- Email: [email protected]
Some thoughts about the past and future of pathology workforce
Perspectives in Pathology Some Thoughts About the Past and Future of Pathology Workforce RICHARD P. VANCE, MD Comprehensive information on pathology workforce is currently not available. Prudent planning for pathology Graduate Medical Education (GME) requires more timely data than presently exist. In addition, we lack understanding of workforce kinetics in academic pathology which often serves as a buffer in times of surplus. Although the heads of community hospital and private laboratory groups control the majority of decisions regarding pathology workforce, a database of these decision-makers does not exist. However, information from the most recent published sources strongly suggests that a significant surplus already exists. Furthermore, this position is supported by earlier unpublished work from the 1994-1995 Conjoint
Committee on Pathology Enhancement (CCOPE) surveys. HUM PATHOL 30:117-122. Copyright © 1999 by W.B. Saunders Company Key words:workforce, managed care. Abbreviations: US, United States; HMOs, health maintenance organizations; CCOPE, Conjoint Committee on Pathology Enhancement; NPMD, National Pathology Manpower Database; CHPL, commtmity hospital/private laboratory; AMA, American Medical Association; IMGs, international medical graduates; COGME, Council on Graduate Medical Education; NRMP, National Resident Matching Program.
Since the failure of health system reform in 1993, managed care has dramatically changed the landscape of the physician workforce. 1,~ Workforce projections in many cases witnessed dramatic downturns after consistent 25 years increases. Although some still believe the managed care backlash will intensify in the future, it is not at all clear that such retrenchments would increase the demand for physicians,s,4 All of the uncertainties in workforce projections are compounded in pathology because pathologists represent only 2% of the total physician workforce, the demand for pathologists is multifactorial, and the workload is poorly standardized or studied. 5 In the pre-1993 healthcare reform era, projections of pathology workforce were hampered by the lack of adequately developed workforce demand methodology.6 The only projections that could be made with any degree of certainty were simple supply projections; comparing those entering and those leaving the specialty. Based on an aging practicing population, declining interest in pathology among United States (US) graduates, and significant trainee attrition from pathology residencies, a prediction of a shortage was straightforward. 6 The rapid expansion of managed care beginning in 1994 changed the workforce landscape, especially when staffand group model health maintenance organizations (HMOs) staffing levels became pubicly k n o w n . 7,a,9,1° These data suggested that the demand for pathologist would be substantially less than the current United States supply, if HMO staff and group models
became the norm. Unfortunately, the data presented in these studies were limited to a handful of HMOs, and data on pathology were not always available. In addition, the wide variability found in pathology staffing ratios raised validity questions, especially if such data were to be extrapolated to the entire US population. In response to these issues, the Conjoint Committee on Pathology Enhancement (CCOPE)--a collaborative effort on the Association of Pathology Chairs, American Society of Clinical Pathology, and the College of American Pathologists--undertook a series of studies in 1994 to 1995 to evaluate the changing pathology workforce environment. These surveys were sent to pathology residency program directors, first year pathology residents, exiting pathology trainees, community hospital private laboratory pathologists, and academic pathologists. In some instances, the paucity of published data and the lack of a well-developed survey methodology forced the committee to attempt to collect information that had been previously unavailable. Consequently, some results from the surveys were incomplete, especially those which predicted dramatic surpluses for pathology workforce. The purpose of this article is to provide a summary of all those studies, except for the academic survey results, and to place those results in the context of workforce publications which have since then referenced pathology. A summary of the last CCOPE surveys from 1994 to 1995 will be used as a baseline, and limitations in the methodology and the data projections will be clearly outlined.
From the Department of Population Health Improvement, Humana Inc., Louisville, KY. Address correspondence and reprint requests to Richard R Vance, MD, Vice President, Population Health Improvement, Humana Inc., 500 W. Main Street, Louisville, KY 40201. Copyright © 1999 by W.B. Saunders Company
MATERIALS AND METHODS The survey of community hospital private laboratory pathologists were conducted using the National Pathology Manpower Database (NPMD) and supplemental data from the American Medical Association's Master-
0046-8177/99/3002-0002510.00/0
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Volume30, No. 2 (February 1999)
file of Physicians. The NPMD was constructed in the 1980s to be a large-scale longitudinal, demographically representative survey of community hospital/private laboratory (CHPL). 6,11,12 The original survey in 1986 included 4,669 pathologists. Of the responses received from the initial mailing, 2,469 pathologists indicated a willingness to participate in future surveys. The NPMD has been previously used three times. In the second and third iterations, pathologists from the American Medical Association (AMA) Masterfile were used as supplements to keep the sample demographically representative. For the fourth (1994 to 1995) iteration, a total of 940 surveys were sent out (753 were respondents from the previous survey and 187 were from a supplemental sample drawn from the 1994 AMA Masterfile). With each of the individual surveys, a second survey labeled "Heads of Group Survey" was sent. The individual pathologists who received the packet was asked to fill out the individual pathologist survey, and instructed to give the "Head of Group Survey" to their head of group (eg, the administrator or president of the individual groups). If the individual pathologist was the head of their group, they were instructed to fill out both surveys. Currently no comprehensive database exists on the heads of groups. CCOPE hoped the data received from the heads of groups would provide some preliminary indication of market dynamics that might not be appreciated by the average practicing pathologist. The 1995 program directors survey was mailed to each of the 184 programs listed as active by the Accreditation Council for Graduate Medical Education (ACGME). Program directors were asked to respond to questions relating to their tenure as directors, the characteristics of their first year residents, the characteristics of their remaining residents and fellows, and the pathways of residents into training and into practice. Program directors were also asked to distribute the first year residents surveys to entering first year residents in July 1995. Program directors were also asked to distribute exit surveys to those trainees who were leaving training to go into CHPL or academic practice. The first year resident survey examined academic and demographic information regarding trainees entering pathology. The exit survey asked exiting trainees to assess the quality of their training and their perceptions of the pathologyjob market.
RESULTS Of the 940 NPMD individual pathologist questionnaires mailed, 532 were returned, 78 of which were deemed ineligible (36 came from academic pathologists and 42 came from people who were not practicing pathology at least 20 hours per week). If those determined to be ineligible are removed from the initial mailing, the response rate is calculated as 454/865 (53%). Both the initial mailing and the subsequent response was demographically representative (by age, gender, and geographic region) of CHPL pathologists in the AMA Masterfile.
TABLE 1.
Percentage Number
Individual Pathologists Planning on Retirement In 1 Year
In Subsequent 2 to 5Years
Total
3 360
22 2,422
25 2,782
A total of 290 NPMD group leader questionnaires were returned, but 6 of these did not have complete information on the number of full-time equivalents in the group, so they were not used in the analysis. Therefore, the total number of usable questionnaires was 284. If the same eligibility rate was assumed as for the individual questionnaires, the response rate for the group leader questionnaire is 284/862 (33%). The 454 CHPL respondents represented 4% of the 11,132 CHPL pathologists in the US in 1994. The 284 heads of groups represent 1258 community hospital private laboratory pathologists or 11% of the practicing pathologists in CHPL in the US. In response to question regarding future retirement, individuals responding to the NPMD provided data as seen in Table 1. Over the next 5 years, 25% of those responding indicated that they would be retiring or leaving pathology practice. Extrapolated to the universe of CHPL practitioners, that yields a total of 2,782 pathologists. These data suggest that on average, 556 pathologists will be retiring in each of the 5 years beginning with 1994. These findings are consistent with the demographics of the pathology population in the AMA Masterfile, and previous iterations of the NPMD. The relatively low response rate for heads of groups in this iteration of the NPMD makes extrapolation to the total market of CHPL pathologists risky. However, Tables 2 and 3 present information about the picture of the pathology market generated by respondents. During the period from 1994 to 1995, the total number of retirements extrapolated to the universe of CHPL pathologists decreased 15%, and resignations decreased 65%; losses of positions caused by mergers increased sixfold, and reductions in positions because of decrease in business volume increased 50%. In contrast, the market demand for new positions decreased 20% and the filling of vacant positions decreased 60%; consequently, the total demand for pathologists during this time period decreased 40%. In addition to the small sample of heads of groups, 11% of the group losses respondents were blank, whereas 22% of those in the market demand questions were left blank. After 100% responses beginning in 1989, the 1995 program directors survey yielded only a 96% response TABLE 2.
Retire Resign Merger Volume loss
118
CHPLGroup Losses 1994
1995
293 295 5 84
243 110 30 125
PERSPECTIVESIN PATHOLOGY(Richard P, Vance) TABLE 3.
Market Demand for CHPL Pathologists
New hires Vacancy Total d e m a n d
200-~
1994
1995
Percentage
359 450 809
289 200 489
- 20 - 60 - 40
195
190.
i~i~iil iii!ii!i!
185./~: rate (176/184 programs). As depicted in Fig 1, the total n u m b e r of trainees has continued to increase. In 1995 the total n u m b e r of trainees exceeded 3,000 for the first time in the history of pathology training. At the same time, the total n u m b e r of programs declined to the lowest n u m b e r before World War II. Figure 2 indicates the total n u m b e r of programs from 1990 through 1996. In 1995, international medical graduate (IMGs) represented 33% of all pathology trainees. As in previous years, the total n u m b e r of first year trainees was approximately 650. Only 56% of first year trainees entered pathology trained directly from medical school. This is consistent with trends since the late 1980s. The total n u m b e r of trainees who attrited to other specialties was less than 100. One third to those who attrited were IMGs. O f the graduating c o h o r t in 1995, approximately 290 trainees went to community hospital private practice; a n o t h e r 70 went into academic positions; 120 entered programs other than their primary training programs for fellowship; and 110 remained at their primary program for additional fellowship training. We do not at this point have good data on the total n u m b e r of highqevel fellows leaving academic practice to find jobs in the CHPL sector or the n u m b e r of academic physicians who are making the same shift. The 1995 exit survey yielded 200 responses representing a 56% response rate. This is consistent with exit surveys c o n d u c t e d in 1992 through 1994. O f those responding, 36% were women. The mean n u m b e r of years of pathology training was 5.2 years. The percentage of respondents who were alpha omega alpha (AOA) was 19.3%. Additionally, 90% were trained in Anatomic Pathology/Clinical Pathology (AP/CP), whereas 7% were trained straight AP. A m o n g US graduates, 94% had jobs as pathologists at the time of the exit survey (May 1995). At that same time period 86% of IMGs had jobs. US graduates applied for an average of 10 positions. IMGs applied for 27 positions on average. The n u m b e r of j o b offers for US graduates was 2.0 on average, whereas the average for IMGs was 1.4. These
ii
180Ai 175 ~i~ilililii
•
[] Programs
iii~ii! iiiii!ii
ii~iiii!i
165.~ 90
ii! °
iii!fiil;~
91
92
93
94
95
96
FIGURE 2. Total pathology training programs.
numbers reflect a declining n u m b e r of offers for exiting trainees in pathology. Overall exiting trainees received 1.9job offers in 1995 (Fig 3)i For the first-year residents survey, we received a total of 377 responses from the approximately 650 first year residents in 1995 (58% response rate). Women represent 42 % of the respondents. O f the US graduates, 8.8% were MD/PhDs. IMGs were represented by 30% of the respondents. O f the entering first year residents 17.4% were AOA. The total mean debt for all respondents was $47,349. Fifty-seven percent of respondents were in the first quartile of their graduating class. DISCUSSION
Workforce modeling is an inexact and confusing science. Even when the health care system displays predictable change, ambiguity in definitions and minor disagreements over presuppositions can yield significant discrepancies in forecasts, is Since 1993, changes in the health care system have been unpredictable and uneven, even though the root cause of the change has been the same: the penetration of managed care.
1,
-3500
[[] Trainees
-3000
.2500 2000 1500 iti:~iiii[ii!!i!i~'~-~
1000 500
Trainees 75
80
85
90
92
95
FIGURE 1. Total pathology GME trainees from 1975.
93
94
FIGURE3, Job offers per exiting trainee,
119
95
HUMAN PATHOLOGY
Volume 30, No. 2 (February 1999)
Although many believe this trend will continue or accelerate, others believe there will be a swing of the pendulum away from managed care (at least as we have seen it so far). 3 Workforce prognosticators are also divided (albeit unevenly) between those who believe a significant surplus is upon us, 7 and those who argue that we are not now or in the foreseeable future far away from workforce balance. 14,15 There can be no denying that the supply of physicians has grown dramatically.2 The supply will be 261 physicians per 100,000 population by the year 2000, up from 156/100,000 in 1971.2 In contrast, the Council on Graduate Medical Education (OGME) has reported that 145 to 185 physicians per 100,000 is the appropriate ratio for the 21st century. 16 The majority of workforce specialists believe there is and will be a substantial surplus of physicians. In large part this conclusion is based (as was the 8th COGME report) on the presupposition that managed care staffing ratios are the most appropriate ones, and that those arrangements will come to dominate the health care system.1 Benchmarking models, constructed by comparing HMO staffing levels with non-HMO levels, such as the ones described by Goodman and Weiner are currently the most popular method for determining workforce levels. 7,9 This sort of benchmarking approach has supplanted perspectives based either on the percentage of generalists to specialists, 17,1s or on supply or demand models. In the past 2 years, physician workforce studies (using benchmarking methods) have once again reiterated that a physician surplus is inevitable under current policies. 16,19,2°Goodman et al showed that nationally the generalist workforce exceeds HMO staffing levels by 35%, and that seven specialties (one of which is pathology) exceed HMO staffing levels by more than 100%.7,s Practicing pathologists represent 4.2 physicians/100,000 population. 9 If residents are factored in, the ratio becomes 5.2/100,000. 7 According to Goodman et al pathology workforce exceeds HMO staffing requirements by a factor of 2.08. s Richard Cooper has argued that the benchmarking model is inadequate because it fails to consider the demographics of the US population. 14,15 Nevertheless, Cooper's presuppositions still show that we have a surplus of physicians currently, and that the surplus will continue through 2010 regardless of what we do to workforce policy now. After 2010, he believes an increasing population will begin to bring the workforce policy supply back into balance. At least part of Cooper's analysis has been supported by Michael Whitcomb's examination of cross-national comparisons of generalist physician workforceY It is fair to say, however, that Cooper's position is currently not the majority opinion. Pathology workforce projections are uncertain when using the benchmarking model because the HMO staffing patterns for pathology have significant variation, and very few staff/group HMOs have been studied. However, even if one takes Cooper's presuppositions, and applies a 60% penetration of managed care by the year 2000, pathology is still probably facing a 120
significant surplus. It is conceivable--using (1) the most optimistic published pathology HMO staffing levels, (2) assumptions that managed care penetration will not be as significant as expected, (3) presuppositions that the dwindling recruitment of medical students into pathology will continue, and (4) arguments about our aging and increasing population--that pathology workforce might be in balance in 2010. However, without those qualifications, most studies suggest that there will be a significant surplus of pathologists over the next decade. There is additional evidence (as shown previously) that the market had begun to tighten substantially in 1994 and 1995 (Tables 2 and 3). Such observations fit well with contemporaneous and subsequent studies on the employment status of newly exiting pathology trainees. Miller et al reported that of all specialties in 1994, pathology had the highest percentage of unemployed exiting trainees--10.8%. 22When the response rate and other factors are considered, this finding was consistent with the exiting trainees surveys conducted by CCOPE. Miller et al also found among the 1995 exiting trainees that the 11.8% of pathology trainees experienced difficulties obtaining positions. 2~ Furthermore, 55% of pathology program directors reported that they anticipated employment problems for future graduates. 23 In the same study, Miller noted that 20% of pathology programs had decreased in size in 1994 to 1995 and that 40% may reduce residency positions in subsequent years, perhaps in anticipation of future difficulties.23 Finally, Miller's 1996 report, reconfirmed pathology's relatively high percentage of training graduates who had not found employment by the time of Miller's survey (14.7%). 24 Furthermore, 50.8% of responding residents had significant difficulty finding a practice position, and 49.2% received only one job offer. Most recent policy reports implicate the high numbers of IMGs as a major factor in the physician surplus. 19,2°,25 IMGs make up 23% of practicing physicians, up from 18% in 1970. 2,25 As reported here (and previously), pathology is one of those specialties with a higher than average proportion of IMGs. 26,27 Key players in the national workforce debate have in recent years begun to focus on the level of funding for IMGs as a means for constricting workforce growth. 2,25,2s Currently, 6,900 IMGs enter US residencies each year. 29% of all residency programs are IMG dependent, filling on average 76% of their positions with IMGs. 29 Whether Congress is prepared to deal with the political issues surrounding this issue remains uncertain. 25 The most recent comprehensive data on pathology GME are in the 1995 CCOPE Program Director's survey. Although there are some indications that programs have already begun to downsize,22 the total GME workforce in 1995 was still the highest in the history of pathology GME. The market for newly exiting trainees has certainly shown signs of significant tightening. Yet, I suspect that the most substantial market pressures are being felt by midcareer pathologists, and those CHPL pathologists who are on the cusp of partnership. The 1997 National Resident Matching Program (NRMP)
PERSPECTIVES IN PATHOLOGY (Richard P. Vance)
600500400PathoIogyNRMP results 1992-1997, FIGURE4.
• Total Positions Offered • US Graduates Filled
300200-
[] IMGs Filled
10001992
1993
1994
1995
1996
1997
REFERENCES
results do suggest that recruitment into pathology may be decreasing (Fig 4).3° However, the NRMP has proven to be a very unreliable guide to recruitment trends, filling less than 50% of total first-year resident cohorts since the late 1980s.
SUMMARY Workforce projections for pathology have always had significant methodological weaknesses, even periods of relative stability. With the lack of systematic workforce evaluation process, the specialty is--especially at this time--flying blind. Data from all the sources examined, do indicate that there is already a surplus, and that there will be a growing surplus of pathologists over the next decade. The magnitude of the surplus, is, however, anyone's guess. There are two additional significant deficiencies in our current knowledge of pathology workforce. The first is the kinetics within academic pathology. We have no idea for example, how many fellows are being used as j u n i o r faculty because of shortages in the CHPL marketplace. Even more important than academic kinetics though, is the absence of a "heads-of-group" database. The latest iteration of the NPMD survey indicates that a heads of groups survey may prove to be a valuable m e t h o d to determine what is happening in the pathology marketplace. We do not currently know how many groups of pathologists there are in the US. We certainly do not know which pathologists lead those groups. Because these pathologists largely control the d e m a n d for CHPL pathologists, organized pathology would be well advised to survey these leaders regularly. In the absence of such information, we are likely to be caught unprepared, once again, when the health care marketplace makes its next major change.
Acknowledgment. T h e a u t h o r will always r e m a i n i n d e b t e d to the wisdom and h u m o r of his mentor, R o b e r t W. Prichard, MD, in guiding his research in pathology workforce. 121
1. Rivo ML, Mays HL, Katzoff J, et al: Managed health care: Implications for the physician workforce and medical education. JAMA 274:712-715, 1995 2. Rivo ML, Kindig DA: A report card on the physician work force in the United States. N EnglJ Med 334:892-896, 1996 3. Ginzberg E, Ostow M: Managed care--A look back and a look ahead. N EnglJ Med 336:1018-1020, 1997 4. Kassirer JR Is Managed Care Here to Stay? N Engl J Med 336(14):1013-1014, 1997 5. Smith RD, Vance RP, Anderson RE, et ah National pathology manpower survey of 1991: Projected Needs in community hospitals and private laboratory practice. Am J Clin Path 100:$33-$36, 1993 (supp 1) 6. Vance RP: Pathology manpower needs in the year 2000: The view from 1990. Lab Med 23:412-415, 1992 7. Goodman DC, Fisher Es, Bubolz TA, et al: Benchmarking the US physician workforce: An alternative to needs-based or demandbased planning.JAMA 276:1811-1817, 1996 8. Goodman DC, Fisher Es, Bubolz TA, et al: Benchmarking the US physician workforce. JAMA 277:964-966, 1997 9. Weiner JP: Forecasting the effects of health reform on US physician workforce requirement: Evidence from HMO staffing patterns.JAMA 272:222-230, 1994 10. Wennberg JE, Goodman DC, Nease RF, et al: Finding equilibrium in U.S. physician supply. Health Affairs 12:89-103, 1993 11. Anderson RE, Benson ES, Smith RD, et al: Special report-National manpower survey of 1987: Manpower needs in community hospital and private laboratory practice of pathology. Am J Clin Patho190:482-486, 1988 12. Benson ES, Smith RD, Anderson RE, et al: National pathology manpower survey of 1988: Manpower needs in community hospitals and private laboratory practice. Arch Pathol Lab Med 114:566-569, 1990 13. Feil EC, Welch HG, Fisher ES: Why estimates of physician supply and requirements disagree. JAMA 269:2659-2663, 1993 14. Cooper RA: Perspectives on the physician workforce to the year 2000.JAMA 274:1534-1543, 1995 15. Cooper RA: Seeking a balanced physician workforce for the 21st century. JAMA 272:680-687, 1994 16. Council on Graduate Medical Education: Patient Care and Supply and Requirements: Testing COGME Recommendations: 8th Report to Congress and the Health and Human Services Secretary. Rockville, MD, Health Resources and Services Administration, 1996 17. Kindig DA, Cultice JM, Mullan F: The elusive generalist physician: Can we reach 50% Goal? JAMA 270:1069-1073, 1993 18. Kindig DA: Counting generalist physicians. JAMA 271:15051507, 1994
HUMAN PATHOLOGY
Volume 30, No. 2 (February 1999)
19. Institute of Medicine: The Nation's Physicians Workforce: Options for Balancing Supply Requirements. Washington, DC, National Academic Press, 1996 20. Pew Health Professions Commission: Critical Challenges: Revitalizing the Health Professions for the Twenty-first Century. San Francisco, University of California, San Francisco, Center for the Health Professions, 1995 21. Whitcomb ME: A Cross-national comparison of generalist physician workforce data: Evidence for US supply adequacy. JAMA 274:692-695, 1995 22. Miller RS, Jonas HS, Whitcomb ME: The initial employment status of physicians completing training in 1994. JAMA 275:708-712, 1996 23. Miller RS, Dunn MR, Whitcomp ME: The initial employment status of physicians completing training in 1995. JAMA 277:1699-1704, 1997 24. Miller RS, Dunn MR, Richter TH, et al: Employment-seeking
experiences of residents completing training during 1966. JAMA 280:777-783, 1988 25. IglehartJK: Health policy report: The quandary over graduates of foreign medical schools in the United States. N Engl J Med 334:1679-1683, 1996 26. Vance RP, Prichard RW, Smith RD: Pathology trainee manpower. HUM PATHOL22:1067-1076, 1991 27. Vance RP, Hartmann WH, Prichard RW: Pathology trainee manpower: Historical perspectives. Arch Pathol Lab Med 116:574577, 1992 28. Whitcomb ME: Correcting the oversupply of specialists by limiting residencies for graduates of foreign medical schools. N EnglJ Med 333:454-456, 1995 29. Whitcomb ME, Miller RS: Comparison of IMG-dependent and non-IMC-dependent residencies in the national resident matching program.JAMA 276:700-703, 1996 30. The National Resident Matching Program. Washington, DC, National Resident Matching Program, 1997
122
Committee on Pathology Enhancement (CCOPE) surveys. HUM PATHOL 30:117-122. Copyright © 1999 by W.B. Saunders Company Key words:workforce, managed care. Abbreviations: US, United States; HMOs, health maintenance organizations; CCOPE, Conjoint Committee on Pathology Enhancement; NPMD, National Pathology Manpower Database; CHPL, commtmity hospital/private laboratory; AMA, American Medical Association; IMGs, international medical graduates; COGME, Council on Graduate Medical Education; NRMP, National Resident Matching Program.
Since the failure of health system reform in 1993, managed care has dramatically changed the landscape of the physician workforce. 1,~ Workforce projections in many cases witnessed dramatic downturns after consistent 25 years increases. Although some still believe the managed care backlash will intensify in the future, it is not at all clear that such retrenchments would increase the demand for physicians,s,4 All of the uncertainties in workforce projections are compounded in pathology because pathologists represent only 2% of the total physician workforce, the demand for pathologists is multifactorial, and the workload is poorly standardized or studied. 5 In the pre-1993 healthcare reform era, projections of pathology workforce were hampered by the lack of adequately developed workforce demand methodology.6 The only projections that could be made with any degree of certainty were simple supply projections; comparing those entering and those leaving the specialty. Based on an aging practicing population, declining interest in pathology among United States (US) graduates, and significant trainee attrition from pathology residencies, a prediction of a shortage was straightforward. 6 The rapid expansion of managed care beginning in 1994 changed the workforce landscape, especially when staffand group model health maintenance organizations (HMOs) staffing levels became pubicly k n o w n . 7,a,9,1° These data suggested that the demand for pathologist would be substantially less than the current United States supply, if HMO staff and group models
became the norm. Unfortunately, the data presented in these studies were limited to a handful of HMOs, and data on pathology were not always available. In addition, the wide variability found in pathology staffing ratios raised validity questions, especially if such data were to be extrapolated to the entire US population. In response to these issues, the Conjoint Committee on Pathology Enhancement (CCOPE)--a collaborative effort on the Association of Pathology Chairs, American Society of Clinical Pathology, and the College of American Pathologists--undertook a series of studies in 1994 to 1995 to evaluate the changing pathology workforce environment. These surveys were sent to pathology residency program directors, first year pathology residents, exiting pathology trainees, community hospital private laboratory pathologists, and academic pathologists. In some instances, the paucity of published data and the lack of a well-developed survey methodology forced the committee to attempt to collect information that had been previously unavailable. Consequently, some results from the surveys were incomplete, especially those which predicted dramatic surpluses for pathology workforce. The purpose of this article is to provide a summary of all those studies, except for the academic survey results, and to place those results in the context of workforce publications which have since then referenced pathology. A summary of the last CCOPE surveys from 1994 to 1995 will be used as a baseline, and limitations in the methodology and the data projections will be clearly outlined.
From the Department of Population Health Improvement, Humana Inc., Louisville, KY. Address correspondence and reprint requests to Richard R Vance, MD, Vice President, Population Health Improvement, Humana Inc., 500 W. Main Street, Louisville, KY 40201. Copyright © 1999 by W.B. Saunders Company
MATERIALS AND METHODS The survey of community hospital private laboratory pathologists were conducted using the National Pathology Manpower Database (NPMD) and supplemental data from the American Medical Association's Master-
0046-8177/99/3002-0002510.00/0
117
HUMAN PATHOLOGY
Volume30, No. 2 (February 1999)
file of Physicians. The NPMD was constructed in the 1980s to be a large-scale longitudinal, demographically representative survey of community hospital/private laboratory (CHPL). 6,11,12 The original survey in 1986 included 4,669 pathologists. Of the responses received from the initial mailing, 2,469 pathologists indicated a willingness to participate in future surveys. The NPMD has been previously used three times. In the second and third iterations, pathologists from the American Medical Association (AMA) Masterfile were used as supplements to keep the sample demographically representative. For the fourth (1994 to 1995) iteration, a total of 940 surveys were sent out (753 were respondents from the previous survey and 187 were from a supplemental sample drawn from the 1994 AMA Masterfile). With each of the individual surveys, a second survey labeled "Heads of Group Survey" was sent. The individual pathologists who received the packet was asked to fill out the individual pathologist survey, and instructed to give the "Head of Group Survey" to their head of group (eg, the administrator or president of the individual groups). If the individual pathologist was the head of their group, they were instructed to fill out both surveys. Currently no comprehensive database exists on the heads of groups. CCOPE hoped the data received from the heads of groups would provide some preliminary indication of market dynamics that might not be appreciated by the average practicing pathologist. The 1995 program directors survey was mailed to each of the 184 programs listed as active by the Accreditation Council for Graduate Medical Education (ACGME). Program directors were asked to respond to questions relating to their tenure as directors, the characteristics of their first year residents, the characteristics of their remaining residents and fellows, and the pathways of residents into training and into practice. Program directors were also asked to distribute the first year residents surveys to entering first year residents in July 1995. Program directors were also asked to distribute exit surveys to those trainees who were leaving training to go into CHPL or academic practice. The first year resident survey examined academic and demographic information regarding trainees entering pathology. The exit survey asked exiting trainees to assess the quality of their training and their perceptions of the pathologyjob market.
RESULTS Of the 940 NPMD individual pathologist questionnaires mailed, 532 were returned, 78 of which were deemed ineligible (36 came from academic pathologists and 42 came from people who were not practicing pathology at least 20 hours per week). If those determined to be ineligible are removed from the initial mailing, the response rate is calculated as 454/865 (53%). Both the initial mailing and the subsequent response was demographically representative (by age, gender, and geographic region) of CHPL pathologists in the AMA Masterfile.
TABLE 1.
Percentage Number
Individual Pathologists Planning on Retirement In 1 Year
In Subsequent 2 to 5Years
Total
3 360
22 2,422
25 2,782
A total of 290 NPMD group leader questionnaires were returned, but 6 of these did not have complete information on the number of full-time equivalents in the group, so they were not used in the analysis. Therefore, the total number of usable questionnaires was 284. If the same eligibility rate was assumed as for the individual questionnaires, the response rate for the group leader questionnaire is 284/862 (33%). The 454 CHPL respondents represented 4% of the 11,132 CHPL pathologists in the US in 1994. The 284 heads of groups represent 1258 community hospital private laboratory pathologists or 11% of the practicing pathologists in CHPL in the US. In response to question regarding future retirement, individuals responding to the NPMD provided data as seen in Table 1. Over the next 5 years, 25% of those responding indicated that they would be retiring or leaving pathology practice. Extrapolated to the universe of CHPL practitioners, that yields a total of 2,782 pathologists. These data suggest that on average, 556 pathologists will be retiring in each of the 5 years beginning with 1994. These findings are consistent with the demographics of the pathology population in the AMA Masterfile, and previous iterations of the NPMD. The relatively low response rate for heads of groups in this iteration of the NPMD makes extrapolation to the total market of CHPL pathologists risky. However, Tables 2 and 3 present information about the picture of the pathology market generated by respondents. During the period from 1994 to 1995, the total number of retirements extrapolated to the universe of CHPL pathologists decreased 15%, and resignations decreased 65%; losses of positions caused by mergers increased sixfold, and reductions in positions because of decrease in business volume increased 50%. In contrast, the market demand for new positions decreased 20% and the filling of vacant positions decreased 60%; consequently, the total demand for pathologists during this time period decreased 40%. In addition to the small sample of heads of groups, 11% of the group losses respondents were blank, whereas 22% of those in the market demand questions were left blank. After 100% responses beginning in 1989, the 1995 program directors survey yielded only a 96% response TABLE 2.
Retire Resign Merger Volume loss
118
CHPLGroup Losses 1994
1995
293 295 5 84
243 110 30 125
PERSPECTIVESIN PATHOLOGY(Richard P, Vance) TABLE 3.
Market Demand for CHPL Pathologists
New hires Vacancy Total d e m a n d
200-~
1994
1995
Percentage
359 450 809
289 200 489
- 20 - 60 - 40
195
190.
i~i~iil iii!ii!i!
185./~: rate (176/184 programs). As depicted in Fig 1, the total n u m b e r of trainees has continued to increase. In 1995 the total n u m b e r of trainees exceeded 3,000 for the first time in the history of pathology training. At the same time, the total n u m b e r of programs declined to the lowest n u m b e r before World War II. Figure 2 indicates the total n u m b e r of programs from 1990 through 1996. In 1995, international medical graduate (IMGs) represented 33% of all pathology trainees. As in previous years, the total n u m b e r of first year trainees was approximately 650. Only 56% of first year trainees entered pathology trained directly from medical school. This is consistent with trends since the late 1980s. The total n u m b e r of trainees who attrited to other specialties was less than 100. One third to those who attrited were IMGs. O f the graduating c o h o r t in 1995, approximately 290 trainees went to community hospital private practice; a n o t h e r 70 went into academic positions; 120 entered programs other than their primary training programs for fellowship; and 110 remained at their primary program for additional fellowship training. We do not at this point have good data on the total n u m b e r of highqevel fellows leaving academic practice to find jobs in the CHPL sector or the n u m b e r of academic physicians who are making the same shift. The 1995 exit survey yielded 200 responses representing a 56% response rate. This is consistent with exit surveys c o n d u c t e d in 1992 through 1994. O f those responding, 36% were women. The mean n u m b e r of years of pathology training was 5.2 years. The percentage of respondents who were alpha omega alpha (AOA) was 19.3%. Additionally, 90% were trained in Anatomic Pathology/Clinical Pathology (AP/CP), whereas 7% were trained straight AP. A m o n g US graduates, 94% had jobs as pathologists at the time of the exit survey (May 1995). At that same time period 86% of IMGs had jobs. US graduates applied for an average of 10 positions. IMGs applied for 27 positions on average. The n u m b e r of j o b offers for US graduates was 2.0 on average, whereas the average for IMGs was 1.4. These
ii
180Ai 175 ~i~ilililii
•
[] Programs
iii~ii! iiiii!ii
ii~iiii!i
165.~ 90
ii! °
iii!fiil;~
91
92
93
94
95
96
FIGURE 2. Total pathology training programs.
numbers reflect a declining n u m b e r of offers for exiting trainees in pathology. Overall exiting trainees received 1.9job offers in 1995 (Fig 3)i For the first-year residents survey, we received a total of 377 responses from the approximately 650 first year residents in 1995 (58% response rate). Women represent 42 % of the respondents. O f the US graduates, 8.8% were MD/PhDs. IMGs were represented by 30% of the respondents. O f the entering first year residents 17.4% were AOA. The total mean debt for all respondents was $47,349. Fifty-seven percent of respondents were in the first quartile of their graduating class. DISCUSSION
Workforce modeling is an inexact and confusing science. Even when the health care system displays predictable change, ambiguity in definitions and minor disagreements over presuppositions can yield significant discrepancies in forecasts, is Since 1993, changes in the health care system have been unpredictable and uneven, even though the root cause of the change has been the same: the penetration of managed care.
1,
-3500
[[] Trainees
-3000
.2500 2000 1500 iti:~iiii[ii!!i!i~'~-~
1000 500
Trainees 75
80
85
90
92
95
FIGURE 1. Total pathology GME trainees from 1975.
93
94
FIGURE3, Job offers per exiting trainee,
119
95
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Volume 30, No. 2 (February 1999)
Although many believe this trend will continue or accelerate, others believe there will be a swing of the pendulum away from managed care (at least as we have seen it so far). 3 Workforce prognosticators are also divided (albeit unevenly) between those who believe a significant surplus is upon us, 7 and those who argue that we are not now or in the foreseeable future far away from workforce balance. 14,15 There can be no denying that the supply of physicians has grown dramatically.2 The supply will be 261 physicians per 100,000 population by the year 2000, up from 156/100,000 in 1971.2 In contrast, the Council on Graduate Medical Education (OGME) has reported that 145 to 185 physicians per 100,000 is the appropriate ratio for the 21st century. 16 The majority of workforce specialists believe there is and will be a substantial surplus of physicians. In large part this conclusion is based (as was the 8th COGME report) on the presupposition that managed care staffing ratios are the most appropriate ones, and that those arrangements will come to dominate the health care system.1 Benchmarking models, constructed by comparing HMO staffing levels with non-HMO levels, such as the ones described by Goodman and Weiner are currently the most popular method for determining workforce levels. 7,9 This sort of benchmarking approach has supplanted perspectives based either on the percentage of generalists to specialists, 17,1s or on supply or demand models. In the past 2 years, physician workforce studies (using benchmarking methods) have once again reiterated that a physician surplus is inevitable under current policies. 16,19,2°Goodman et al showed that nationally the generalist workforce exceeds HMO staffing levels by 35%, and that seven specialties (one of which is pathology) exceed HMO staffing levels by more than 100%.7,s Practicing pathologists represent 4.2 physicians/100,000 population. 9 If residents are factored in, the ratio becomes 5.2/100,000. 7 According to Goodman et al pathology workforce exceeds HMO staffing requirements by a factor of 2.08. s Richard Cooper has argued that the benchmarking model is inadequate because it fails to consider the demographics of the US population. 14,15 Nevertheless, Cooper's presuppositions still show that we have a surplus of physicians currently, and that the surplus will continue through 2010 regardless of what we do to workforce policy now. After 2010, he believes an increasing population will begin to bring the workforce policy supply back into balance. At least part of Cooper's analysis has been supported by Michael Whitcomb's examination of cross-national comparisons of generalist physician workforceY It is fair to say, however, that Cooper's position is currently not the majority opinion. Pathology workforce projections are uncertain when using the benchmarking model because the HMO staffing patterns for pathology have significant variation, and very few staff/group HMOs have been studied. However, even if one takes Cooper's presuppositions, and applies a 60% penetration of managed care by the year 2000, pathology is still probably facing a 120
significant surplus. It is conceivable--using (1) the most optimistic published pathology HMO staffing levels, (2) assumptions that managed care penetration will not be as significant as expected, (3) presuppositions that the dwindling recruitment of medical students into pathology will continue, and (4) arguments about our aging and increasing population--that pathology workforce might be in balance in 2010. However, without those qualifications, most studies suggest that there will be a significant surplus of pathologists over the next decade. There is additional evidence (as shown previously) that the market had begun to tighten substantially in 1994 and 1995 (Tables 2 and 3). Such observations fit well with contemporaneous and subsequent studies on the employment status of newly exiting pathology trainees. Miller et al reported that of all specialties in 1994, pathology had the highest percentage of unemployed exiting trainees--10.8%. 22When the response rate and other factors are considered, this finding was consistent with the exiting trainees surveys conducted by CCOPE. Miller et al also found among the 1995 exiting trainees that the 11.8% of pathology trainees experienced difficulties obtaining positions. 2~ Furthermore, 55% of pathology program directors reported that they anticipated employment problems for future graduates. 23 In the same study, Miller noted that 20% of pathology programs had decreased in size in 1994 to 1995 and that 40% may reduce residency positions in subsequent years, perhaps in anticipation of future difficulties.23 Finally, Miller's 1996 report, reconfirmed pathology's relatively high percentage of training graduates who had not found employment by the time of Miller's survey (14.7%). 24 Furthermore, 50.8% of responding residents had significant difficulty finding a practice position, and 49.2% received only one job offer. Most recent policy reports implicate the high numbers of IMGs as a major factor in the physician surplus. 19,2°,25 IMGs make up 23% of practicing physicians, up from 18% in 1970. 2,25 As reported here (and previously), pathology is one of those specialties with a higher than average proportion of IMGs. 26,27 Key players in the national workforce debate have in recent years begun to focus on the level of funding for IMGs as a means for constricting workforce growth. 2,25,2s Currently, 6,900 IMGs enter US residencies each year. 29% of all residency programs are IMG dependent, filling on average 76% of their positions with IMGs. 29 Whether Congress is prepared to deal with the political issues surrounding this issue remains uncertain. 25 The most recent comprehensive data on pathology GME are in the 1995 CCOPE Program Director's survey. Although there are some indications that programs have already begun to downsize,22 the total GME workforce in 1995 was still the highest in the history of pathology GME. The market for newly exiting trainees has certainly shown signs of significant tightening. Yet, I suspect that the most substantial market pressures are being felt by midcareer pathologists, and those CHPL pathologists who are on the cusp of partnership. The 1997 National Resident Matching Program (NRMP)
PERSPECTIVES IN PATHOLOGY (Richard P. Vance)
600500400PathoIogyNRMP results 1992-1997, FIGURE4.
• Total Positions Offered • US Graduates Filled
300200-
[] IMGs Filled
10001992
1993
1994
1995
1996
1997
REFERENCES
results do suggest that recruitment into pathology may be decreasing (Fig 4).3° However, the NRMP has proven to be a very unreliable guide to recruitment trends, filling less than 50% of total first-year resident cohorts since the late 1980s.
SUMMARY Workforce projections for pathology have always had significant methodological weaknesses, even periods of relative stability. With the lack of systematic workforce evaluation process, the specialty is--especially at this time--flying blind. Data from all the sources examined, do indicate that there is already a surplus, and that there will be a growing surplus of pathologists over the next decade. The magnitude of the surplus, is, however, anyone's guess. There are two additional significant deficiencies in our current knowledge of pathology workforce. The first is the kinetics within academic pathology. We have no idea for example, how many fellows are being used as j u n i o r faculty because of shortages in the CHPL marketplace. Even more important than academic kinetics though, is the absence of a "heads-of-group" database. The latest iteration of the NPMD survey indicates that a heads of groups survey may prove to be a valuable m e t h o d to determine what is happening in the pathology marketplace. We do not currently know how many groups of pathologists there are in the US. We certainly do not know which pathologists lead those groups. Because these pathologists largely control the d e m a n d for CHPL pathologists, organized pathology would be well advised to survey these leaders regularly. In the absence of such information, we are likely to be caught unprepared, once again, when the health care marketplace makes its next major change.
Acknowledgment. T h e a u t h o r will always r e m a i n i n d e b t e d to the wisdom and h u m o r of his mentor, R o b e r t W. Prichard, MD, in guiding his research in pathology workforce. 121
1. Rivo ML, Mays HL, Katzoff J, et al: Managed health care: Implications for the physician workforce and medical education. JAMA 274:712-715, 1995 2. Rivo ML, Kindig DA: A report card on the physician work force in the United States. N EnglJ Med 334:892-896, 1996 3. Ginzberg E, Ostow M: Managed care--A look back and a look ahead. N EnglJ Med 336:1018-1020, 1997 4. Kassirer JR Is Managed Care Here to Stay? N Engl J Med 336(14):1013-1014, 1997 5. Smith RD, Vance RP, Anderson RE, et ah National pathology manpower survey of 1991: Projected Needs in community hospitals and private laboratory practice. Am J Clin Path 100:$33-$36, 1993 (supp 1) 6. Vance RP: Pathology manpower needs in the year 2000: The view from 1990. Lab Med 23:412-415, 1992 7. Goodman DC, Fisher Es, Bubolz TA, et al: Benchmarking the US physician workforce: An alternative to needs-based or demandbased planning.JAMA 276:1811-1817, 1996 8. Goodman DC, Fisher Es, Bubolz TA, et al: Benchmarking the US physician workforce. JAMA 277:964-966, 1997 9. Weiner JP: Forecasting the effects of health reform on US physician workforce requirement: Evidence from HMO staffing patterns.JAMA 272:222-230, 1994 10. Wennberg JE, Goodman DC, Nease RF, et al: Finding equilibrium in U.S. physician supply. Health Affairs 12:89-103, 1993 11. Anderson RE, Benson ES, Smith RD, et al: Special report-National manpower survey of 1987: Manpower needs in community hospital and private laboratory practice of pathology. Am J Clin Patho190:482-486, 1988 12. Benson ES, Smith RD, Anderson RE, et al: National pathology manpower survey of 1988: Manpower needs in community hospitals and private laboratory practice. Arch Pathol Lab Med 114:566-569, 1990 13. Feil EC, Welch HG, Fisher ES: Why estimates of physician supply and requirements disagree. JAMA 269:2659-2663, 1993 14. Cooper RA: Perspectives on the physician workforce to the year 2000.JAMA 274:1534-1543, 1995 15. Cooper RA: Seeking a balanced physician workforce for the 21st century. JAMA 272:680-687, 1994 16. Council on Graduate Medical Education: Patient Care and Supply and Requirements: Testing COGME Recommendations: 8th Report to Congress and the Health and Human Services Secretary. Rockville, MD, Health Resources and Services Administration, 1996 17. Kindig DA, Cultice JM, Mullan F: The elusive generalist physician: Can we reach 50% Goal? JAMA 270:1069-1073, 1993 18. Kindig DA: Counting generalist physicians. JAMA 271:15051507, 1994
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19. Institute of Medicine: The Nation's Physicians Workforce: Options for Balancing Supply Requirements. Washington, DC, National Academic Press, 1996 20. Pew Health Professions Commission: Critical Challenges: Revitalizing the Health Professions for the Twenty-first Century. San Francisco, University of California, San Francisco, Center for the Health Professions, 1995 21. Whitcomb ME: A Cross-national comparison of generalist physician workforce data: Evidence for US supply adequacy. JAMA 274:692-695, 1995 22. Miller RS, Jonas HS, Whitcomb ME: The initial employment status of physicians completing training in 1994. JAMA 275:708-712, 1996 23. Miller RS, Dunn MR, Whitcomp ME: The initial employment status of physicians completing training in 1995. JAMA 277:1699-1704, 1997 24. Miller RS, Dunn MR, Richter TH, et al: Employment-seeking
experiences of residents completing training during 1966. JAMA 280:777-783, 1988 25. IglehartJK: Health policy report: The quandary over graduates of foreign medical schools in the United States. N Engl J Med 334:1679-1683, 1996 26. Vance RP, Prichard RW, Smith RD: Pathology trainee manpower. HUM PATHOL22:1067-1076, 1991 27. Vance RP, Hartmann WH, Prichard RW: Pathology trainee manpower: Historical perspectives. Arch Pathol Lab Med 116:574577, 1992 28. Whitcomb ME: Correcting the oversupply of specialists by limiting residencies for graduates of foreign medical schools. N EnglJ Med 333:454-456, 1995 29. Whitcomb ME, Miller RS: Comparison of IMG-dependent and non-IMC-dependent residencies in the national resident matching program.JAMA 276:700-703, 1996 30. The National Resident Matching Program. Washington, DC, National Resident Matching Program, 1997
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