A major source of data for U.S. pathologist workforce figures undercounted the specialty size by 40% and needs to be fixed, according to a study published online July 16 in JAMA Network Open.
The study was sponsored by the College of American Pathologists (CAP) and followed up on an article with workforce data published in JAMA Netw Open in May 2019. Alarmingly, that study concluded that the number of active pathologists dropped from 15,568 to 12,839 between 2007 and 2017, a trend that suggested great risk for a shortage of specialists in the field in the future. These data were based on information published by the American Association of Medical Colleges (AAMC), which in turn drew from the American Medical Association (AMA) Physician Masterfile.
Some in the field had noted that the 12,839 figure appeared low compared with other workforce analyses and explored discrepancies in the new study sponsored by CAP.
For the study, Dr. Stanley Robboy, vice chair for diagnostic pathology at Duke University, and colleagues reviewed the AMA masterfile directly. They found that as of June 2019, there were 21,292 active pathologists, which is about 40% higher than the 12,839 figure.
Why such a huge gap? Due to the way information was recorded in the AMA masterfile and extracted by the AAMC, the 12,839 figure mainly includes doctors with a primary specialty in anatomic/clinical pathology, while excluding many of those who went on to get subspecialty training. In fact, 11 subspecialty areas were excluded, Robboy and colleagues wrote.
"We recommend that the AAMC or any other organization relying on these data alters how it reports the pathology workforce and includes all individuals in the AMA Physician Masterfile list as pathologists," the authors wrote. "We recommend [further that] previously published reports on pathology workforce based on AAMC information be reexamined."
CAP will be collaborating directly with the AAMC to address issues with the data, and ensure understanding of the complexities of pathology, Dr. Donald Karcher, vice chair of CAP’s Council of Government and Professional Affairs, commented in an interview.
“They are very motivated to make this right; they want to make sure they are publishing accurate numbers of pathologists,” said Karcher, who is also chair of pathology and director of laboratories at George Washington University.
Subspecialties set aside
The article highlights a big problem for organizations planning for the future of the pathology specialty and for pathologists themselves. Subspecialty areas that have been left out of AAMC estimates include blood banking, cytopathology, hematopathology, and microbiology.
Furthermore, there are issues in data sources with the classification of dermatopathologists, who are categorized as dermatologists even if their primary training is in pathology. And those who had subspecialty training in molecular genetics pathology were deemed to be geneticists. Similar issues are likely to affect other physician specialties where subspecialization is common, such as surgery.
"Accurate physician workforce assessment for all specialties may require a reexamination of the methods used in producing current and previous estimates," Robboy et al wrote.
While the masterfile is a large database on physicians, the information is not published, rather it is sold to third parties for a range of purposes, including marketing. Due to its cost, it has not been used in some studies on the pathology workforce.
For the May 2019 study showing a decline in the workforce, the AMA masterfile data was not available, so analysis was based on AAMC’s distilled version, commented Dr. Jason Park, PhD, associate professor of pathology at the University of Texas Southwestern Medical Center, who was a co-author. At the time, the authors didn’t know how to reconcile what seemed to be a diminishing workforce with what they knew about the job market and what people were saying anecdotally, Park commented in an interview.
Park is also a co-author on the new study showing the shortcomings of the AAMC data. It’s clear now that the AAMC data underrepresented pathologists and this has led to some confusion in the field, he said.
Low numbers create image problem
Undercounting has consequences, the authors noted. For example, it can give the impression of a shrinking, less attractive field of medicine.
"Inaccurate or incomplete depictions of the existing or projected supply of physician subspecialties can misleadingly affect career choices," Robboy et al wrote.
Robboy et al's study and an accompanying JAMA Netw Open article also published on July 16 underscored the importance of reliable data in order to model the workforce accurately and plan for shortages and surpluses in the future.
"Use of the AAMC data, which has undercounted the number of pathologists needed for a given amount of work, would lead to a much lower predicted number of pathologists needed for a given increase in population and/or complexity of work," wrote Dr. Christopher VandenBussche, PhD, associate professor of pathology and oncology at Johns Hopkins University, in the editorial.
VandenBussche called for the development of standardized, unbiased methods by physician organizations and greater participation in census counts.
"Physicians entering a specialty should be taught the importance of workforce assessment and be asked to commit to career-long participation. Ideally, the process would remain nonintrusive and streamlined to avoid further physician burnout and detachment," VandenBussche advised.
A glaring error
The “glaring error” in pathology workforce data raises questions about why the specialty’s organizations were not on top of the figures, commented Dr. George Lundberg, clinical professor of pathology at Northwestern University, who wrote an editorial about the May 2019 study and was not involved in the article published July 16.
Organized pathology should keep track of its own numbers rather than relying on two different outside organizations, Lundberg suggested in an interview.
“This could be very disconcerting,” Lundberg said. “I would call upon the leaders of the specialty to figure out a way to do it right on behalf of people in the specialty.”
Karcher noted that there is no single definitive source of data and it’s very difficult for one organization to collect all of it. CAP has nearly 18,000 members, but this is not the whole base of pathologists in the U.S. Also, it includes retired physicians; CAP has not published what percentage of its members are actively practicing.
The AMA masterfile data are not perfect, but come closest to what the leaders of the specialty think is the true number of actively practicing pathologists, according to Karcher. CAP is in communication with the AMA regarding the database, he added.