2013 Pathology Workforce Summit Propositions on Workforce Issues Affecting Pathology and Laboratory Medicine Context The future of the pathology and laboratory medicine workforce is uncertain, with substantial projected changes in the numbers of its various component members over the coming several decades. Advances in science continue to dramatically affect the practice of medicine and patient care. Likewise, innovative technologies are changing the practice of laboratory medicine, and in turn, the educational requirements and qualifications needed to provide quality-testing services. Increasing volume of clinical testing and a growing menu of available clinical tests, often using new testing platforms, have the potential to influence not only the numbers and types of pathologists and laboratory professionals needed, but also their knowledge base and skill set. As we look to the future, we believe that action is needed now if pathology and laboratory services are able to meet the needs of the American health care system in future decades. The following statements (i.e. draft propositions and proposed recommendations) illustrate many of the workforce issues facing pathology and laboratory medicine. These statements will guide our discussions at the December 3 rd Pathology Workforce Summit, and presumably serve as the foundation for action steps coming out of the Summit. For purposes of this document, we defined the following terms as follows: Pathology The study of the nature and processes of diseases, the structural and functional changes produced by them, and the anatomic and physiological deviations from the norm that constitute disease or characterize a particular disease. The tools of Pathology have evolved significantly over the last century. General pathology is still determined by observing whole organs or organisms, or by viewing tissue specimens, such as tumors, on microscopic slides. Frequently today, deeper pathology is determined through cellular and molecular analysis or is inferred through biochemical testing. Increasingly, pathology is employing highly-specialized electronic tools, such as informatics, in vivo microscopy, and digital analysis across large data sets of genetic information and tissue bio-repositories. When laboratory equipment is employed to discover disease pathology or cause of death, this set of services is commonly referred to as Laboratory Medicine. Pathology also includes the research of disease pathogenesis, leading to an understanding of disease processes and potentially new diagnostic tools, therapies or cures. Pathologist The physician trained to perform, authorize or oversee medical services covered under the medical specialty of Pathology (as outlined above) or to conduct research in disease pathogenesis. The Pathologist also serves as a clinical consultant to other physicians, who need more specific information or disease description to determine next steps in patient therapy or treatment. Laboratory Medicine, Laboratory Medical Services or Laboratory Services These terms are used interchangeably to mean the set of services offered under the medical specialty of Pathology that are conducted in a laboratory. Nearly all services provided 1
in Pathology fit this description, which leads to commonly referencing Pathology as Pathology and Laboratory Medicine. Pathology and Laboratory Medicine As explained above, a common description of the services performed under the medical specialty of Pathology is Laboratory Medicine or Laboratory Services. Therefore, Pathology is commonly referred to as Pathology and Laboratory Medicine. Laboratory Professional This term generally includes non-physician individuals whose skill set is the result of specific training and certification. It refers to highly-specialized PhD scientists, pathologist assistants and medical laboratory scientists, technologists and technicians. Laboratory Workforce The fulfillment of pathology-related services, including research in pathogenesis, requires a talented team, with skills ranging from laboratory support staff and non-certified technicians to Laboratory Professionals and Pathologists. The full spectrum of team members is referred to as the Laboratory Workforce. Anatomic Pathology The medical specialty that is obtained by a Pathologist, who concentrates in the diagnosis of disease based on the gross, microscopic, chemical, immunologic and molecular examination of organs, tissues, and whole bodies (autopsy). Primary subspecialties of these Pathologists include: forensic pathology, cytopathology, dermatopathology, and surgical pathology. Clinical Pathology The medical specialty that is obtained by a Pathologist, who concentrates in the diagnosis of disease based on the laboratory analysis of tissues and bodily fluids, such as blood and urine, using the tools of chemical pathology, blood banking/transfusion medicine, medical microbiology, hematology and molecular genetic pathology. Proposition 1: The supply of pathologists and laboratory professionals will decrease substantially over the next 20 years According to recent projections published in the Archives of Pathology and Laboratory Medicine, the supply of active pathologists in the United States is projected to fall from about 17,600 full-time equivalents (FTEs) in 2010 to about 14,000 FTEs in 2030. The reason for this projected decrease is simple: the number of pathologists expected to enter the profession for most of these years are far fewer than those expected to leave the profession. Currently, pathology residency programs are expected to graduate fewer than 600 new pathologists each year between now and 2030, assuming neither cuts nor increases in resources for graduate pathology training. At the same time, a substantial number of currently practicing FTE pathologists are expected to leave the workforce between now and 2030 about 500 per year by 2015, 1,000 per year by the end of the decade, and 700-1,000 per year for most of the subsequent decade. This trend reflects a workforce that is the second oldest among medical specialties: about 75 percent were age 45+ in 2010, of whom over half were age 55+. The cumulative effect of these trends is an expected drop in supply of about 3,600 FTEs compared to the current workforce. The U.S. Bureau of Labor Statistics (BLS) maintains data for only two categories of laboratory professionals: medical/clinical laboratory scientists and medical/clinical laboratory technicians. According to the most current BLS report, in 2010 330,600 clinical laboratory technologists and technicians were employed. Using estimates of future size and composition of the labor force, aggregate economic growth, detailed estimates of industry productivity, and industry and occupational employment, BLS reports that employment of medical laboratory technologists and technicians is expected to grow by 13 percent between 2010 and 2020 to 373,500, adding an average of approximately 4,300 new positions each year. i The average number of job openings due to replacement needs over the ten-year period of 2010 to 2020 for these two occupations will be 6,430 per year. These figures add up to an average of 10,730 job openings each 2
year, while only 6,125 students graduate each year from MLS/CLS and MLT/CLT programs. ii The 2012 ASCP Vacancy Survey asked about the total positions anticipated to open in the next 24 months due to the retirement of personnel. Departments reporting the highest projected retirement rates include core lab (9%), microbiology (9%), chemistry/toxicology (10%), and immunology (10%). iii Proposition 2A: The demand for pathology and laboratory services will not remain constant. The health care system will encounter several disruptions over the next several years, including the changing age and gender distribution of the population, changes in disease incidence, new technology, and consolidation. These disruptions are likely to change the overall demand for all medical services, including pathology and laboratory medicine. The magnitude of those changes, however, is still difficult to project. Proposition 2B: There are likely to be substantial changes in the mix of pathology and laboratory services provided. Population trends, the changing nature of health care technology and the changing organization of health care delivery systems combine to put qualitative pressures on pathology and laboratory medicine (i.e. demand for a different mix of services). Laboratory medicine needs are changing. The expected growth in genomic medicine will increase the demand for specialists in genomics, and will require community pathologists to acquire greater expertise in the selection and analysis of genomic tests. The expected growth of coordinated care and ACOs gives pathologists the opportunity to use their skills in managing health information systems, improving choice of diagnostic tests and interpretation of test results, and applying new technologies toward achievement of health system goals in population health. Proposition 3: These factors require creative reconsideration of the nature of recruitment and training, as well as advocacy for adequate resources. In some areas of laboratory medicine, these challenges are forecasted for the future 10 or 20 years down the road. In others, the problem is now. In pathology, the present number of training positions and trainees is insufficient to maintain the present ratio of practitioners to population. Based on the number of pathology residence positions currently funded in U.S. medical schools, about 600 new pathologists are expected to graduate each year for the foreseeable future, assuming no changes in funding for pathology slots. This is far below the number of pathologists expected to leave practice between now and 2030, and will result in an estimated 3,600 fewer FTE pathologists in 2030 than were practicing in 2010. This circumstance needs to be brought to the attention of policy makers who may be unaware of this instability in pathology practitioner demographics, and the discipline itself needs to undertake a timely reconsideration of how best to make use of its available training capacity. Attention needs to be directed both to present areas of need such as forensic medicine and to future needs such as in pathology informatics and genomic medicine. Correspondingly, compared with the results of ASCP s 2010 Vacancy survey, this year s data reveal decreased overall vacancy rates for the blood bank (6%), cytology (5%), hematology/coagulation (6%), histology (4%), immunology (4%), and microbiology (5%) departments. Data also show a slight decrease in staff (non-supervisor) and supervisor vacancy rates by department except for the cytology department, whose staff vacancy rate has doubled since 2010. The rate of staff positions that take longer to fill (i.e., those 3
that remain open for longer than six months) is highest for the molecular biology and diagnostics department, and the rate for the corresponding supervisor positions is highest for blood banks. The cytology department has the lowest rate of positions that remain open for longer than six months. While it appears that vacancies are low, factors such as the economy, aging workforce, innovations in science and technology, and laboratory education program closures must be taken into consideration. Laboratory professionals are taking extra shifts and/or second jobs within the lab. Facilities also indicate due to funding issues, some positions left open are eliminated or creating new positions becomes difficult. iv Proposition 4: Workforce projections must take into account all members of the laboratory team. It is essential to assert an integrated value proposition and communicate the distinct need for each of the elements that make up the laboratory healthcare workforce. The team should be led by a pathologist. For many years, PhD Clinical Scientists have been integral to clinical laboratory operations, overseeing and directing clinical laboratories, rendering technical interpretative services of patient tests, and especially developing next generation diagnostic devices to improve the quality of laboratory diagnostics. Working closely with their pathologist colleagues, these high-level laboratory professionals enable pathologists to concentrate on those laboratory procedures and operations requiring their medical training. As pathology and laboratory medicine has evolved over the years, so too has the PhD Clinical Scientist s responsibility, skill set and understanding of the clinical issues driving diagnostic testing. These laboratory professionals frequently interpret complex patient clinical pathology procedures and consult with both pathologists and clinicians regarding patient diagnostic testing. While patients are probably unfamiliar with the overall clinical laboratory profession, there is likely to be an even greater knowledge gap in understanding the role of a PhD Clinical Scientist. Moreover, their role within the laboratory setting is increasingly critical to the ability of clinical laboratories to meet the challenges of 21 st century. While cytotechnologists still interpret almost 30 million PAP tests every year, high-risk human papillomavirus (HPV) testing has proven to be a valuable adjunct to prevent cervical cancer or detect its precursors. With their background in biology and genetics, prerequisites for laboratory training programs, cytotechnologists possess the knowledge base required for molecular testing. In response to changes in practice increasing demand for cervical cancer screening utilizing molecular techniques, broader training offered in cytotechnology education programs will provide graduates the relevant broad skills to continue as key health care professionals in women s health. Likewise, digital slide imaging has the potential to replace the traditional microscope in many settings, presenting an opportunity for histotechnologists. As experts in the management of tissue specimens, histotechnologists have a great interest and potential in the development of these technologies. Equipping students with the necessary skills to assist in implementing these new technologies could help laboratories adapt and adopt these new technologies to more efficiently manage their workloads. Proposition 5: Maintaining an adequate supply of qualified pathologists and laboratory professionals depends on access to education and training opportunities. The availability of training programs, particularly those that can offer online and distance education, can be critical to the development of an adequate, stable, and/or competent laboratory workforce. The University of Nebraska, for example, maintains a clinical laboratory education program that includes an effective distance training program that has served other nearby states as well. Bureau of Labor Statistics data analyzed by ASCP reveals that Nebraska, which is served by five accredited training 4
programs including one that has a robust distance education program, has more than 149 laboratory professionals per 100,000 residents. That is almost twice the number of Idaho, which has only one training program, and one of the highest concentrations of laboratory personnel in the United States. v The development of a certified physician-scientist training pathway in pathology, as well as a sustained or increased channel of PhD clinical scientists, currently depends on the availability of NIH grants or Medicare-based GME funds to support such training positions. In an era of increased Federal budgetary scrutiny, these funding levels are under intense pressure and are likely to decrease. Enhancing the strategies for success in obtaining funding for these training positions is vital for pathology. A variety of new approaches to illustrate pathology s value proposition will be essential: 1) to increase success in obtaining funds from existing sources, such as NIH T32 grants; 2) to apply and obtain funds from alternative sources, such as PCORI and AHRQ grants; and 3) to effectively liaise with hospital administrators and medical school deans to reduce or eliminate further internal institutional cuts to physician or PhD pathology training positions or programs. 5
Recommendations Recommendation 1: With regard to medical education, trainers, testers, and regulators should re-evaluate whether pathologist training programs (i.e. residency programs) need to/can be revised to meet the future needs of the American health care system. In particular, these groups should re-assess what every pathologist needs to know, and identify new ways to ensure that adequate numbers of pathologists acquire subspecialized expertise, especially in key emerging areas. We believe that it is necessary to assess whether the current process for training pathologists will give the discipline the skills to meet the future demands likely to face laboratory. Currently, training programs require all pathologists to learn the same set of skills, even though many of those skills will have little application in their careers. One example of this is forensic medicine, which while an important subspecialty, given the current shortage of medical examiners is rarely practiced by most pathologists. By contrast, there are a number of areas where at least some subset of pathologists need to have specialized skills (e.g. Genomic Medicine, Clinical Informatics, and Population Health). While one way to have pathologists acquire these skills is by increasing the length of training, we believe that this solution is impractical and should be avoided. Pathologists are already required to complete four years of post-graduate training, and adding one more year of training would simply slow the pipeline for new pathologists to enter the market. In addition, most pathologists add one or, increasingly, two years of fellowship training to their post-residency training. This results in a total of up to ten years of training (including four years of medical school) before the typical pathologist begins practicing medicine. To address these issues, we recommend that the discipline of pathology consider the development of new models of residency education that better align training with current resources and with future job requirements. Pathology educators and certification boards should therefore re-assess what every pathologist needs to know, as well as determine what areas of expertise need to be served by a subset of pathologists. ACGME, APC, and ABP, the entities primarily responsible for developing criteria for pathology training programs, approving programs, certifying pathologists for practice, should lead this effort and report on their proposals to other pathology organizations. We also recommend consideration of policies that would promote workforce development in areas where shortages are already evident. An example would a medical school loan forgiveness program for students who enter the field of forensic pathology, an occupation that has substantial public health value but for which financial remuneration tends to be low. Recommendation 2: Organized pathology should develop a plan to attract and recruit qualified medical students and Science, Technology, Engineering, and Mathematics (STEM) students to pathology and laboratory professions. In recent years, undergraduate medical education has changed the way that pathology is presented in medical school. While medical students used to get a designated part of their training in pathology (the second year pathology course ), pathology is now typically broadly, but diffusely incorporated into a variety of vertically integrated courses over the first two years of medical school training. In addition, anecdotal evidence suggests that many undergraduate medical students view pathology as a specialty with poor job prospects. We believe that, as a result, medical students do not receive good information on the employment opportunities for pathologists. This means that those who might be 6
attracted to pathology do not have adequate information to compare pathology to other clinical disciplines as a possible specialty choice. This is particularly true for students interested in the emerging areas of pathology, such as genomic medicine, informatics, and population health. The development of a certified physician-scientist training pathway in pathology will enhance the medical specialty s appeal to research-oriented medical students and increase the channel of these highly-skilled physicians into pathology versus competitive specialties already offering certified research tracks. Having a certified physicianscientist training pathway will raise the profile of pathology in emerging clinicallyapplicable innovations, increase pathology s competiveness for recognition and funding in translational and clinical science, as well as outcomes research, and generate more professional avenues for graduates seeking private-sector R&D career opportunities. For the current academic year, 30 institutions are receiving grants of up to $1,000 from the Intersociety Council for Pathology Information (ICPI) to fund Medical Student Interest Group programs and increase the visibility of opportunities in pathology. Progress reports from participating departments from last year indicate that there is an increase in the number of students matching into pathology residency programs. An unpublished survey conducted by the Coordinating Council on the Clinical Laboratory Workforce revealed that 76% of practicing laboratory professionals did not know about the medical laboratory science profession until after high school. Promoting the role of laboratory professionals as an integral part of the clinical care team in a transitioning healthcare system to pre-college students as well as patients, other providers, healthcare administrators, educators, policy-makers, and the public at large, will increase awareness and support for recruitment. The medical laboratory professions require highly technical skills and a solid foundation in the sciences. For this reason, students with backgrounds in science, technology, engineering and mathematics, or the STEM fields are aptly prepared for the specialized education and training necessary for a successful career in laboratory medicine. Engaging in outreach opportunities that promote STEM education to support and promote the development of high-level skills critically important to the performance of quality laboratory testing and management will serve to bolster the pipeline of potential candidates for the profession and leadership in health care. Professional opportunities for PhD clinical scientists in pathology and laboratory medicine are broad from basic research in disease pathogenesis to innovation in healthcare delivery through molecular diagnostics, genomics, and informatics. Communication strategies that describe and promote this robust range of career opportunities should be developed to encourage greater interest in the field from talented PhD candidates. Recommendation 3: The laboratory medicine community should commit to a reevaluation of the long-term training expectations and practice roles of the members of the laboratory healthcare team. This action would allow our community to critically assess the future needs for laboratory healthcare service, while explicitly recognizing the limitations on the health care system s likely capacity to recruit and train future pathologists and laboratory professionals. Advances in science continue to dramatically affect the practice of medicine and patient care. Likewise, innovative technologies are changing the practice of laboratory medicine, and in turn, the educational requirements and qualifications needed to provide quality-testing services. Technological advancement of laboratory testing, emerging pharmacogenomic and proteomic testing, digital imaging, and greater laboratory automation could significantly change the qualifications required of the next generation of pathologists and laboratory professionals. Increasing volume of clinical testing and a growing menu of available clinical tests, often using new testing platforms, 7
have the potential to influence not only the numbers and types of pathologists and laboratory professionals needed, but also their knowledge base and skill set. Increasingly sophisticated diagnostics will require increasing sophisticated test interpretation and utilization management. Nationally, given the diversity of practice settings, the coming milieu seems likely to necessitate the need for both generalists as well as specialists. Such an evolution in practice would require a corresponding evolution in training, and would open new and different career paths and practice roles. The key participants of the laboratory sector leaders in the laboratory community, clinical educators, and accrediting and credentialing agencies will need to continually monitor and review of the practice roles of the various member of the laboratory healthcare team, to ensure staffing qualifications and workforce level requirements are clearly and practically defined to meet current and future needs. The healthcare field applauds innovation and progress, but continual self-scrutiny will be the key to effective development and deployment of the laboratory medicine s most valuable resource its pathologists and laboratory professionals. i Department of Labor. Bureau of Labor Statistics. Occupational Employment Outlook Handbook. Medical and clinical laboratory technologists and technicians. (Accessed October 15, 2013 at http://www.bls.gov/ooh/healthcare/medical-and-clinical-laboratory-technologists-and-technicians.htm) ii Cearlock DM. NAACLS programs, graduates, pass rates and placements: findings from the 2011 annual survey, NAACLS News, January 25, 2012. iii Garcia, EC. The American Society for Clinical Pathology s 2012 vacancy survey of clinical laboratories in the United States.LabMedicine, Winter 2013, Volume 44, Number 1. iv Ibid. v ASCP Analysis of Bureau of Labor Statistics Occupational Employment Statistics Query System, Accessed July 19 th, 2011. 8