So You Want to Be a Pathologist…

It’s understandable that members of the public might not be sure who pathologists are or what they do. But when even medical students are asking, “What exactly is pathology?” then we know we have a problem – and it is costing us new recruits.

The “pipeline” is the educational and experiential track every aspiring pathologist must take before ending up in the laboratory. When does it begin? Many of us feel that, for students interested in a medical career, it should start in high school and be sustained throughout post-secondary education. Of course, it reaches its full extent in medical school – although it should continue throughout residency, fellowship, and even into the early years of a pathologist’s career. But does it? And is it doing a good enough job of inviting new pathologists into the fold?

What factors positively impact this pipeline?

Nadeem Zafar: Pathologists offer a very broad array of services to virtually every aspect of clinical medicine – an attractive feature for physicians-in-training. Pathology is an intellectually endowed field that typically attracts thinkers and problem-solvers. Anatomic pathologists resolve diagnostic mysteries in a methodical and sequential manner, using a “keen eye” and expertise in pattern recognition. Cytopathologists have developed adept cognition through the third dimension; the trained mind reconstructs the lesion from which the sample is drawn by mentally recreating its spatial configuration, a more abstract approach to the diagnostic process. Clinical pathologists not only run highly sophisticated and quality-controlled laboratories, but also provide critical expertise to help run various hospital services through a broad array of testing and diagnostic procedures; for example, bone marrow and body fluid testing, electrophoresis, molecular pathology, and genetic studies. Every doctor – and every patient – has drawn on laboratory services. And it doesn’t end there! There is a very strong component of basic and translational research that is an integral part of almost any academic pathology department. So I think there should be a lot of respect and appreciation for pathologists and for the work we do.

Jennifer Baccon: Pathologists who are visible to students and trainees are seen as role models. Many budding pathologists went into the field because they happened to meet a pathologist who inspired them. In addition, pathologists’ frequent presence in all aspects of medical school training has a hugely positive impact on the pipeline. That’s not all that matters, though. An optimistic forecast for job availability, lifestyle factors, and compensation are all key elements for medical students – and we can’t forget the impact, like it or not, of popular television shows where forensic pathology portrayals reach young people and spark an interest in our field.

Which factors negatively impact the pipeline?

NZ: Although pathologists are direct care providers, most don’t come into direct contact with their patients – or even many physicians or administrators – on a daily basis. The laboratory is a 24/7 operation, but we still have a major visibility issue. We seem to deliver our services from behind a wall, which makes us appear almost inconsequential. That’s why we are not seen as the professionals who shape virtually every diagnosis (and treatment) through one or more laboratory services. As medical laboratories become increasingly automated and many of the services once delivered by pathologists are gradually undertaken by non-MD diagnosticians in the clinical laboratory, our input into the world of medicine may become narrowed.

Significant restructuring of the medical school curriculum – making it more integrated using the “flipped classroom” model, with teachers as facilitators of self-learning – has further diminished pathology’s visibility. Medical school curricula are not typically led by pathologists and, in most instances, pathology constitutes a very small – and not very visible – component of the curriculum. Anecdotally, I have heard that the success of these new curricula is mainly gauged by medical students’ completion thereof, and by their performance on the United States Medical Licensing Exam, rather than by a true appreciation of the critical and seminal nature of pathology to the practice of medicine. Fewer opportunities for student electives within pathology, diminishing numbers of post-sophomore fellowships, and an inability to procure recognition of the training associated with post-sophomore fellowships may have further dampened students’ interest in pathology. Upstream, bundled payments for patient care, diminishing reimbursement for biopsies (the bread and butter of anatomic pathology), continued automation of clinical pathology, and the replacement of pathologists with non-MD personnel may have had a negative impact on overall pathologist reimbursements – and thereby on medical students’ interest in pathology as a career.

JB: I agree that we are not always visible to students, patients, and other practitioners. If students don’t have the opportunity to interact with pathologists in a clinical setting, we graduate physicians who lack a full understanding of the role of the pathologist on the patient care team. With regard to the educational environment, I have a slightly different take. As an educator, I feel that the “flipped classroom” experience, where students prepare for a session, rather than coming in cold to hear me lecture, gives me the opportunity to use my time with them to actively engage them in discussion and thoughtful analysis. In my opinion, we should be taking every opportunity to volunteer to be more involved with education. The pedagogies are changing and our style of teaching needs to change with them. There’s only one way we will be left out of the conversation in medical schools – and that’s if we refuse to update our educational philosophies.

How many pathologists will we need over the next few decades?

NZ & JB: TThis is the key question. At the moment, we are seeing exciting new practice models implemented that integrate everything from digital pathology to deep neural networks (that is, artificial intelligence). The landscape is changing, and we need to do our best to accurately project what the future pathologist workforce should be, in terms of both numbers and composition. This will allow us to adjust the supply and demand relationship by tailoring the total number of available residency positions.

Published data back in 2008 projected a looming shortfall of pathologists, with a report from The Workforce Project Work Group five years later that suggested this shortfall would extend through the 2020s. The reasons presented in these predictive models included an aging population with imminent retirement from the pathology workforce (considered among the oldest in any field of medicine) and a large cohort of women with a preference for part-time practice.

On the other hand, there is also evidence – contradictory to some of the published job forecasts – to suggest that not only is the pathology job market not hot, but it may be warming up very slowly at best. Personal communications with our colleagues indicate that each advertised job in pathology attracts numerous applicants, and that many trainees are doing more than one fellowship simply because they are unable to find employment. Pathology also attracts a high number of international medical graduates, many of whom are not eligible to work in the US unless they are recruited through special visas.

Unfortunately, we cannot know with any degree of certainty how many pathologists we will need in 2020 – or in 2025, 2030, 2035… We don’t know what the composition of the future pathologist workforce will need to be – how many cytopathologists will we need? How many surgical pathologists, hematopathologists, neuropathologists, or any other type of laboratory medicine specialist? And what about the expanding roles for clinical microbiologists, chemists, bioinformaticians, or the as-yet undefined jobs with unknown skill requirements in the field of artificial intelligence (AI)? We need to be innovative and optimistic about our ability to recruit trainees and prepare them for whatever the future may hold.

What challenges does the world of pathology currently face?

NZ: I would not call them challenges; I prefer to think of them as opportunities. The future of pathology will look like nothing in its past. Personalized medicine will be the next big thing. The healthcare system will expect pathology to get a better handle on big data; we’ll be expected to provide more, faster, and better-integrated information to allow earlier interventions and improved preventive care under predictive care models. For surgical pathology, a recent seminal event was the FDA approval of a proprietary digital pathology system for primary diagnosis. This will not only change the typical layout of the surgical pathology sign-out area, but also allow us to transfer images across borders and time zones (like radiology already does) for a quicker diagnostic turnaround time and a potentially lower management cost. Improved image compression and resolution will facilitate this process. Deep neural networks and cognitive computing are already beginning to show their value in surgical and cytopathology and, as they become more sophisticated and the neural network cloud continues to develop, AI will enhance our ability to provide more accurate information in a much shorter amount of time. One day soon, growing databases may even be able to identify new therapy options and clinical trials for patients before they have been widely publicized!

JB: Pathologists face the challenge of growing our field as rapidly as our technologies evolve. I would love to see us as drivers of technological development so that we can chart our own course, rather than just reacting to the presence of new technologies in the diagnostic medicine space. We also face the timeless challenge of demonstrating the value of pathology in clinical decision-making. The field is active in discussions about both emerging technologies and the role of pathologists in clinical care – but my personal feeling is that these conversations are still driven by only a small subset of our ranks, while many more pathologists are comfortable simply doing what they have always done (whether at the microscope or in the clinical laboratory).

I think it will be essential to attract trainees who both appreciate the traditional diagnostic aspects of their jobs and have the skillset to rapidly adopt new technologies into practice as they become available. I predict that we will see the repeated evolution of the role of the pathologist over the coming few decades.

How can we make pathology a more attractive career choice?

JB: Make it exciting! We need to frame pathology as a cutting-edge, technologically advanced field that will lead the practice of medicine in the future. We must aim to attract the best and the brightest – the future thought leaders of medicine. To show ourselves as leaders, we need to get out into high schools and colleges, enhance our presence in medical schools, focus on genomics and personalized medicine when we “market” our field, engage in social media outlets, and create career trajectories where trainees are supported continuously from the time they start training through their first position.

NZ: The world of US pathology has always benefited from gifted pathologists who were educated in non-US institutions. This will not change – but how can we re-energize American medical students to consider the field of pathology as well? I don’t think that cosmetic measures will bring about durable change. If we are committed to a long-term fix – and if we believe that this diminished interest is not cyclical – then we will work to change the future landscape of pathology. There are some milestones we must aim for, diligently and deliberately, with exceptional planning and execution and with a very broad buy-in. There are six vital points we must address:

1. Reintroducing pathology to our high school and undergraduate students
   Outreach into high schools and undergraduate institutions has become critical now that pathology has a smaller footprint in the medical school curriculum. Introducing pathology and pathologists through exhibits, sponsored projects, and summer electives can be very helpful. It’s important that such events and activities are in sync with the contemporary adult style of learning – including being significantly technology-driven. The events must highlight the lives and contributions of pathologists to patient care, as well as the technology-heavy (future) nature of the field. Technology companies in Seattle and other tech-savvy cities are tapping into student interests through crowd-sourcing. Pathology needs to do the same. The world of US pathology needs to promote strong, communal outreach in a systematic way, driven by a unified institutional leadership.
2. Improving the visibility of pathology at medical school
   We must make learning pathology innovative and fun. Classroom didactics are quickly falling out of favor; in my opinion, pathologist-facilitated small group self-learning – vignettes with a rich admixture of media and progressive learning and testing – is where we all have to go. If we keep waiting for the entire educational system at our institutions to evolve, we will keep losing our own medical students’ interest. Pathologists must be seen taking charge. We must copy those US institutions where medical students are paired with primary care physicians at the first-year level so that they may learn backwards (starting from patients and going back to texts). It would also be helpful to identify a model for post-sophomore fellowships that allows more streamlined training – and, ideally, even recognition through eligibility for the American Board of Pathology’s diplomate status. I am currently working with a post-sophomore fellow and he is every bit as good as the PGY-1 (first post-graduate year) resident with whom I also work. We should also promote Pathology Interest Groups – especially ones that are action-based and innovative. And, finally, tapping into summer research grants could introduce those interested in pathology to the world of research in our field.
3. Harnessing the resident workforce to attract more medical students
   Harnessing residents and fellows is vital to encouraging US medical graduates to opt for pathology. If medical students interact with happy residents and fellows who are progressively achieving initial competency and have an optimistic view of their futures – and who give the impression of being facilitators and problem-solvers – then many more medical students will want to be a part of the pathology community. Every resident who does well in training should be able to convey to others the firm belief they have in their own future wellbeing: getting good fellowships and great jobs that pay well and allow a well-rounded balance between professional and private life. Millennials want a clear work-life balance – something pathology should promote as a strength of its working style. Along with that balance, pathology already has strong representation from women and a very diverse work environment, but we must better showcase these positive attributes to attract more students to the field.
4. Better connecting the pathologist workforce with the world of data
   (Of course, this is in addition to – not in place of – the diagnostic proficiency we maintain through continued medical education and recertification.)
   Data is big and will only get bigger with time. A great deal of information flows through the laboratory, but it is raw, uncollated, and often deeply fragmented. The pathology team ensures the quality and validity of the test results in the clinical laboratory, but is not necessarily in a position to bring this information together, collate it, or organize it to help with the clinical management of the patient. The responsibility therefore fully shifts to the ordering physician to gather all of the information, make clinical sense of it, act on it, or gather still more information through additional testing to ensure optimal diagnosis and management. The newer molecular and genetic tests are producing a tremendous amount of raw data; at the moment, we don’t even use all of it, but what we do not use may develop clinical value as more research unfolds. In other words, we are now collecting a huge amount of data, some of which we need immediately, and the rest of which we may need at some future point. This galaxy of information needs to be conscientiously archived and processed in real time as new information becomes available. The field is ripe for benefiting from AI to facilitate the work of diagnosticians, clinicians, administrators, and community thought leaders. We are rapidly heading into a future when neural networks will prompt diagnoses, treatments and systemic improvements through much-improved data analysis, using a robust, cloud-based neural network and without losing data confidentiality. Pathology is one of the biggest data generators in the healthcare field, so it’s logical that pathologists should assume significant leadership in the field of data mining. But without a better pipeline of new, well-trained recruits, we may not have the capacity to produce enough highly sophisticated informaticians, or to retrain the current workforce in this area. It’s also past time for medical schools and computer science institutions to move much closer to one another, so that we can help to shape the evolution of medical data and technology. We need to start a robust, ongoing discourse on the impact of new technologies and their applications on the future pathologist workforce.
5. Improving supply and demand in pathology
   Calculating the future demand for – and supply of – pathologists has been the single most important challenge to predicting the job market. Changes in healthcare delivery models, reimbursements, and the induction of technology make this task even more difficult. The time is ripe for us to meticulously survey pathology practices across the nation so that thought leaders may use those numbers to project workforce needs for the future. We know that healthcare costs are ballooning in a way that won’t be sustainable for much longer. There will be cuts and streamlining of services with impact on reimbursements – not just limited to pathology, of course, but we will certainly have our share to bear. As more sophisticated technologies arise – molecular tests are increasingly inducted as first-line tests for certain cancers – and as our work embraces more automation and a greater input from deep neural networks (the “Alexa” of medicine) – there will be significant cost shifts between current and future reimbursement models. But there is also room to open new reimbursement streams, such as diagnostic medical practice through clinical pathology consultations. On the anatomic pathology side, the use of digitized images for primary surgical pathology diagnosis could have a significant impact on the practice of surgical pathology itself, especially because the current workforce hasn’t had extensive digital pathology training or experience; such images could be moved around (just as radiology does) for consolidation and cost savings. In cytopathology, results from Papanicolaou smears are likely to be increasingly routed through deep neural networks simply because of the limited (and repetitive) nature of their findings, and the early maturation of the cloud-based neural network for gynecologic cytology. Human papillomavirus vaccination will also impact both gynecologic cytopathology and the incidence of HPV-associated lesions. I also think we need to carefully study the impact of national and regional providers of pathology services, and of pathology practices owned by clinician specialists. Many of the jobs in pathology are still offered through word of mouth and never advertised, making it difficult to accurately calculate the job market for pathologists. It seems unlikely to me that there will be a big gap between supply and demand anytime soon; in fact, gauging by the trend among current trainees of opting for multiple pathology fellowships, there may actually be a shortage of jobs (or an overproduction of pathologists – some of whom may not be eligible to work within the US unless sponsored on special visas). This generous supply could potentially put pressure on pathologist salaries. A realistic question to ask is: should the number of pathology training slots be decreased to keep the supply and demand balanced, and to keep reimbursements at a desirable level? Or should the training structure be significantly changed so that we produce pathologists with better leadership potential for the new technologies being unveiled in data management and AI?
6. Improving the efficiency of professional pathology organizations through consolidation and a shared vision and mission
   Professional pathology organizations are doing an exceptional job of lobbying for pathology and pathologists, maintaining proficiency and quality, allowing the sharing of ideas and research, and helping to develop academic medicine and private pathology. More recently, there has been an increased focus on “synergy” and the sharing of ideas and actions to promote the growth of pathology. It may not be possible to join every pathology professional organization, but consolidating pathology organizations may facilitate broader overall membership and help elevate our stature in the world of medicine.

Are we tailoring the training for our residents and fellows appropriately for the available jobs?

JB: Not entirely. At the moment, our training is a combination of the practical and the noble. We base it largely on the available residency and fellowship spots (practical), coupled with the individual trainee’s interests (noble)… but we don’t adjust based on the specific job market at a given time. Trainees today feel that they need to do two or even three fellowships to be able to find a job. Granted, some employers seek candidates who have training in multiple subspecialty areas, but many others post jobs that are focused on a single area. We could discuss the literature on the job market outlook for days – but suffice it to say that there are conflicting opinions as to whether there is undersupply or an overabundance of trainees in the pipeline. For me, the salient point is that there is a mismatch somewhere. Trainees feel that it is almost impossible to find a job, whereas the data suggest that the vast majority of them do land jobs. Similarly, some employers feel that there are abundant applicants for each position, while others feel that there aren’t any people out there (particularly with extensive clinical pathology training) to fill their open position, and search for years for someone to fill the spot. Which perspective is true? If employers consistently have open positions, but trainees feel like there are none, then we need to find – and fix – the miscommunication. For instance, I’d like to see us get more involved in social media and other outlets that reach trainees, rather than having students and trainees alone enculturate the students in the early stages of the pipeline.

NZ: Our current training is based on the traditional model of pathology practice. Harnessing our new and still-developing role in the areas of personalized medicine, informatics, digital pathology, and artificial intelligence demands that – to appropriately prepare the new cadre of pathologists – we revisit the educational curriculum in medical school and residency. I believe that the most important areas to induct or expand into our educational curriculum in the very short term are informatics, molecular and genetic pathology, and the business of pathology. Our trainees are better wired for informatics than we, the mentors; they still need to learn to engage and triage big data, but the fundamentals are already there. What they need, but currently lack, is the art and science of traditional pathology and the skills to run cost-effective, patient-oriented practices. Only by equipping the next generation with a comprehensive set of skills and competencies can we ensure that we not only have enough pathologists to meet our needs, but also that they have the tools they need to cope with a constantly evolving specialty.

Nadeem Zafar is the Chief of Pathology at VA Puget Sound in Seattle, USA.

Jennifer Baccon is Chair of Pathology and Laboratory Medicine at Akron Children’s Hospital, Akron, and Chair and Professor of Pathology at the Northeast Ohio Medical University, Rootstown, USA.