty in U.S. Medical Schools
13 U.S. ACADEMIC PATHOLOGY: U.S. MEDICAL SCHOOL FACULTY (2000) Approximately 4900 pathology faculty (or 18% of all Pathologists) (5% of all faculty) 28% Female: About 56% MDs (clinical) About 30% PhDs (research; clinical pathology labs) About 12% MD/PhD
14 THE AVERAGE PATHOLOGY DEPARTMENT (PDAS: 2003 Survey: Sandi Jaros: 50 Depts Responding) Hybrid of Basic Science and Clinical Departments 48 Faculty: 34 MD or MD/PhD 14 PhD Faculty Efforts: 34% Clinical Service 26% Research 19% Teaching 12% Administration
15 House Staff: 18 Residents 8 Postdoctoral Fellows 10 Graduate Students Workload/Year: 31,336 Surgicals 3400 Pap Smears 1.85 million Clinical Lab tests Teaching Hospital: 560 beds
16 The Present Practice of Pathology in the United States
17 CAP 2002 SURVEY 94% OF SURVEY RESPONDENTS PRACTICE PATHOLOGY FULL TIME: 63% Pathology Group 13% University Medical School 12% Hospital employee 11% Independent Lab 7% Multispecialty Group
18 Richard Horowitz Study % Pathologists in Community Hospital Practice 54% Pathology Group (32% in groups of nine or more pathologists) 10% Hospital Employee 6% Multi-Specialty Group 5% Solo Practitioner 11% University Medical School 9% Independent Laboratory 5% Other (BB, Coroner, other)
19 CAP 2002 SURVEY 24.6 hrs/week (51%): Surgical pathology 81%: more than a quarter of time in SP: Trend: spending more time in SP 7.8 hrs/week (16%): Clinical pathology for which no separate bills issued: Trend: spending less time 5.7 hrs/week (12%): Cytopathology (9% spend more than 1/4 th time; 14 th do not do cytopathology) Autopsies: Amount of time spent not change since 1996: but more pathologists report they are not performing autopsy (64% vs. 57%)
20 DR. HOROWITZ S STUDY: PRACTICE CHARACTERISTICS Median Time Worked: 48 hours Surgical Pathology: 25 hours (52%) Cytology: 6 hours (12.5%) Management: 7.5 hours (15.6%) CP Consultation: 2.5 hours (5.2%) Others (autopsy, teaching, research, misc.)
21 SPECIALIZATION SOUGHT BY PATHOLOGY GROUPS (New Pathologists hired by 481 Groups between ) 62% Wanted Sub-Specialty Training 38% Did not Subspecialties desired: Cytopathology Dermatopathology Hematopathology Horowitz 03
22 CRITERIA FOR HIRING A COMMUNITY PATHOLOGIST RICHARD E. HOROWITZ, MD CLINICAL PROFESSOR OF PATHOLOGY UCLA and USC SCHOOLS OF MEDICINE ADASP MEETING, WASHINGTON, DC MARCH 22, 2003
23 BASIC SKILLS NEEDED IN A NEW PATHOLOGIST ESSENTIAL USEFUL NOT IMPT SURGICAL PATHOLOGY DX 100 FROZEN SECTION DX 93 GROSS DISSECT / DESCRIPT 85 NON-GYN CYTOLOGY 83 AUTOPSY PATHOLOGY 70 GYN CYTOLOGY 68 FNA 61
24 OTHER SKILLS NEEDED IN A NEW PATHOLOGIST ESSENTIAL USEFUL NOT IMPT IMMUNOCYTOCHEMISTRY 81 FLOW CYTOMETRY 26 MOLECULAR PATHOLOGY 23 PCR 19 GENETICS 14 ELECTRON MICROSCOPY 4 CLINICAL RESEARCH 23 SCIENTIFIC PUBLICATIONS 16 BASIC RESEARCH 8
25 AP SKILLS NEEDED IN A NEW PATHOLOGIST ESSENTIAL USEFUL NOT IMPT DERMATOPATHOLOGY 53 CYTOPATHOLOGY 49 NEUROPATHOLOGY 28 PEDIATRIC PATHOLOGY 23 FORENSIC PATHOLOGY 3
26 SURVEY OF PATHOLOGY: WHAT PATHOLOGISTS THINK Most Positive Aspects (1) Hours worked (18%) (2) Intellectual challenge something new to learn (14%) (3) Broad scope of knowledge used (12%) Other (4) Very controlled work conditions
27 SURVEY OF PATHOLOGISTS Least appealing aspects (1) Hospital bureaucracy + paperwork (15%) (2) Stress level in the group that impacts one s routine (14%) (3) Assumption that all pathologists lack direct patient contact Also concern regarding hospital mergers and what it means to pathologists
28 PATHOLOGY SURVEY: SCALE OF 1-10 (BEST) Innovative Thinking Diversity Pressure Security Income Manual & Mechanical Activities Continuity of Care
29 DEFINITIONS OF A PATHOLOGIST 1.) In the Literature: Different definitions 2.) Functional: A Pathologist is what a Pathologist does 3.) Inclusive: Someone being paid by the Department of Pathology 4.) Inclusive: PhD s in the Clinical Labs? 5.) Exclusive: Service-oriented Pathologist (AP and/or CP) 6.) More Important Things to Worry About!!! Keeping the Clinical and the Research/Academic Enterprises Together (Ramzi Cotran) Balancing the Books Doing well all the things we re asked to do
30 TOP TEN MEDICAL SCHOOLS PRODUCING MEDICAL STUDENTS ENTERING PATHOLOGY RESIDENCY PROGRAMS University Number of Students Average/Year Medical University of South Carolina University of Minnesota University of Texas HSC San Antonio University of Iowa University of Chicago Wayne State University University of Texas - Houston Louisiana Sate University New Orleans Indiana University School of Medicine Thomas Jefferson University
31 SCHOOL OF ORIGIN FOR USMG S WHO WERE APB CERTIFIED FROM (Courtesy of the American Board of Pathology Research Foundation) Indiana University 184 University of Minnesota 160 University of Michigan 151 MUSC/Charleston 143 University of Texas/SA 133 Washington Univ. 133 University of Illinois 131 University of Iowa 130 LSU 118 Wayne State Univ. 118 University of Tennessee 117
32 University of Nebraska 107 UTSW/Dallas 107 Thomas Jefferson 107 Loma Linda Univ. 104 Tulane Univ. 104 Duke Univ. 103 Vanderbilt 100 MCG/Augusta 99 Ohio State 97 University of Kansas 96 University of Louisville 95 Case Western Reserve 93 University of Colorado 93 University of Miami 92
33 METHODS TO RECRUITING MEDICAL STUDENTS INTO PATHOLOGY 1) Individuals (effort; early exposure) A. Charismatic characters/find the best students B. Show them what we do C. Exposure throughout four years/nite reviews D. Students always watching you/role models/ be positive
34 2) Programs: A. Early exposure: get the message outthere are jobs B. Jobs for students: 1.) Summer fellowships 2.) Postsophomore fellowships 3.) Autopsy/forensic call C. Exposure to pathology house staff/labs/ CPC s D. MD/PhD programs E. Honor great teaching faculty F. Mini-medical schools
35 3) National: A. ASCP awards B. Honorary societies (Virchow; APC) C. Resident fairs 4) Let them know there is a future for them: A. Good job market B. Proud of discipline C. Aggressive in placing house staff into jobs
36 ACKNOWLEDGEMENTS C. Bruce Alexander/Margaret Grimes (PRODS) William Hartmann/Betsy Bennett (ABP) Kenneth Sims (Nebraska; Utah) William Bradford (Duke) Donald West King/Bill Gardner (ARP/AFIP) Liz Lostumbo (NRMP/AAMC) Jerry Garvin et al. (APC) John Holliman (GRIPE) Steve Nestler (RRC) Randy Hennigar (MUSC) Sharon Weiss (Emory) Jane Upshur (MUSC) Richard Horowitz (California)
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