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Pathology trainee manpower: APC program directors' questionnaire, 1989 results
Pathology Education Pathology Trainee Manpower: APC Program Directors’ Questionnaire,
1989 Results
RICHARD P. VANCE, MD, ROBERT W. PRICHARD, MD, AND ROGER D. SMITH, MD llw Aasoc.iation of Pathology Chairmen’s (AP<:) surveys from l!)X5 to 1988 have shown a persistent dccline in the number of medical students choosing patholoby folr residency training.‘,’ These reports are supported by data from the American Medical Association (AMA), thse Association of American Medical Colleges (AAMC). and the National Residency Matching Program (NRMP), as well as other published manpower studie5.‘.“-” To better understand this decline, we modified the 1989 AP(I program directors’ questionnaire to collect comprehensive data on the total number of pat hology trainers. Previous program directors’ questionnaires have had response rates ranging from 49% to 68%. The 1989 response rate was 100%. We report the results of I:his survev. METHODS Names alid ,Itlciressrs of program directors wt‘rc’ obtained from the f&s of the Accreditation Council for Graduate Medic-al Education (A
l)athologT [(J’/. straight Al’. sti-sight (:I’). 31~1 thr )ear4 of training Ge. v~irs I through 5 and fczllows). IL!)the nrmlber- of trainees c,llt?r-ing pathology practice (ie. iilc.luclitig all settingsacademic stafl positions, militarv. (.oillmlmit) hospital, Iahoratory-but not further training in arly spr(.ialty and 1101prxtic.r in another specialty), and those rnttring specifically acaciemic patliolo~~ prxtic~e (ie. full-timr lacl1llt\ position .1t 2 medical school teachitlg hospital for purposm of teaching. r(Asearch. or service work). (3) first-year posit iotls funded and filled, (1) filling through the NKMP, (5) whrthcr- positions had been renloved froni the match because the match was per-ceived as ineffrc.ti\r OI-drtrilnental. (6) whether thrr’r was kilowledgc of cheating OII thr match. (7) the uurnber 01 rcsiclents who c;mc directlv 1.1.mumrdical school, (8) the rlulnbcr of residents who had previc)us clinical training, (9) the nunlbel- of firstytx residents who were graduates of folci~n nlrdical sc~l~ools (FM(&). (I 0) Mhcthcr ariy of their tirst-\c2r r-rsideiits had a I)ostsop~ioii~or~ fellowship. ( 1 1) whethrr- tllrii- pl-ograni offered a tifth year of training, ( IL’) if their program tlicl after- 3 fifth vc31 of trainiiig, how it is strut turrd and fllndecl, and (I 3) whrther the p1 ogr-a111dixctor- is also the. c-h,lirman of the departiiient. To contact programs not responding to t ht. questionnaire. and to clarifv \eeriiingly colitradictory iirf~~ixration received. WC’provided a cx)clecl program identification uumbel on ~a~11 prc,gram director’s cluestionnaire. ‘l‘he data Ironi the questionnaires werr entered into a 1)ataEntt.v I I (CI’SS. (Chicago. II.) prograni mcl analyzed using SPSS./P( :- 3 I (SI’SS, ChiCago. Ii J.
FWIII tbr Dq,ar-trnent of Pathology, Wake Forest Llniversity. The Bowrna~~C;r;cvS&ool of Medicine, Winston-Salem, NC:; and the Department of bathology and Laboratory Medicine. Ilniversity of Cincinnati Medical Centrr, Cincinnati. OH. Accepted Ii,l- publication ,J;~II;IIT 8, 1‘!J!ll .4ddress c or-respondence and wprint requests to Richard I’. Vane-r. MD, Department of Pathology. Bowman Gray SChool of Mrdicine. 300 S Hawthorne Kd, Winston-Salem, NC 27103. (Zopyrighr 1-l 1OII I by W.B. Saunders Company 00~6-8 I77/‘!1 I /‘““I 1.000Y?$5.00/0
1067
RESULTS As of July 1989. there were 203 ac.tive programs with status as an anatomic pathology program (AP-3). clinical pathology program (Cl’-S), or cx)mbined anatomic and clinical pathology program (Al’ /CP-3). Therr were 202 AP/CP-4 programs and two AP-3 programs in our survey. One AP-3 program is located at a medical school; the other is a university-affiliated program. All clinical pathology programs are currentlv classified by the ACGME as part of an AP/CP-3 program. There are currently no freestanding CP-3 programs. There are five AP/CP-4 programs that haie separately administered AP and CP programs, and have different program directors (co-directors). We have counted each of these dual programs as a single program because they are assigned the same ACGME number. A111 duallv administered programs are in medical school departments. Two separate AP/CP-4 programs have the same pro,ggam director, even though the programs are at different institutions. Therefore, there are 208 total program di-
HUMAN PATHOLOGY
Volume 22, No. 11 (November
1991)
TABLE 1. Pathology Trainee Distribution by Program Type: 1989 APC Program Directors’ SurveyAll APKP-4 and AP-3 Programs Reporting’
Promam
Type
Program
Program Total
Medical schools University-affiliated Independent Other (military, NIH)
115 49 28 12
Total
204
Percentage (%I
No. of Trainees
Mean No. of Trainees
Percentage of All Trainees
56 24 14 6
1,997 429 198 109
17.4 8.8 7.1 9.1
73 16 7 4
2,733
13.4
Program total is the total number of programs of that particular type; program percentage is the percentage of all programs that are of that particular type; no. of trainees is the total number of trainees in that particular type of residency program; mean no. of trainres is the average number of trainees in that particular type of residency program; Percentage of all trainees is the percentage of all trainees that are in that particular type of residency program. * Includes all AP, CP, fifth year, and fellowship trainees.
rectors associated with 204 AP/CP-4 and AP-3 programs. We received responses from all 204 active programs. Other programs with shorter training times include selective pathology programs (SP programs) and various types of subspecialty fellowship programs. Selective pathology and fellowship programs have no first-year residents because prior pathology training is required. In July 1989, there were 10 SP programs and approximately 170 ACGME-accredited fellowship programs. Selective pathology programs are most often located at sites separate from the AP/CP-4 and AP-3 programs, such as the Children’s Hospital of Los Angeles, CA. In contrast, the vast majority (over 80%) of the fellowship programs are located at AP/CP-4 or AP-3 program sites. The SP and fellowship programs were not separately polled in the survey. However, almost all of the trainees in fellowship programs are counted in our results. Table 1 shows the distribution of pathology trainees in all 204 programs surveyed. Medical school programs constitute 56% of the total, but account for 73% of all trainees. Therefore, the mean number of trainees in the medical school programs is much higher than in other program types. The total number of trainees in all programs for all years of training (including fifth year and fellowships) is 2,733. The mean number of trainees per program is 13.4, counting those in all years offered. Table 2 shows the distribution of all pathology trainees by year of training and by primary certification
TABLE 2. Pathology Trainee Manpower: APC Program Directors’ Survey Responses Year of Training Which Resident Assigned
AP/CP Straight Straight
AP CP
Total Total fifth-year trainees Fellows, etc beyond fifth year Total of all pathology trainees
to is
1
2
3
4
4-Year Total
589 72 24
470 65 18
418 61 21
406 35 16
1,883 233 79
685
553
500
457
2,195 273 265 2,733
1068
pathway (ie, AP/CP, straight AP, or straight CP). Trainees who plan to finish training in both AP and CP constitute from 84% to 89% of the trainees in each year. Those who plan straight AP training range from 8% to 12% in each year. Those who plan straight CP make up 3% to 4% of the trainees in each year. In the 4-year totals, AP/CP trainees constitute 85.8%, AP trainees make up 10.6%, and CP residents account for 3.6% of the 2,195 residents. Fifth-year and fellowship trainees make up 20% of the overall total of 2,733. It is also worth noting that the straight AP and CP residents remain part of the resident pool in the fourth year and make up 11% of the fourth-year residents. Table 3 shows the AMA data regarding pathology trainee manpower from 1983 to 1989.” In the past, the AMA database has been the most comprehensive source for manpower data because of the high response rate. In 1989, the data collection methods were changed to a computerized system. This may account for the lower response rate in 1989. The 217 programs surveyed by the AMA include the 10 SP programs. In addition, three programs that the ACGME considers to be inactive were surveyed. In almost all cases, these programs became inactive because they did not recruit residents. Most of the inactive programs that returned questionnaires to us, or that were contacted by phone, reported no current residents in training. Consequently, we chose not to include these programs in our totals. Inactive programs and the SP programs account for the 13-program discrepancy between our data and the AMA’s. Nonresponding programs in the AMA data include 25 AP/ CP-4 programs, five SP programs, and two AP-3 programs. By convention, residents are grouped by the country in which their medical school is located. Those referred to as US graduates are those graduated from institutions accredited by the Liaison Committee on Medical Education in the United States. Foreign medical graduates (FMGs) are those graduated from any other medical school. GYl residents are those who are in their first postgraduate year (ie, they do not have any previous graduate medical education experience). NonGYl residents are those who have had at least some graduate medical education experience, whether in pathology or in another specialty. All GY 1 and nonGY 1 first-year residents make up the total first-year resident pool.
PATHOLOGY MANPOWER (Vance et al)
TABLE 3.
AMA Survey of Graduate Medical Education: Pathology Programs and Trainees 1989
Programs No. of programs surveyed No. of programs responding Percentage of programs responding frainees [reported (1 OO%)] All pathology trainers Total trainees Total first-year residents <;Y 1 residents Non-GY 1 first-year residents FMG pathology trainees Total FMG trainers Total first-year FMGs GYI FM& Non-GY I first-year FMGs Percentage of FMG pathology Irainees SE Total FM& in all years % Total first-year FMGs W GYl FM& ‘+I NowC;Y 1 first-year FM& * Based on A(X;ME t Figures from 1989 represent simple numeric 1 ,411 FMG projected
1987
217* 185
240 230
85%
2,007 626 387 239 628 194 102 92
261 249
!SYn
(2,304H (736)t (420)t (316H
2. I93 639 403 236
(739): (228): (120): (108):
(2 “84) (SC6) (420) (246)
706 (735) NA NA NA
32% 31% 29% 34%
1985
32%> N.4 NA NA
L’T!) 260
959
2,358 6 16 151 165 670 175 150 ?5
1983
96%
(2,472) (646) (4i3) (153) (702) (1X3) (157) (261
28Y@ 28% :330/o 15%
2,472 752 549 203 65X 202 I31 il
(“-1 564) (780) (569) (211) (683) (2 10) (136,) (74)
27%’ “7%’ 24% 35%
listing of pathology programs, which includes SP programs and some inactive programs. (actual and projected to 100%) have been prepared by the AMA.R Projected data in the YKIIS 1986 through 198X corrections to 100% based on the percentage of programs I-esponding. data (1986 to 1989) represent simple numeric corrections to 100% based on the percentage of progrdms re\ponding.
Based on the survey response rate, the AMA estimates the total number of first-year pathology residents to be 736, or 51 more than our APC survey total. In addition, the AMA projects a total pathology resident manpower pool of 2,304. The discrepancy of 329 trainees between the AMA total and our total of 2,733 is due to several factors. First, the AMA total is smaller because of the small number of fifth-year trainees and subspecialty fellows recorded in their data. While AMA data show only 145 (projected to 100%) fifth-year trainees,’ the APC count of those trainees is 273 (Table 2). The AMA total also does not include fellows in either accredited or nonaccredited programs. The APC data include 265 fellows in both nonaccredited and accredited fellowship programs. Third, SP program trainees are included in the AMA data, but are not included in the APC total. These pro ams account for no more than 4 1 trainees in 1989. $ The fourth reason for the discrepancy is the inherent inaccuracies in the 1989 AMA data resulting from projecting (rather than counting) the trainees in the nonresponding programs (15% of the total). The AMA projections are based on historic rates of filling rather than actual data received. Since the APC data are based on a 100% response rate, supplemented by numerous telephone conversations with most of the program directors to verify responses, we believe our data are more reliable. One of the most important findings from the 1989 APC data is the rate of trainee attrition over the first 4 years of pathology training (Table 4). These findings are supported by AMA data. Table 4 shows retention rates of residents in each of the 4 years of training as of July 1989. The numerators are derived from both 1989 APC data and 1989 AMA data.’ The AMA data for first-year 1069
residents are also subdividecl into [IS graduates and FMGs. The denominator in each year is the total number of first-year residents entering pathology; AMA data collected each year are the only comprehensive estimates of these numbers.# In year 2 of training, ,4PC data are consistent with a 7% decrease, while AMA data show a 3% decrease. When AMA data are broken down into US graduates and FMGs, their numbers suggest that there has been a slight increase in US graduates in the second year. The increase is due, most likely, to LIS graduates entering pathology after a year of accredited training in another specialty. However, during this same time, 10% of FMGs left pathology training. In year 3. APC data indicate that the attrition rate is 25% when compared with the first year of that resident cohort. According to AMA data, the attrition rate for this group was 34%. In year 4, APC data show an attrition rate of 31%, while AMA data show attrition to ble 40% overall, with a 33% loss of US graduates and a 5 1% loss of FMGs. By both AMA and APC estimates, therefore, a significant percentage of residents who begin pathology training do not remain long enough to begin their fourth year of training. The APC data show that the attrition is real and not merely the effect of losing residents who finish straight 3-year programs. As shown in Table 2, straight AP and CP residents constitute no more than 16% of residents in any given year, and 111%of residents in the fourth year are straight AP or straight CP. Table 5 provides data on the impact on private and academic practice that trainees have hald over the last 5 years. We defined pathology practice as any activity other than further training (ie, further residency or fellowship training, etc). Therefore, total entering practice includes all those trainees going into academic practice,
HUMAN PATHOLOGY
Volume 22, No. 11 (November
TABLE 4. Retention Estimates Over 4 Years of Pathology Training: APC and AMA Data on Pathology Manpower as of July/September 1989
1
?
3
4
XII resident\
AMA l;hl(; residrtbts
as well as those going into practice at a community hospital, private laboratory, the military, etc. We defined academic practice as a full-time staff position at a medical school. Therefore, in 1989, 297 trainees finished their training and were available to fill practice positions. Of these, 102 went into academic openings, leaving 195 available for community hospital/private laboratory (CHPL) positions. As expected, medical school training programs provide the largest number of pathologists entering academic practice. Over the 5 years surveyed, medical school/university hospital programs sent 37% of their graduates into academic positions. The range for all types of programs during the same period was from 25.5% in 1986 to 34.4% in 1988. The average for all programs during this time was 30%. This is higher than the traditional estimate of 25%.” Yet, this higher estimate is consistent with resident data on their career plans. In the 1988 APC residents’ survey, 30.6% of hrstyear residents indicated that they planned to enter ac-
1070
1991)
ademics.2 Similarly, 32.7% of the 450 first-year residents responding to the 1989 APC residents’ questionnaire indicated an intention to enter academic practice (Vance RP, Prichard RW, Smith RD, unpublished data, 1989 to 1990). Table 5 gives further support to the argument that there is a significant attrition of residents over the first 4 years of training. While approximately 600 to 700 residents enter first-year pathology training (Table 3), only about 354 on average go into pathology practice each year (Table 5). Of these 354, an average of 107 go into academic positions, leaving an average of 247 to fill CHPL openings. Table 5 also gives some indication of the impact the fifth year of training had on the number of trainees entering practice. The first group of residents expected to remain in training for a fifth year began their fifth year in July 1989. At that time, only 297 trainees entered practice, in contrast to the 350 to 400 who typically finish their training each year. This drop was seen only in 1989, however, since approximately 353 trainees are predicted to enter practice in 1990. Table 6 shows the APC survey results of questions on first-year funded and filled positions during the years 1987 through 1989. The total number of filled positions for 1988 is exactly the same as reported by the AMA.* The APC total of 575 filled positions is, however, 91 positions lower than the AMA estimate of 666. This is not surprising since there were 240 programs surveyed by the AMA during that year. Since we are surveying only 204 programs in 1989, our total is proportionally very close to the 1987 AMA total. This finding reinforces the impression that residents who enter programs that give up their accreditation do not switch to accredited programs in pathology. We have no data on these residents. However, they are clearly part of the attrition from pathology training. As already mentioned, the differences between 1989 AMA and APC data are most likely due to the AMA’s use of historic data, rather than reported data, to project a 100% figure. Overall filling rates (Table 6) for first-year positions in all programs remain high, averaging 90.4% over 3 years. The filling rate increased slightly from 88.7% in 1987 to over 92% in 1989. These rates are higher than reported in the 1987 and 1988 APC Program Directors’ survey results, where the 1987 filling rate was reported as 82% and the 1988 filling rate was reported to be 83%.’ However, the previous survey included only 64% of the active programs at that time. Table 6 also shows the distribution of FMGs among the first-year pathology residents. We show only 24.1% FMGs filling positions in 1989, an 8% drop from 1988. The 1989 AMA data do not support a drop in the FMG percentage (Table 3). The discrepancy may be due to the inaccuracies in 1989 AMA estimates as discussed above. Our data regarding the percentage of FMGs in 1987 and 1988 compare quite well with AMA dataH and previously published APC data.’ Similarly, we find close agreement with the previous APC data on the percentage of FMG filling by program type.” In particular, previous and current APC data show a very high percentage of first-year FMG filling in the university-affiliated pro-
PATHOLOGY
TABLE
5.
MANPOWER
(Vance et al)
Resident Impact on Practice-Total Practice Impact Versus Academic Practice* APC Program Directors’ Survey Responses
:iti!f
grams. However, we also note that among universityaffiliated programs there has been a drop in the percentage of first-year FM&, from 69% in 1987 and 60% in 1988 to 45.7% in 1989. The percentage of first-yeal. FMG in independent programs also dropped in the period from 1987 to 1989. from 52.5% to 43.6%. Not surprisingly, the FMG percentage in military programs and the NIH remained small, less than 5%, during this same period. In 1989, there were no first-year FM<; residents in military programs or the NIH. Table 7 shows APC data on the percentage of firstyear resident filling through the NRMP during the years 1987 to 1989. The total numbers of residents we show that entered through the match are very close to the published NRMP numbers.” For example. we show that 318 filled through the 1989 match, while the NRMP reported 305. Similarly, the percentage of first-year residents filling through the match in our data accords quite well with the results of the 1987 and 1988 program directors’ survey.” Our current data show that the 1987 percentage was 49.9% and the 1988 percentage was 47.1,%. 1071
:S’tti
3 i:i
Our survey included two additional cluestions rc‘garding the match. First, we asked if the progranl had removed positions from the match becausfr it was fomld to be harmful or useless. Overall, 17.6%) answered yes to this question; 17 of 204 programs did not answer. primaril), because they were not involved in the match (ie, mostly military programs). We also asked if the program directors had firm evidence of cheating on the match; again, 17.6% of program directors answered affirmatively. The distribution of affirmative answers was slightly different in these two questions. For example. while 15% of medical school programs had withdrawn positions from the match , 22% reported they had evidence of cheating on the match. We did ‘not count the small number of program directors who stated they had suspicions of cheating, but no tirm evidencr. in the total number of affirmative responses. Furthermore. WC did not ask how the program directors defined cheating. Subsequent surveys will allow more carvf111 analysis of this issue. Medical graduates can enter pat holob3; training through a number of diKerent pathways. I’hc-y can entrr
HUMAN PATHOLOGY
TABLE
Program Total* Percentage Percentage Percentage
6.
Filling of the First-Year
Funded Positions: APC Program Directors’ Survey Responses First-Year Positions Filled 1988
First-Year Positions Filled 1989
Type
685 92.2YO
filling-1989 filling-1988 filling-1987
First-Year Positions Filled 1987
597
First-Year Funded Positions 1988
First-Year Funded Positions 1987
743
661
648
575
88.7%
Program
Foreign
Medical
Graduates:
APC Program 1989
Tvpe
represents
the percentage
Directors’
Survey
Responses
1988
165 24.1%
filled FMGs--1989
191
1987 207
32.0?71
filled FMGs-1988 Perrerltage filled FMGs-1987
* “Pel-centagr”
First-Year Funded Positions 1989
90.3%
First-Year
ToTal* Percentage Percentage
Volume 22, No. 11 (November 1991)
Y6.0% of all first-year
residents
directly from medical school as GYl residents or indirectly after 1 or more years of accredited training in an ACGME-accredited program in another specialty. They can also enter pathology after 1 or more years of nonaccredited training in a program that is not ACGME approved. This last pathway is one taken by some FMGs. Tables 8 and 9 summarize APC data on these various pathways. Table 8 shows the number and percentage of firstyear residents who came directly from medical school into pathology training (ie, graduated from medical school in 1989). When all the programs are combined, only 50.2% of all first-year residents came directly into pathology training. Almost half of first-year pathology residents are coming to pathology training through other means: US graduates who have had previous accredited training in another specialty and FMGs with both accredited and nonaccredited training. In 1989, 59.6% of those residents who entered first-year positions in medical school/university hospital programs came directly from medical school, while only 25% of the residents entering the university-affiliated programs came directly from medical school. The various pathways to pathology training are summarized in Table 9. In 1989, 39.3% came to pathology after 1 or more accredited years of training in another specialty. When these residents are combined with those who came directly from medical school, there were 10.5% of 1989 first-year residents who came into pathology training after 1 or more years of nonaccredited training. The percentage of first-year residents with nonaccredited training varied from a low of 9.1% in 1988 to a high of 16.5% in 1987. Postsophomore fellowships have frequently been discussed as an important recruitment tool. Therefore, we asked how many postsophomore fellows entered pathology as first-year residents. Over the past 4 years, only 39 first-year residents have had postsophomore fellowships. All have entered medical school or university-affiliated programs. The overall percentage of firstyear residents with previous experience in postsophomore fellowships has remained fairly constant over the 1072
who filled in that program
type
last 3 years, ranging from approximately 1.5% to 2.2% of the first-year residents per year. We also asked whether program directors are also departmental chairmen. Slightly over half (53.9%) of departmental chairmen are also program directors. However, among medical school programs, only 42.6% of chairmen are program directors. In contrast, over 70% of university-affiliated programs have chairmen as program directors, and over 80% of the chairmen at other (ie, military, NIH) programs are program directors. Approximately 78% of the 204 programs surveyed currently offer a fifth year of training. This is an increase from 65% among those rograms that reported in the ! University-affiliated 1988 APC questionnaire. programs show the lowest percentage of fifth-year offerings (65.3%), while the medical school programs (81.7%) and the other (ie, military and NIH) programs (9 1.7%) have the highest percentages. Overall, only 22%, or 45 of 204 programs, do not offer a fifth year. The American Board of Pathology (ABP) defines four ways that the fifth-year (credentialing year) requirement can be satisfied”: 1 1. “One year of full-time, approved graduate medical education in a transitional year training program; or in a clinical area of medicine...,” 2. “One year of full-time research in pathology or in another clinical discipline providing that the research has clearly defined clinical implications,” 3. “One year of training in one of the recognized specialty fields of pathology that includes clinical correlation and patient contact,” or 4. “The satisfactory completion of one full year of a combination of clinical training, clinical experience, clinical research, or subspecialty pathology training. . ..” The largest group of programs (44.2%) describes their fifth year as flexible and try to accommodate the needs of each particular resident so that they can fit any one, or a combination, of the ABP definitions. Thirteen percent of programs offer only clinical training, 7% only
PATHOLOGY
TABLE 7.
Progtxm
MANPOWER
(Vance et
al)
First-Year NRMP Filling Percentages: APC Program Directors’ Survey Responses First-Year Filled by NRMP 1989
Type
270 54.9%
Medicall school/university hospital* % NRMP of all filled 1989 W NRMP of all filled 1988 % NF!MP of all filled 1987 Ilniversity-;iffiliat~d/not university Or,NRMP of all filled 1989 % NRMP of all filled 1988 B N&IMP of all filled 1987
First-Year Filled by NRMP 1988 228
.‘,ti.G% hospital*
3I
“7 25.2%
W5% IX
17 30.9%
:19.5% 4
14.3%
H.9% “Xl
49 9%
of all who filled in that program
experience, and 10% only clinical research. The remainder offer specific combinations of the ABP definitions. By far the most common method of funding this year is through hospital revenue (63.9%). Five percent of programs fund it solely through practice income, 8% solely through extramural grants, and less than 1% solely from medical school monies. The remainder fund the year through a combination of sources. DISCUSSION General Clomments A shortage in pathology manpower already exists, both among community and private laboratory practices and among academic departments.5-7,“.“.” Based on all available evidence, the shortage will become much worse
TABLE 8. First-Year Residents Direct from Medical School: APC Program Directors’ Survey Responses
Independent ‘6 Dire< I from medical
Totals
Type hospital school*
293
59.6% hospital
“7 “5.2%
Program-Related
* “%” Rq”ewnts thr percentage fillrd in that lx~~gram type.
3-14 50.2% of all first-year
residents
the NRMP
Issues
During the years 1986 to 1989, the number of pathology training programs decreased by approximately 12%.s Although we do not have exact numbers on the types of programs that have relinquished their active accreditation status, all were university-affiliated, independent, or military programs. As a result, medical school programs now train three fourths of the trainees,
1 12.9%
school
type who filled through
over the next 5 years. For this reason, accurate data on pathology trainee manpower are crucial in order to take appropriate action. Previous APC program directors’ surveys did not have a mechanism that allowed followup contact to encourage participation and to check on the accuracy of data submitted. The 198’9 APC survey constitutes a complete census of all AP-3 and AP/CP4 pathology programs. With the unusually high (100%) response rate and the extensive follow-up for validation, this survey represents the most accurate and comprehensive report on pathology trainee manpower yet conducted. After extensive conversations with the AMA, and comparisons with their database, we have concluded that the trainees we have not included in our total of 2,733 (ie, SP programs and some fellowship prsograms) could add no more than 3% to our current total.’ However, it is important to note that our current data already account for all first-year residents entering pathology in 1989, because there are no first-year residents in SP or fellowship programs. The discussion of our findings will focus on four topics: (1) residency program issues, (2) recruitment patterns among trainees, (3) manpower attrition during the training period, and (4) projected manpower shortage in pathology.
“0 :Q?.4?5
school*
Other
‘flItal ‘?&1Ilrec.t from medical
?X7
47.1%
the percentage
Iltliversity-a~lili;lted/not university qS Direct from medical school*
.>
1
12.9%
clinical
Medical v hool/‘urliversity 4, Dir0 t from medical
I3
40.9RJ
‘I otal ‘!L NRMI’ of all filled 1989 B NKMP of all filled 1988 % NRMP of all filled 1987
Program
x7
32.0%
()rher* % NRMI’ of all filled 1989 % NRMP of all filled 1988 va NRMP of all filled 1987
I eprrsent\
23.5
53.3%
Independent* % NRMP of all filled 1989 Qj NRMP of all filled 1988 “/> NRMI’ r,f.all filled 19X7
:* “‘# NRMP”
First-Year Filled by NRMP 1987
who
1073
HUMAN PATHOLOGY TABLE 9.
Volume 22, No. 11 (November 1991)
Summary of Pathways to Pathology Training: APC Program Directors’ Survey Data
Total no. of first-year
residents Direct from medical school Total no. dirrct from medical school (“0) Previous accredited training I Year to prepare for path0lOh?; (%a) I Year and changed mind to go into Iyathology (%) More than I yea*- and changed mind lo go into patholow Total previous accr-edited tl-king (%) Previous nonaccredited tl-aining Total nonaccredited trainimz I%) * Pcrcent,lges
come from m~put~lished
(‘%“o)
Recruitment
685
597
575
344 (50.2)
241 (40.3)*
254 (44.2)*
lo? 103 64 269
1 I? 121 69 30?
03 82 52 226
(14.9) (15.0) (9.3) (39.3)
data in the I987 and 1988 APC Program
Issues
The AAMC data derived from the senior questionnaire include LJS graduates who plan to take their first postgraduate year in pathology.” The AAMC data in 1989, therefore, provide demographics on only 29% (202 of 685) of the total first-year residents. Similarly, the NRMP data in 1989 account for only 45% (305 of 685) of the total first-year residents in the APC survey.” These findings confirm those of our previous report that the NRMP and AAMC data provide inadequate benchmarks for overall manpower trends.’ Both the 1074
Directors
(18.7) (20.3) (1 1.6) (.50.6)
54 (9. I)
7? (10.5)
even though they account for slightly over one half of the programs (Table 1). Our data show that during the same period, programs that have remained active have increased their funded first-year positions from 648 to 743 (15% increase) and increased their first-year positions filled from 575 to 685 (19% increase) (Table 6). However, this comparison is in some ways misleading. The increases have certainly not made up for the positions lost when other programs became inactive. The AMA data on total funded positions show an overall drop of 12%, from 2,598 in 1986 to 2,274 in 1989.# Similarly, the AMA data show that the overall number of first-year positions filled has certainly not increased (Table 3).’ Therefore, from 1986 to 1989, total programs and total funded positions have decreased 12% and total first-year positions filled have remained about the same. Active programs, as a result, show an increase in their funded and filled positions. First-year filling rates have remained high (over 80%), not only in the current survey (Table 6), but also in our previous surveys.‘.” However, first-year filling rates are misleading. Our telephone conversations this year confirm that there is a widespread practice of moving funded but unfilled first-year positions to accommodate residents entering the program at more advanced levels of training. Many programs, in fact, keep 100% first-year filling rates because they define the number of unfilled first-year positions by the number of first-year slots they are able to fill. Any unfilled slots are thereby designated for more advanced residents. To better assess filling of funded positions, therefore, the 1990 program directors’ questionnaire will ask not only about filling rates in the first year, but also about filling rates for all funded positions.
1987
I988
1989
(16.2) (14.3) (9.0) (30.3)
95 (16.5)
Surveys.
AAMC and the NRMP data show an increase of approximately 40 to 50 residents entering first-year pathology training in 1989 compared with 1988. The 1990 match data indicate that the small increase seen in 1989 was not sustained.” Current APC data (Table 7) support our previous finding that the percentage of first-year positions filled through the match continues to fall.” Although the absolute numbers of residents filling through the match increased in 1989,:’ the increase remains less than the overall increase in first-year resident positions filled. Approximately 18% of program directors have removed positions from the match because they find the match useless or harmful. We have no firm data on the effect of these actions on the overall filling through the NRMP. Eighteen percent of directors also indicated that they have firm evidence that cheating on the match has occurred. The nature of these violations will be examined in more detail in the 1990 questionnaire. Among the US and FMG trainees beginning their residency in July 1989, only 50% came directly from medical school (Table 8). When compared with our previous APC report,’ our current data also show a substantial increase in the overall percentage of first-year trainees who have had previous ACGME-approved clinical training (Table 9). However, the figures in the earlier APC report may be low simply because they were based on a survey with a response rate of 64%.’ When compared with AMA data (Table 3), our data show somewhat better agreement. For example, our current finding of 39% in 1987 is very close to the AMA estimate of 37%. Over the period from 1987 to 1989, 39% to 51% of first-year residents had previous accredited training (Table 9). The US and FMG trainees who have had previous training in ACGME-approved programs are best analyzed as two groups: (1) those residents who took a clinical GYl year but who planned to enter pathology and (2) those residents who originally planned to go into a specialty other than pathology and who took one or more years of clinical training. In 1989, program directors report that 15% of the first-year residents took an accredited clinical year to prepare for pathology residency (Table 9). Another 15% of the 1989 first-year residents had taken an accredited clinical year and changed their mind to enter pathology, while still an-
PATHOLOGY
MANPOWER
other 9.3% had taken more than one accredited clinical training year before entering pathology. These figures do not include those first-year FMGs who have lhad previous training in nonaccredited programs (Table 9). We do not know how many of these FMGs originally planned to enter another specialty. However, they constitute 10.5% (n = 72) of the total 1989 first-year pathology resident cohort and 44% of the 1989 first year FMGs. For several reasons, we believe that almost all the FMG first-year residents with nonaccredited training changed their specialty plans to enter pathology training. From the 1989 resident data, we know that 51%) of the 1989 pathology FMGs had some previous clinical training (both accredited and nonaccredited), that the mean training time for FMGs who have had previous clinical training was 2.7 years, and that 72% of first-year pathology FMGs decide to enter pathology only after graduation from medical school (Vance RP. Prichard RW, Smith RD, unpublished data, 1989 to 1990). We estimate, therefore, that approximately 35% of the first-yc?ar residents in 1989 were recruited after planning to enter another specialty and after completing at least 1 year of accredited or nonaccredited clinical training in those other specialties. Our data are supported by our 1988 and 1989 APC first-year resident surveys. Tlhese surveys show a very high percentage of postgradu,&te recruiting: 38% (283 of 742) of first-year residents reporting in these 2 years indicated that they decided to enter pathology training only after graduating from medical school (Vance RP, Prichard RW, Smith RD. unpulblished data, 1989 to 1990). Attrition
Issues
Previous estimates indicated that approximately 500 trainees entered pathology practice each year.“’ With average first-year cohorts of approximately 680, an attrition levlel of 25% was assumed. The present report suggests that trainee attrition may be greater than previously believed. Among those trainees who began their fourth year of training in July 1989, APC data show that only 68% remain from those who began their residency in pathology in July 1986 (Table 4); of the original entering cohort of 662 residents in July 1986, only 457 began their fourth year of pathology training in July 1989. These findings are more optimistic than AMA data, which show a 40% attrition rate in the first 4 years (Table 4). The most complete databases of pathology trainee manpower both suggest, therefore, that a significant attrition problem exists. If these attrition rates are accurate, we can expect that no more than 60% to 70% of those residents who enter pathology will finish their training and enter pathology practice of any kind. Future APC surveys will examine attrition in much more detail. Projected
Manpower
Shortage
in Pathology
The most recently published manpower study shows that there is a need for approximately 600 pathologists per year to fill CHPL pathology slots for the 5 years beginning in 1988.” This means that the manpower
(Vance et al)
needs in CHPL pathology positions over the years 1988 to 1993 will be approximately 3,100 to 3,200.” This is an increase in the estimated need of 4.900 for the 5 years from 1987 to 1992.” Demographic data indicate that the demand will accelerate over the decade beginning in 1988.:’ Three methods for estimating the number of trainees going into practice are available. All three yield pessimistic results. When we use APC data on trainees going into practice (Table 5), a total of 1.768 trainees went into pathology practice (both academic. and CHPL practice) in the 5 years beginning July 1, 1986 and ending June 30, 1990. Of these. 30% went into academic positions (n = 535), leaving only 1,233 trainees to fill CHPL slots. Assuming the supply of CHPI. trainees does not change, we will have produced only 39% to 40% of the CHPL trainees needed in the years I988 to 1993. We can also estimate the magnitude (of the shortage using AMA data. According to the AMA, approximately 3,300 residents began their residencies in pathology for the 5 years beginning July 1, 1985.’ The AMA data from 1989, however, show a 40% attrition rate of these residents over the first 4 years of training (Table 4). Based on these numbers, no more than 1,980 trainees will finish training over the next 5 years and enter pathology practice. Of these 1,980 trainees, approximately 30% will enter academic practice (approximately 594 trainees). This leaves approximately 1,386 newly trained pathologists to fill CHPL positions. Assuming the projected need for CHPL positions over the next 5 years is no greater than in the years 1988 to 1993 (3,100 to 3,200). we will have produced onlv 45% of the (:HPL pathologists needed. The third method to calculate the shortage provides strong evidence that APC and ,4MA figures overestimate the magnitude of the shortfall for the years 1986 to 1988. The ABP data for initial candidates who completed training with 16 months of application indicate that over the years 1986 through 1988 the mean number of candidates from US training programs was 546 per year (Abel1 MR, personal communication, 1991). If all these candidates (n = 1,637) entered pathology practice during these years, approximately 70%) would have entered CHPL pathology practice (n = 1,136). Based on National Manpower Taskforce data, these trainees would have filled 72% of the vacant CHPL positions (n = 1,600) in these years. The ABP data confirm the existence of a serious shortage of CHPL pathologists over the years 1986 to 1988. We consider the ABP data to represent the gold standard for trainees entering the pathology practice arena. Therefore, the discrepancy between APC and ABP data most likely is to be explained by underreporting by program directors for the years 1986 to 1988. The ABP and APC data jfrom 1989 and 1990, in contrast, show very good agreement. At this point, therefore, the only argument that can be made is over the magnitude of the shortage. Even a 28% shortage is very significant. This is especially true since APC and ABP data from 1989 and 1990 indicate that the magnitude of the shortage is becoming worse. Regardless of the method used to predict manpower in CHPL practice, it is no longer possible to believe that
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HUMAN PATHOLOGY
Volume 22, No. 11 (November
there will be enough trained pathologists leaving residencies to provide replacements for practice-position vacancies. If recruitment of residents does not increase significantly and the attrition rate of our trainees remains high, a severe shortage is inevitable. Current data from the 1990 survey of academic pathology indicate that a manpower shortage already exists in academic departments.“.‘” There are approximately 350 existing vacancies, as well as an attrition of 60 pathologists per year due to retirements, disabilities, and death. ‘* This does not include loss of manpower to academic departments because of terminations or resignations (n = 195 in 1989).‘? Based on the 1989 APC Program Directors’ survey, we can estimate that an average of 107 newly trained MD pathologists will be available to academic pathology each year. These supply and demand data indicate that there will continue to be, for the foreseeable future, a modest undersupply of academic pathologists. However, we doubt that the shortage in community and private practice pathology will leave academic pathology unaffected. With significant shortages in CHPL positions, the income gap will certainly widen, and other incentives will be created to lure additional pathologists into private practice. For example, 79 of the 172 pathologists who resigned from academic positions in 1989 took positions in community hospitals or private laboratories.” If this trend continues, we seriously doubt that there will be an adequate supply of academic pathologists to teach medical students, train pathology residents, and staff pathology services in university hospitals. SUMMARY The shortage of pathologists is being created by a combination of three factors: inadequate trainee recruitment, high trainee attrition, and accelerating practitioner attrition. The current report provides comprehensive data on the first two factors. The third factor is, by every estimate, likely to become worse over the decade beginning in 1988.” Demographics show that greater numbers of pathologists will be reaching retirement age every year.” The trainee attrition problem appears to be very serious, and we currently do not have data on why residents leave pathology training, when they leave, or where they go (ie, to what other specialties, etc). Future APC program directors’ questionnaires must address these issues. Yet, we must also solve a serious problem in recruitment. Currently, about 35% to 38% of all first-year pathology residents decide to enter pathology only after entering residency programs in other specialties with the intent to remain in that specialty. Therefore, we need to recognize both the problem
1991)
of inadequate recruitment and the problem of high attrition in order to address the serious manpower shortage facing pathology. When shortages occur in specialties, practitioners tend to cease performing the most time-intensive tasks (eg, autopsy). However, shortages of the magnitude predicted for pathology suggest that many more tasks traditionally performed by pathologists may very well be in jeopardy. In such a setting, other specialties (especially subspecialties) are likely to fill the void. This is likely to be catalyzed by the emergence of the new resource-based relative-value scale. Subspecialties in medicine and surgery will be looking for additional ways to retain income when they cannot expect as much for their services as before. This scenario is especially worrisome given the necessity for the practice of pathology to expand into the domain of molecular biology. Unless problems causing the shortage in pathology manpower are addressed, not only are our traditional practices threatened, we are also likely to have inadequate manpower to take advantage of those areas crucial for the future of pathology. REFERENCES 1. Smith RS, Prichard RW: A survey of first-year pathology residents: Factors in career choice. HUM PATHOI. 18: 1089-l 096. 1987 2. Vance RP, Prichard RW, Smith RD: Recruitment of pathology residents: APC questionnaire results, 1987 and 1988. HUM PATHOI. 21:28-33, 1990 3. NRMP Data-1990. Evanston, IL, National Resident Matching Program, 1990 4. Medical Student Graduation Questionnaire 1989: Subset Report Pathology. Washington. DC, Association of American Medical Colleges, 1989 5. Smith RD, Anderson RE, Benson ES: Manpower needs and supply in academic pathology. Arch Pathol I.ab Med 109:889-893. 1985 6. Anderson RE, Benson ES, Smith RS, et al: Manpower needs in community hospital and private laboratory practice of pathology. Am J Clin Pathol 90:482-486, 1988 7. Benson ES, Anderson RE, Smith RD, et al: An impending shortage of community hospital pathologists. HUM PATHOI. 20:405406, 1989 8. Crowley AE: AMA Division of Medical Education Research and Information. Chicago, II. 9. Benson ES, Smith RD. Anderson RE, et al: National pathology manpower survey of 1988. Arch Path01 Lab Med 114:566-569, 1990 10. The American Board of Pathology: Information. Tampa, FL, 1989 11. Anderson RE, Smith RD, Benson ES: Academic manpower survey of 1990: I. Descriptors of departments of pathology in the United States. HUM PATHOI. 22:892-896, 1991 12. Anderson RE, Smith RD, Benson ES: Academic manpower survey of 1990: II. Kinetics in the United States. HUM PATHOI. 22: 944-947, 1991 13. Prichard RW. Anderson RE, Anderson HC: The recruitment of pathology residents: A 1987 conference report on challenges and responses. HUM PATHIIL 19:501-506. 1988
1989 Results
RICHARD P. VANCE, MD, ROBERT W. PRICHARD, MD, AND ROGER D. SMITH, MD llw Aasoc.iation of Pathology Chairmen’s (AP<:) surveys from l!)X5 to 1988 have shown a persistent dccline in the number of medical students choosing patholoby folr residency training.‘,’ These reports are supported by data from the American Medical Association (AMA), thse Association of American Medical Colleges (AAMC). and the National Residency Matching Program (NRMP), as well as other published manpower studie5.‘.“-” To better understand this decline, we modified the 1989 AP(I program directors’ questionnaire to collect comprehensive data on the total number of pat hology trainers. Previous program directors’ questionnaires have had response rates ranging from 49% to 68%. The 1989 response rate was 100%. We report the results of I:his survev. METHODS Names alid ,Itlciressrs of program directors wt‘rc’ obtained from the f&s of the Accreditation Council for Graduate Medic-al Education (A
l)athologT [(J’/. straight Al’. sti-sight (:I’). 31~1 thr )ear4 of training Ge. v~irs I through 5 and fczllows). IL!)the nrmlber- of trainees c,llt?r-ing pathology practice (ie. iilc.luclitig all settingsacademic stafl positions, militarv. (.oillmlmit) hospital, Iahoratory-but not further training in arly spr(.ialty and 1101prxtic.r in another specialty), and those rnttring specifically acaciemic patliolo~~ prxtic~e (ie. full-timr lacl1llt\ position .1t 2 medical school teachitlg hospital for purposm of teaching. r(Asearch. or service work). (3) first-year posit iotls funded and filled, (1) filling through the NKMP, (5) whrthcr- positions had been renloved froni the match because the match was per-ceived as ineffrc.ti\r OI-drtrilnental. (6) whether thrr’r was kilowledgc of cheating OII thr match. (7) the uurnber 01 rcsiclents who c;mc directlv 1.1.mumrdical school, (8) the rlulnbcr of residents who had previc)us clinical training, (9) the nunlbel- of firstytx residents who were graduates of folci~n nlrdical sc~l~ools (FM(&). (I 0) Mhcthcr ariy of their tirst-\c2r r-rsideiits had a I)ostsop~ioii~or~ fellowship. ( 1 1) whethrr- tllrii- pl-ograni offered a tifth year of training, ( IL’) if their program tlicl after- 3 fifth vc31 of trainiiig, how it is strut turrd and fllndecl, and (I 3) whrther the p1 ogr-a111dixctor- is also the. c-h,lirman of the departiiient. To contact programs not responding to t ht. questionnaire. and to clarifv \eeriiingly colitradictory iirf~~ixration received. WC’provided a cx)clecl program identification uumbel on ~a~11 prc,gram director’s cluestionnaire. ‘l‘he data Ironi the questionnaires werr entered into a 1)ataEntt.v I I (CI’SS. (Chicago. II.) prograni mcl analyzed using SPSS./P( :- 3 I (SI’SS, ChiCago. Ii J.
FWIII tbr Dq,ar-trnent of Pathology, Wake Forest Llniversity. The Bowrna~~C;r;cvS&ool of Medicine, Winston-Salem, NC:; and the Department of bathology and Laboratory Medicine. Ilniversity of Cincinnati Medical Centrr, Cincinnati. OH. Accepted Ii,l- publication ,J;~II;IIT 8, 1‘!J!ll .4ddress c or-respondence and wprint requests to Richard I’. Vane-r. MD, Department of Pathology. Bowman Gray SChool of Mrdicine. 300 S Hawthorne Kd, Winston-Salem, NC 27103. (Zopyrighr 1-l 1OII I by W.B. Saunders Company 00~6-8 I77/‘!1 I /‘““I 1.000Y?$5.00/0
1067
RESULTS As of July 1989. there were 203 ac.tive programs with status as an anatomic pathology program (AP-3). clinical pathology program (Cl’-S), or cx)mbined anatomic and clinical pathology program (Al’ /CP-3). Therr were 202 AP/CP-4 programs and two AP-3 programs in our survey. One AP-3 program is located at a medical school; the other is a university-affiliated program. All clinical pathology programs are currentlv classified by the ACGME as part of an AP/CP-3 program. There are currently no freestanding CP-3 programs. There are five AP/CP-4 programs that haie separately administered AP and CP programs, and have different program directors (co-directors). We have counted each of these dual programs as a single program because they are assigned the same ACGME number. A111 duallv administered programs are in medical school departments. Two separate AP/CP-4 programs have the same pro,ggam director, even though the programs are at different institutions. Therefore, there are 208 total program di-
HUMAN PATHOLOGY
Volume 22, No. 11 (November
1991)
TABLE 1. Pathology Trainee Distribution by Program Type: 1989 APC Program Directors’ SurveyAll APKP-4 and AP-3 Programs Reporting’
Promam
Type
Program
Program Total
Medical schools University-affiliated Independent Other (military, NIH)
115 49 28 12
Total
204
Percentage (%I
No. of Trainees
Mean No. of Trainees
Percentage of All Trainees
56 24 14 6
1,997 429 198 109
17.4 8.8 7.1 9.1
73 16 7 4
2,733
13.4
Program total is the total number of programs of that particular type; program percentage is the percentage of all programs that are of that particular type; no. of trainees is the total number of trainees in that particular type of residency program; mean no. of trainres is the average number of trainees in that particular type of residency program; Percentage of all trainees is the percentage of all trainees that are in that particular type of residency program. * Includes all AP, CP, fifth year, and fellowship trainees.
rectors associated with 204 AP/CP-4 and AP-3 programs. We received responses from all 204 active programs. Other programs with shorter training times include selective pathology programs (SP programs) and various types of subspecialty fellowship programs. Selective pathology and fellowship programs have no first-year residents because prior pathology training is required. In July 1989, there were 10 SP programs and approximately 170 ACGME-accredited fellowship programs. Selective pathology programs are most often located at sites separate from the AP/CP-4 and AP-3 programs, such as the Children’s Hospital of Los Angeles, CA. In contrast, the vast majority (over 80%) of the fellowship programs are located at AP/CP-4 or AP-3 program sites. The SP and fellowship programs were not separately polled in the survey. However, almost all of the trainees in fellowship programs are counted in our results. Table 1 shows the distribution of pathology trainees in all 204 programs surveyed. Medical school programs constitute 56% of the total, but account for 73% of all trainees. Therefore, the mean number of trainees in the medical school programs is much higher than in other program types. The total number of trainees in all programs for all years of training (including fifth year and fellowships) is 2,733. The mean number of trainees per program is 13.4, counting those in all years offered. Table 2 shows the distribution of all pathology trainees by year of training and by primary certification
TABLE 2. Pathology Trainee Manpower: APC Program Directors’ Survey Responses Year of Training Which Resident Assigned
AP/CP Straight Straight
AP CP
Total Total fifth-year trainees Fellows, etc beyond fifth year Total of all pathology trainees
to is
1
2
3
4
4-Year Total
589 72 24
470 65 18
418 61 21
406 35 16
1,883 233 79
685
553
500
457
2,195 273 265 2,733
1068
pathway (ie, AP/CP, straight AP, or straight CP). Trainees who plan to finish training in both AP and CP constitute from 84% to 89% of the trainees in each year. Those who plan straight AP training range from 8% to 12% in each year. Those who plan straight CP make up 3% to 4% of the trainees in each year. In the 4-year totals, AP/CP trainees constitute 85.8%, AP trainees make up 10.6%, and CP residents account for 3.6% of the 2,195 residents. Fifth-year and fellowship trainees make up 20% of the overall total of 2,733. It is also worth noting that the straight AP and CP residents remain part of the resident pool in the fourth year and make up 11% of the fourth-year residents. Table 3 shows the AMA data regarding pathology trainee manpower from 1983 to 1989.” In the past, the AMA database has been the most comprehensive source for manpower data because of the high response rate. In 1989, the data collection methods were changed to a computerized system. This may account for the lower response rate in 1989. The 217 programs surveyed by the AMA include the 10 SP programs. In addition, three programs that the ACGME considers to be inactive were surveyed. In almost all cases, these programs became inactive because they did not recruit residents. Most of the inactive programs that returned questionnaires to us, or that were contacted by phone, reported no current residents in training. Consequently, we chose not to include these programs in our totals. Inactive programs and the SP programs account for the 13-program discrepancy between our data and the AMA’s. Nonresponding programs in the AMA data include 25 AP/ CP-4 programs, five SP programs, and two AP-3 programs. By convention, residents are grouped by the country in which their medical school is located. Those referred to as US graduates are those graduated from institutions accredited by the Liaison Committee on Medical Education in the United States. Foreign medical graduates (FMGs) are those graduated from any other medical school. GYl residents are those who are in their first postgraduate year (ie, they do not have any previous graduate medical education experience). NonGYl residents are those who have had at least some graduate medical education experience, whether in pathology or in another specialty. All GY 1 and nonGY 1 first-year residents make up the total first-year resident pool.
PATHOLOGY MANPOWER (Vance et al)
TABLE 3.
AMA Survey of Graduate Medical Education: Pathology Programs and Trainees 1989
Programs No. of programs surveyed No. of programs responding Percentage of programs responding frainees [reported (1 OO%)] All pathology trainers Total trainees Total first-year residents <;Y 1 residents Non-GY 1 first-year residents FMG pathology trainees Total FMG trainers Total first-year FMGs GYI FM& Non-GY I first-year FMGs Percentage of FMG pathology Irainees SE Total FM& in all years % Total first-year FMGs W GYl FM& ‘+I NowC;Y 1 first-year FM& * Based on A(X;ME t Figures from 1989 represent simple numeric 1 ,411 FMG projected
1987
217* 185
240 230
85%
2,007 626 387 239 628 194 102 92
261 249
!SYn
(2,304H (736)t (420)t (316H
2. I93 639 403 236
(739): (228): (120): (108):
(2 “84) (SC6) (420) (246)
706 (735) NA NA NA
32% 31% 29% 34%
1985
32%> N.4 NA NA
L’T!) 260
959
2,358 6 16 151 165 670 175 150 ?5
1983
96%
(2,472) (646) (4i3) (153) (702) (1X3) (157) (261
28Y@ 28% :330/o 15%
2,472 752 549 203 65X 202 I31 il
(“-1 564) (780) (569) (211) (683) (2 10) (136,) (74)
27%’ “7%’ 24% 35%
listing of pathology programs, which includes SP programs and some inactive programs. (actual and projected to 100%) have been prepared by the AMA.R Projected data in the YKIIS 1986 through 198X corrections to 100% based on the percentage of programs I-esponding. data (1986 to 1989) represent simple numeric corrections to 100% based on the percentage of progrdms re\ponding.
Based on the survey response rate, the AMA estimates the total number of first-year pathology residents to be 736, or 51 more than our APC survey total. In addition, the AMA projects a total pathology resident manpower pool of 2,304. The discrepancy of 329 trainees between the AMA total and our total of 2,733 is due to several factors. First, the AMA total is smaller because of the small number of fifth-year trainees and subspecialty fellows recorded in their data. While AMA data show only 145 (projected to 100%) fifth-year trainees,’ the APC count of those trainees is 273 (Table 2). The AMA total also does not include fellows in either accredited or nonaccredited programs. The APC data include 265 fellows in both nonaccredited and accredited fellowship programs. Third, SP program trainees are included in the AMA data, but are not included in the APC total. These pro ams account for no more than 4 1 trainees in 1989. $ The fourth reason for the discrepancy is the inherent inaccuracies in the 1989 AMA data resulting from projecting (rather than counting) the trainees in the nonresponding programs (15% of the total). The AMA projections are based on historic rates of filling rather than actual data received. Since the APC data are based on a 100% response rate, supplemented by numerous telephone conversations with most of the program directors to verify responses, we believe our data are more reliable. One of the most important findings from the 1989 APC data is the rate of trainee attrition over the first 4 years of pathology training (Table 4). These findings are supported by AMA data. Table 4 shows retention rates of residents in each of the 4 years of training as of July 1989. The numerators are derived from both 1989 APC data and 1989 AMA data.’ The AMA data for first-year 1069
residents are also subdividecl into [IS graduates and FMGs. The denominator in each year is the total number of first-year residents entering pathology; AMA data collected each year are the only comprehensive estimates of these numbers.# In year 2 of training, ,4PC data are consistent with a 7% decrease, while AMA data show a 3% decrease. When AMA data are broken down into US graduates and FMGs, their numbers suggest that there has been a slight increase in US graduates in the second year. The increase is due, most likely, to LIS graduates entering pathology after a year of accredited training in another specialty. However, during this same time, 10% of FMGs left pathology training. In year 3. APC data indicate that the attrition rate is 25% when compared with the first year of that resident cohort. According to AMA data, the attrition rate for this group was 34%. In year 4, APC data show an attrition rate of 31%, while AMA data show attrition to ble 40% overall, with a 33% loss of US graduates and a 5 1% loss of FMGs. By both AMA and APC estimates, therefore, a significant percentage of residents who begin pathology training do not remain long enough to begin their fourth year of training. The APC data show that the attrition is real and not merely the effect of losing residents who finish straight 3-year programs. As shown in Table 2, straight AP and CP residents constitute no more than 16% of residents in any given year, and 111%of residents in the fourth year are straight AP or straight CP. Table 5 provides data on the impact on private and academic practice that trainees have hald over the last 5 years. We defined pathology practice as any activity other than further training (ie, further residency or fellowship training, etc). Therefore, total entering practice includes all those trainees going into academic practice,
HUMAN PATHOLOGY
Volume 22, No. 11 (November
TABLE 4. Retention Estimates Over 4 Years of Pathology Training: APC and AMA Data on Pathology Manpower as of July/September 1989
1
?
3
4
XII resident\
AMA l;hl(; residrtbts
as well as those going into practice at a community hospital, private laboratory, the military, etc. We defined academic practice as a full-time staff position at a medical school. Therefore, in 1989, 297 trainees finished their training and were available to fill practice positions. Of these, 102 went into academic openings, leaving 195 available for community hospital/private laboratory (CHPL) positions. As expected, medical school training programs provide the largest number of pathologists entering academic practice. Over the 5 years surveyed, medical school/university hospital programs sent 37% of their graduates into academic positions. The range for all types of programs during the same period was from 25.5% in 1986 to 34.4% in 1988. The average for all programs during this time was 30%. This is higher than the traditional estimate of 25%.” Yet, this higher estimate is consistent with resident data on their career plans. In the 1988 APC residents’ survey, 30.6% of hrstyear residents indicated that they planned to enter ac-
1070
1991)
ademics.2 Similarly, 32.7% of the 450 first-year residents responding to the 1989 APC residents’ questionnaire indicated an intention to enter academic practice (Vance RP, Prichard RW, Smith RD, unpublished data, 1989 to 1990). Table 5 gives further support to the argument that there is a significant attrition of residents over the first 4 years of training. While approximately 600 to 700 residents enter first-year pathology training (Table 3), only about 354 on average go into pathology practice each year (Table 5). Of these 354, an average of 107 go into academic positions, leaving an average of 247 to fill CHPL openings. Table 5 also gives some indication of the impact the fifth year of training had on the number of trainees entering practice. The first group of residents expected to remain in training for a fifth year began their fifth year in July 1989. At that time, only 297 trainees entered practice, in contrast to the 350 to 400 who typically finish their training each year. This drop was seen only in 1989, however, since approximately 353 trainees are predicted to enter practice in 1990. Table 6 shows the APC survey results of questions on first-year funded and filled positions during the years 1987 through 1989. The total number of filled positions for 1988 is exactly the same as reported by the AMA.* The APC total of 575 filled positions is, however, 91 positions lower than the AMA estimate of 666. This is not surprising since there were 240 programs surveyed by the AMA during that year. Since we are surveying only 204 programs in 1989, our total is proportionally very close to the 1987 AMA total. This finding reinforces the impression that residents who enter programs that give up their accreditation do not switch to accredited programs in pathology. We have no data on these residents. However, they are clearly part of the attrition from pathology training. As already mentioned, the differences between 1989 AMA and APC data are most likely due to the AMA’s use of historic data, rather than reported data, to project a 100% figure. Overall filling rates (Table 6) for first-year positions in all programs remain high, averaging 90.4% over 3 years. The filling rate increased slightly from 88.7% in 1987 to over 92% in 1989. These rates are higher than reported in the 1987 and 1988 APC Program Directors’ survey results, where the 1987 filling rate was reported as 82% and the 1988 filling rate was reported to be 83%.’ However, the previous survey included only 64% of the active programs at that time. Table 6 also shows the distribution of FMGs among the first-year pathology residents. We show only 24.1% FMGs filling positions in 1989, an 8% drop from 1988. The 1989 AMA data do not support a drop in the FMG percentage (Table 3). The discrepancy may be due to the inaccuracies in 1989 AMA estimates as discussed above. Our data regarding the percentage of FMGs in 1987 and 1988 compare quite well with AMA dataH and previously published APC data.’ Similarly, we find close agreement with the previous APC data on the percentage of FMG filling by program type.” In particular, previous and current APC data show a very high percentage of first-year FMG filling in the university-affiliated pro-
PATHOLOGY
TABLE
5.
MANPOWER
(Vance et al)
Resident Impact on Practice-Total Practice Impact Versus Academic Practice* APC Program Directors’ Survey Responses
:iti!f
grams. However, we also note that among universityaffiliated programs there has been a drop in the percentage of first-year FM&, from 69% in 1987 and 60% in 1988 to 45.7% in 1989. The percentage of first-yeal. FMG in independent programs also dropped in the period from 1987 to 1989. from 52.5% to 43.6%. Not surprisingly, the FMG percentage in military programs and the NIH remained small, less than 5%, during this same period. In 1989, there were no first-year FM<; residents in military programs or the NIH. Table 7 shows APC data on the percentage of firstyear resident filling through the NRMP during the years 1987 to 1989. The total numbers of residents we show that entered through the match are very close to the published NRMP numbers.” For example. we show that 318 filled through the 1989 match, while the NRMP reported 305. Similarly, the percentage of first-year residents filling through the match in our data accords quite well with the results of the 1987 and 1988 program directors’ survey.” Our current data show that the 1987 percentage was 49.9% and the 1988 percentage was 47.1,%. 1071
:S’tti
3 i:i
Our survey included two additional cluestions rc‘garding the match. First, we asked if the progranl had removed positions from the match becausfr it was fomld to be harmful or useless. Overall, 17.6%) answered yes to this question; 17 of 204 programs did not answer. primaril), because they were not involved in the match (ie, mostly military programs). We also asked if the program directors had firm evidence of cheating on the match; again, 17.6% of program directors answered affirmatively. The distribution of affirmative answers was slightly different in these two questions. For example. while 15% of medical school programs had withdrawn positions from the match , 22% reported they had evidence of cheating on the match. We did ‘not count the small number of program directors who stated they had suspicions of cheating, but no tirm evidencr. in the total number of affirmative responses. Furthermore. WC did not ask how the program directors defined cheating. Subsequent surveys will allow more carvf111 analysis of this issue. Medical graduates can enter pat holob3; training through a number of diKerent pathways. I’hc-y can entrr
HUMAN PATHOLOGY
TABLE
Program Total* Percentage Percentage Percentage
6.
Filling of the First-Year
Funded Positions: APC Program Directors’ Survey Responses First-Year Positions Filled 1988
First-Year Positions Filled 1989
Type
685 92.2YO
filling-1989 filling-1988 filling-1987
First-Year Positions Filled 1987
597
First-Year Funded Positions 1988
First-Year Funded Positions 1987
743
661
648
575
88.7%
Program
Foreign
Medical
Graduates:
APC Program 1989
Tvpe
represents
the percentage
Directors’
Survey
Responses
1988
165 24.1%
filled FMGs--1989
191
1987 207
32.0?71
filled FMGs-1988 Perrerltage filled FMGs-1987
* “Pel-centagr”
First-Year Funded Positions 1989
90.3%
First-Year
ToTal* Percentage Percentage
Volume 22, No. 11 (November 1991)
Y6.0% of all first-year
residents
directly from medical school as GYl residents or indirectly after 1 or more years of accredited training in an ACGME-accredited program in another specialty. They can also enter pathology after 1 or more years of nonaccredited training in a program that is not ACGME approved. This last pathway is one taken by some FMGs. Tables 8 and 9 summarize APC data on these various pathways. Table 8 shows the number and percentage of firstyear residents who came directly from medical school into pathology training (ie, graduated from medical school in 1989). When all the programs are combined, only 50.2% of all first-year residents came directly into pathology training. Almost half of first-year pathology residents are coming to pathology training through other means: US graduates who have had previous accredited training in another specialty and FMGs with both accredited and nonaccredited training. In 1989, 59.6% of those residents who entered first-year positions in medical school/university hospital programs came directly from medical school, while only 25% of the residents entering the university-affiliated programs came directly from medical school. The various pathways to pathology training are summarized in Table 9. In 1989, 39.3% came to pathology after 1 or more accredited years of training in another specialty. When these residents are combined with those who came directly from medical school, there were 10.5% of 1989 first-year residents who came into pathology training after 1 or more years of nonaccredited training. The percentage of first-year residents with nonaccredited training varied from a low of 9.1% in 1988 to a high of 16.5% in 1987. Postsophomore fellowships have frequently been discussed as an important recruitment tool. Therefore, we asked how many postsophomore fellows entered pathology as first-year residents. Over the past 4 years, only 39 first-year residents have had postsophomore fellowships. All have entered medical school or university-affiliated programs. The overall percentage of firstyear residents with previous experience in postsophomore fellowships has remained fairly constant over the 1072
who filled in that program
type
last 3 years, ranging from approximately 1.5% to 2.2% of the first-year residents per year. We also asked whether program directors are also departmental chairmen. Slightly over half (53.9%) of departmental chairmen are also program directors. However, among medical school programs, only 42.6% of chairmen are program directors. In contrast, over 70% of university-affiliated programs have chairmen as program directors, and over 80% of the chairmen at other (ie, military, NIH) programs are program directors. Approximately 78% of the 204 programs surveyed currently offer a fifth year of training. This is an increase from 65% among those rograms that reported in the ! University-affiliated 1988 APC questionnaire. programs show the lowest percentage of fifth-year offerings (65.3%), while the medical school programs (81.7%) and the other (ie, military and NIH) programs (9 1.7%) have the highest percentages. Overall, only 22%, or 45 of 204 programs, do not offer a fifth year. The American Board of Pathology (ABP) defines four ways that the fifth-year (credentialing year) requirement can be satisfied”: 1 1. “One year of full-time, approved graduate medical education in a transitional year training program; or in a clinical area of medicine...,” 2. “One year of full-time research in pathology or in another clinical discipline providing that the research has clearly defined clinical implications,” 3. “One year of training in one of the recognized specialty fields of pathology that includes clinical correlation and patient contact,” or 4. “The satisfactory completion of one full year of a combination of clinical training, clinical experience, clinical research, or subspecialty pathology training. . ..” The largest group of programs (44.2%) describes their fifth year as flexible and try to accommodate the needs of each particular resident so that they can fit any one, or a combination, of the ABP definitions. Thirteen percent of programs offer only clinical training, 7% only
PATHOLOGY
TABLE 7.
Progtxm
MANPOWER
(Vance et
al)
First-Year NRMP Filling Percentages: APC Program Directors’ Survey Responses First-Year Filled by NRMP 1989
Type
270 54.9%
Medicall school/university hospital* % NRMP of all filled 1989 W NRMP of all filled 1988 % NF!MP of all filled 1987 Ilniversity-;iffiliat~d/not university Or,NRMP of all filled 1989 % NRMP of all filled 1988 B N&IMP of all filled 1987
First-Year Filled by NRMP 1988 228
.‘,ti.G% hospital*
3I
“7 25.2%
W5% IX
17 30.9%
:19.5% 4
14.3%
H.9% “Xl
49 9%
of all who filled in that program
experience, and 10% only clinical research. The remainder offer specific combinations of the ABP definitions. By far the most common method of funding this year is through hospital revenue (63.9%). Five percent of programs fund it solely through practice income, 8% solely through extramural grants, and less than 1% solely from medical school monies. The remainder fund the year through a combination of sources. DISCUSSION General Clomments A shortage in pathology manpower already exists, both among community and private laboratory practices and among academic departments.5-7,“.“.” Based on all available evidence, the shortage will become much worse
TABLE 8. First-Year Residents Direct from Medical School: APC Program Directors’ Survey Responses
Independent ‘6 Dire< I from medical
Totals
Type hospital school*
293
59.6% hospital
“7 “5.2%
Program-Related
* “%” Rq”ewnts thr percentage fillrd in that lx~~gram type.
3-14 50.2% of all first-year
residents
the NRMP
Issues
During the years 1986 to 1989, the number of pathology training programs decreased by approximately 12%.s Although we do not have exact numbers on the types of programs that have relinquished their active accreditation status, all were university-affiliated, independent, or military programs. As a result, medical school programs now train three fourths of the trainees,
1 12.9%
school
type who filled through
over the next 5 years. For this reason, accurate data on pathology trainee manpower are crucial in order to take appropriate action. Previous APC program directors’ surveys did not have a mechanism that allowed followup contact to encourage participation and to check on the accuracy of data submitted. The 198’9 APC survey constitutes a complete census of all AP-3 and AP/CP4 pathology programs. With the unusually high (100%) response rate and the extensive follow-up for validation, this survey represents the most accurate and comprehensive report on pathology trainee manpower yet conducted. After extensive conversations with the AMA, and comparisons with their database, we have concluded that the trainees we have not included in our total of 2,733 (ie, SP programs and some fellowship prsograms) could add no more than 3% to our current total.’ However, it is important to note that our current data already account for all first-year residents entering pathology in 1989, because there are no first-year residents in SP or fellowship programs. The discussion of our findings will focus on four topics: (1) residency program issues, (2) recruitment patterns among trainees, (3) manpower attrition during the training period, and (4) projected manpower shortage in pathology.
“0 :Q?.4?5
school*
Other
‘flItal ‘?&1Ilrec.t from medical
?X7
47.1%
the percentage
Iltliversity-a~lili;lted/not university qS Direct from medical school*
.>
1
12.9%
clinical
Medical v hool/‘urliversity 4, Dir0 t from medical
I3
40.9RJ
‘I otal ‘!L NRMI’ of all filled 1989 B NKMP of all filled 1988 % NRMP of all filled 1987
Program
x7
32.0%
()rher* % NRMI’ of all filled 1989 % NRMP of all filled 1988 va NRMP of all filled 1987
I eprrsent\
23.5
53.3%
Independent* % NRMP of all filled 1989 Qj NRMP of all filled 1988 “/> NRMI’ r,f.all filled 19X7
:* “‘# NRMP”
First-Year Filled by NRMP 1987
who
1073
HUMAN PATHOLOGY TABLE 9.
Volume 22, No. 11 (November 1991)
Summary of Pathways to Pathology Training: APC Program Directors’ Survey Data
Total no. of first-year
residents Direct from medical school Total no. dirrct from medical school (“0) Previous accredited training I Year to prepare for path0lOh?; (%a) I Year and changed mind to go into Iyathology (%) More than I yea*- and changed mind lo go into patholow Total previous accr-edited tl-king (%) Previous nonaccredited tl-aining Total nonaccredited trainimz I%) * Pcrcent,lges
come from m~put~lished
(‘%“o)
Recruitment
685
597
575
344 (50.2)
241 (40.3)*
254 (44.2)*
lo? 103 64 269
1 I? 121 69 30?
03 82 52 226
(14.9) (15.0) (9.3) (39.3)
data in the I987 and 1988 APC Program
Issues
The AAMC data derived from the senior questionnaire include LJS graduates who plan to take their first postgraduate year in pathology.” The AAMC data in 1989, therefore, provide demographics on only 29% (202 of 685) of the total first-year residents. Similarly, the NRMP data in 1989 account for only 45% (305 of 685) of the total first-year residents in the APC survey.” These findings confirm those of our previous report that the NRMP and AAMC data provide inadequate benchmarks for overall manpower trends.’ Both the 1074
Directors
(18.7) (20.3) (1 1.6) (.50.6)
54 (9. I)
7? (10.5)
even though they account for slightly over one half of the programs (Table 1). Our data show that during the same period, programs that have remained active have increased their funded first-year positions from 648 to 743 (15% increase) and increased their first-year positions filled from 575 to 685 (19% increase) (Table 6). However, this comparison is in some ways misleading. The increases have certainly not made up for the positions lost when other programs became inactive. The AMA data on total funded positions show an overall drop of 12%, from 2,598 in 1986 to 2,274 in 1989.# Similarly, the AMA data show that the overall number of first-year positions filled has certainly not increased (Table 3).’ Therefore, from 1986 to 1989, total programs and total funded positions have decreased 12% and total first-year positions filled have remained about the same. Active programs, as a result, show an increase in their funded and filled positions. First-year filling rates have remained high (over 80%), not only in the current survey (Table 6), but also in our previous surveys.‘.” However, first-year filling rates are misleading. Our telephone conversations this year confirm that there is a widespread practice of moving funded but unfilled first-year positions to accommodate residents entering the program at more advanced levels of training. Many programs, in fact, keep 100% first-year filling rates because they define the number of unfilled first-year positions by the number of first-year slots they are able to fill. Any unfilled slots are thereby designated for more advanced residents. To better assess filling of funded positions, therefore, the 1990 program directors’ questionnaire will ask not only about filling rates in the first year, but also about filling rates for all funded positions.
1987
I988
1989
(16.2) (14.3) (9.0) (30.3)
95 (16.5)
Surveys.
AAMC and the NRMP data show an increase of approximately 40 to 50 residents entering first-year pathology training in 1989 compared with 1988. The 1990 match data indicate that the small increase seen in 1989 was not sustained.” Current APC data (Table 7) support our previous finding that the percentage of first-year positions filled through the match continues to fall.” Although the absolute numbers of residents filling through the match increased in 1989,:’ the increase remains less than the overall increase in first-year resident positions filled. Approximately 18% of program directors have removed positions from the match because they find the match useless or harmful. We have no firm data on the effect of these actions on the overall filling through the NRMP. Eighteen percent of directors also indicated that they have firm evidence that cheating on the match has occurred. The nature of these violations will be examined in more detail in the 1990 questionnaire. Among the US and FMG trainees beginning their residency in July 1989, only 50% came directly from medical school (Table 8). When compared with our previous APC report,’ our current data also show a substantial increase in the overall percentage of first-year trainees who have had previous ACGME-approved clinical training (Table 9). However, the figures in the earlier APC report may be low simply because they were based on a survey with a response rate of 64%.’ When compared with AMA data (Table 3), our data show somewhat better agreement. For example, our current finding of 39% in 1987 is very close to the AMA estimate of 37%. Over the period from 1987 to 1989, 39% to 51% of first-year residents had previous accredited training (Table 9). The US and FMG trainees who have had previous training in ACGME-approved programs are best analyzed as two groups: (1) those residents who took a clinical GYl year but who planned to enter pathology and (2) those residents who originally planned to go into a specialty other than pathology and who took one or more years of clinical training. In 1989, program directors report that 15% of the first-year residents took an accredited clinical year to prepare for pathology residency (Table 9). Another 15% of the 1989 first-year residents had taken an accredited clinical year and changed their mind to enter pathology, while still an-
PATHOLOGY
MANPOWER
other 9.3% had taken more than one accredited clinical training year before entering pathology. These figures do not include those first-year FMGs who have lhad previous training in nonaccredited programs (Table 9). We do not know how many of these FMGs originally planned to enter another specialty. However, they constitute 10.5% (n = 72) of the total 1989 first-year pathology resident cohort and 44% of the 1989 first year FMGs. For several reasons, we believe that almost all the FMG first-year residents with nonaccredited training changed their specialty plans to enter pathology training. From the 1989 resident data, we know that 51%) of the 1989 pathology FMGs had some previous clinical training (both accredited and nonaccredited), that the mean training time for FMGs who have had previous clinical training was 2.7 years, and that 72% of first-year pathology FMGs decide to enter pathology only after graduation from medical school (Vance RP. Prichard RW, Smith RD, unpublished data, 1989 to 1990). We estimate, therefore, that approximately 35% of the first-yc?ar residents in 1989 were recruited after planning to enter another specialty and after completing at least 1 year of accredited or nonaccredited clinical training in those other specialties. Our data are supported by our 1988 and 1989 APC first-year resident surveys. Tlhese surveys show a very high percentage of postgradu,&te recruiting: 38% (283 of 742) of first-year residents reporting in these 2 years indicated that they decided to enter pathology training only after graduating from medical school (Vance RP, Prichard RW, Smith RD. unpulblished data, 1989 to 1990). Attrition
Issues
Previous estimates indicated that approximately 500 trainees entered pathology practice each year.“’ With average first-year cohorts of approximately 680, an attrition levlel of 25% was assumed. The present report suggests that trainee attrition may be greater than previously believed. Among those trainees who began their fourth year of training in July 1989, APC data show that only 68% remain from those who began their residency in pathology in July 1986 (Table 4); of the original entering cohort of 662 residents in July 1986, only 457 began their fourth year of pathology training in July 1989. These findings are more optimistic than AMA data, which show a 40% attrition rate in the first 4 years (Table 4). The most complete databases of pathology trainee manpower both suggest, therefore, that a significant attrition problem exists. If these attrition rates are accurate, we can expect that no more than 60% to 70% of those residents who enter pathology will finish their training and enter pathology practice of any kind. Future APC surveys will examine attrition in much more detail. Projected
Manpower
Shortage
in Pathology
The most recently published manpower study shows that there is a need for approximately 600 pathologists per year to fill CHPL pathology slots for the 5 years beginning in 1988.” This means that the manpower
(Vance et al)
needs in CHPL pathology positions over the years 1988 to 1993 will be approximately 3,100 to 3,200.” This is an increase in the estimated need of 4.900 for the 5 years from 1987 to 1992.” Demographic data indicate that the demand will accelerate over the decade beginning in 1988.:’ Three methods for estimating the number of trainees going into practice are available. All three yield pessimistic results. When we use APC data on trainees going into practice (Table 5), a total of 1.768 trainees went into pathology practice (both academic. and CHPL practice) in the 5 years beginning July 1, 1986 and ending June 30, 1990. Of these. 30% went into academic positions (n = 535), leaving only 1,233 trainees to fill CHPL slots. Assuming the supply of CHPI. trainees does not change, we will have produced only 39% to 40% of the CHPL trainees needed in the years I988 to 1993. We can also estimate the magnitude (of the shortage using AMA data. According to the AMA, approximately 3,300 residents began their residencies in pathology for the 5 years beginning July 1, 1985.’ The AMA data from 1989, however, show a 40% attrition rate of these residents over the first 4 years of training (Table 4). Based on these numbers, no more than 1,980 trainees will finish training over the next 5 years and enter pathology practice. Of these 1,980 trainees, approximately 30% will enter academic practice (approximately 594 trainees). This leaves approximately 1,386 newly trained pathologists to fill CHPL positions. Assuming the projected need for CHPL positions over the next 5 years is no greater than in the years 1988 to 1993 (3,100 to 3,200). we will have produced onlv 45% of the (:HPL pathologists needed. The third method to calculate the shortage provides strong evidence that APC and ,4MA figures overestimate the magnitude of the shortfall for the years 1986 to 1988. The ABP data for initial candidates who completed training with 16 months of application indicate that over the years 1986 through 1988 the mean number of candidates from US training programs was 546 per year (Abel1 MR, personal communication, 1991). If all these candidates (n = 1,637) entered pathology practice during these years, approximately 70%) would have entered CHPL pathology practice (n = 1,136). Based on National Manpower Taskforce data, these trainees would have filled 72% of the vacant CHPL positions (n = 1,600) in these years. The ABP data confirm the existence of a serious shortage of CHPL pathologists over the years 1986 to 1988. We consider the ABP data to represent the gold standard for trainees entering the pathology practice arena. Therefore, the discrepancy between APC and ABP data most likely is to be explained by underreporting by program directors for the years 1986 to 1988. The ABP and APC data jfrom 1989 and 1990, in contrast, show very good agreement. At this point, therefore, the only argument that can be made is over the magnitude of the shortage. Even a 28% shortage is very significant. This is especially true since APC and ABP data from 1989 and 1990 indicate that the magnitude of the shortage is becoming worse. Regardless of the method used to predict manpower in CHPL practice, it is no longer possible to believe that
1075
HUMAN PATHOLOGY
Volume 22, No. 11 (November
there will be enough trained pathologists leaving residencies to provide replacements for practice-position vacancies. If recruitment of residents does not increase significantly and the attrition rate of our trainees remains high, a severe shortage is inevitable. Current data from the 1990 survey of academic pathology indicate that a manpower shortage already exists in academic departments.“.‘” There are approximately 350 existing vacancies, as well as an attrition of 60 pathologists per year due to retirements, disabilities, and death. ‘* This does not include loss of manpower to academic departments because of terminations or resignations (n = 195 in 1989).‘? Based on the 1989 APC Program Directors’ survey, we can estimate that an average of 107 newly trained MD pathologists will be available to academic pathology each year. These supply and demand data indicate that there will continue to be, for the foreseeable future, a modest undersupply of academic pathologists. However, we doubt that the shortage in community and private practice pathology will leave academic pathology unaffected. With significant shortages in CHPL positions, the income gap will certainly widen, and other incentives will be created to lure additional pathologists into private practice. For example, 79 of the 172 pathologists who resigned from academic positions in 1989 took positions in community hospitals or private laboratories.” If this trend continues, we seriously doubt that there will be an adequate supply of academic pathologists to teach medical students, train pathology residents, and staff pathology services in university hospitals. SUMMARY The shortage of pathologists is being created by a combination of three factors: inadequate trainee recruitment, high trainee attrition, and accelerating practitioner attrition. The current report provides comprehensive data on the first two factors. The third factor is, by every estimate, likely to become worse over the decade beginning in 1988.” Demographics show that greater numbers of pathologists will be reaching retirement age every year.” The trainee attrition problem appears to be very serious, and we currently do not have data on why residents leave pathology training, when they leave, or where they go (ie, to what other specialties, etc). Future APC program directors’ questionnaires must address these issues. Yet, we must also solve a serious problem in recruitment. Currently, about 35% to 38% of all first-year pathology residents decide to enter pathology only after entering residency programs in other specialties with the intent to remain in that specialty. Therefore, we need to recognize both the problem
1991)
of inadequate recruitment and the problem of high attrition in order to address the serious manpower shortage facing pathology. When shortages occur in specialties, practitioners tend to cease performing the most time-intensive tasks (eg, autopsy). However, shortages of the magnitude predicted for pathology suggest that many more tasks traditionally performed by pathologists may very well be in jeopardy. In such a setting, other specialties (especially subspecialties) are likely to fill the void. This is likely to be catalyzed by the emergence of the new resource-based relative-value scale. Subspecialties in medicine and surgery will be looking for additional ways to retain income when they cannot expect as much for their services as before. This scenario is especially worrisome given the necessity for the practice of pathology to expand into the domain of molecular biology. Unless problems causing the shortage in pathology manpower are addressed, not only are our traditional practices threatened, we are also likely to have inadequate manpower to take advantage of those areas crucial for the future of pathology. REFERENCES 1. Smith RS, Prichard RW: A survey of first-year pathology residents: Factors in career choice. HUM PATHOI. 18: 1089-l 096. 1987 2. Vance RP, Prichard RW, Smith RD: Recruitment of pathology residents: APC questionnaire results, 1987 and 1988. HUM PATHOI. 21:28-33, 1990 3. NRMP Data-1990. Evanston, IL, National Resident Matching Program, 1990 4. Medical Student Graduation Questionnaire 1989: Subset Report Pathology. Washington. DC, Association of American Medical Colleges, 1989 5. Smith RD, Anderson RE, Benson ES: Manpower needs and supply in academic pathology. Arch Pathol I.ab Med 109:889-893. 1985 6. Anderson RE, Benson ES, Smith RS, et al: Manpower needs in community hospital and private laboratory practice of pathology. Am J Clin Pathol 90:482-486, 1988 7. Benson ES, Anderson RE, Smith RD, et al: An impending shortage of community hospital pathologists. HUM PATHOI. 20:405406, 1989 8. Crowley AE: AMA Division of Medical Education Research and Information. Chicago, II. 9. Benson ES, Smith RD. Anderson RE, et al: National pathology manpower survey of 1988. Arch Path01 Lab Med 114:566-569, 1990 10. The American Board of Pathology: Information. Tampa, FL, 1989 11. Anderson RE, Smith RD, Benson ES: Academic manpower survey of 1990: I. Descriptors of departments of pathology in the United States. HUM PATHOI. 22:892-896, 1991 12. Anderson RE, Smith RD, Benson ES: Academic manpower survey of 1990: II. Kinetics in the United States. HUM PATHOI. 22: 944-947, 1991 13. Prichard RW. Anderson RE, Anderson HC: The recruitment of pathology residents: A 1987 conference report on challenges and responses. HUM PATHIIL 19:501-506. 1988