An aging population calls for an adequate response in the workforce of medical professionals. The field of pathology has seen a downward trend in numbers of graduating US allopathic medical students choosing the specialty. Concerns about the job market after residency and fellowship graduation may be a contributing factor.
To provide an update on the trends emerging from a survey of pathology graduates' job search experience for their first nonfellowship position.
Data from an annual job search survey sent by the College of American Pathologists Graduate Medical Education Committee between 2017 and 2019 to College of American Pathologists junior members and fellows in practice 3 years or less actively looking for a nonfellowship position was analyzed. Various indicators of the job search experience were compared year to year and with the previously published 2012 to 2016 benchmark data.
Analysis revealed positive trends between the 2017 to 2019 data and the 2012 to 2016 benchmark data, including participants' perceiving more ease in finding a position, improved availability of jobs in their subspecialty choice, and higher ratings of satisfaction with the position accepted, as well as a greater proportion of respondents finding a position within 6 months of initiating their job search.
The job market for pathology residents and fellows looking for their first nonfellowship position has improved with respect to multiple indicators, such as ease of finding a position, length of job search, and satisfaction with the position accepted when comparing 2017 to 2019 data with the 2012 to 2016 benchmark data.
Patient demographics in the United States continue to change as the percentage of the population older than 65-years old is projected to reach 48% by 2032.1 The increase in demand for medical care translates into an anticipated deficit of 24 800 to 65 800 nonprimary care physicians. In particular, the supply of pathologists is decreasing at a time when aging demographics point to increased demand. Robboy et al2 anticipated that the efflux of pathologists due to retirement would lead to an increased need for new pathologists to enter the workforce. In 2019, 1.1% of US allopathic seniors entered pathology, a 40% reduction from 1.7% in 2015.3 Similarly as of 2019, US allopathic seniors filled 33.4% of postgraduate year 1 pathology positions, compared with 46.6% in 2015.3 At the same time, pathologists' scope of practice continues to expand to include evolving fields, such as informatics, precision medicine, and diagnostic management teams.4 Indeed, a recent survey of practice leaders indicated that demand for pathologists may soon exceed supply.5 The data of Gratzinger et al6 from 2012 to 2016 showed a stable job market with the majority of respondents satisfied with positions accepted. Moreover, surveys indicate that pathology graduates seeking their first position were able to find a job in a geographic region that met their expectations and that there were no differences in job search experience or satisfaction based upon sex.7,8 We now present an update on the initial job search experience of first time pathologist job seekers using data collected between 2017 and 2019.
Since 2012, an annual job search survey has been emailed in early June by the College of American Pathologists (CAP) Graduate Medical Education Committee (GMEC) to approximately 3000 CAP junior members and fellows in practice 3 years or less. The target population is captured through initial screening questions to identify respondents who actively searched for a first-time nonfellowship position since completing residency or fellowship training during the prior year, typically during their last year of residency/fellowship training. The online survey is voluntary and anonymous. Survey questions have remained largely consistent over the years to allow for year-to-year job market comparisons, with the exception of additional demographic questions incorporated in 2015 and citizenship questions added in 2018. The survey questions are provided in Document 1 within the supplemental digital content, also containing 8 tables at https://meridian.allenpress.com/aplm in the September 2021 table of contents. Job market trend data, expressed as either mean values or a percentage, were compared between the Gratzinger et al6 2012 to 2016 “benchmark” or “initial” cohort and the “current” 2017 to 2019 cohort.
As in previous CAP Graduate Medical Education Committee Job Market publications, United States medical school graduates include graduates of US Doctor of Medicine and Doctor of Osteopathic Medicine programs; international medical graduates are graduates of international medical schools, including US citizen graduates of international medical schools. Aggregate data from the 2017 to 2019 CAP Graduate Medical Education Committee Job Market surveys were analyzed across multiple job market indicators, including percentage of respondents accepting a position, perceived difficulty in finding a position, satisfaction with the position accepted, number of fellowships completed, job search success in relation to medical school type, and length of job search.
Standard statistical methods employed include independent samples t-tests and 2-way X2 tests to evaluate relationships between factors. Statistical analyses were performed using IBM SPSS Statistics for Windows, version 23.0. (IBM Corp, Armonk, NY) as indicated in the text. Statistical comparisons were not performed on multiple response data.
During 3 years between 2017 and 2019, there were 316 respondents to the survey. Respondents are self-selected as the survey is voluntary. During the last 3 years of data collection, the number of respondents has been stable. It is important to note that the survey is sent once in early June and captures the respondent's job search at that point in time. In cases where the respondent has only recently started looking for a position, the data collected does not encompass the final result of the respondent's job search.
Respondent demographics have remained stable between the initial (2012–2016) and current (2017–2019) survey cohorts. The initial cohort was 55% female (149 of 270) and 45% male (121 of 270), with the current cohort remaining balanced at 49% female (148 of 299) and 48% male (144 of 299); the option not to indicate a sex was added in 2017 and chosen by 3% of respondents (3 of 99). The majority of respondents were in the 25- to 34-year-old range in both the initial (57% [156 of 272]) and current (51% [151 of 298]) survey cohorts, with most of the rest in the 35- to 44-year-old range (36%, [98 of 272] and 40% [118 of 298], respectively). The majority of respondents in both cohorts were graduates of US allopathic schools (64% [484 of 760] and 56% [167 of 299]), with significant numbers of graduates of international medical schools (27% [204 of 760] and 33% [98 of 299], respectively) and US osteopathic schools (8% [58 of 760] and 9% [26 of 299], respectively). The majority of respondents had combined Anatomic Pathology and Clinical Pathology training, 83% (642 of 769) and 80% (239 of 300), initial and current cohorts, respectively. Fewer respondents (11% [84 of 769] and 13% [39 of 300]) completed Anatomic Pathology training only, and even fewer (5% [39 of 769] and 5% [16 of 300]) completed Clinical Pathology training only. The majority of respondents in both cohorts had either 1 fellowship (66% [505 of 767] and 59% [178 of 302]) or 2 or more fellowships (25% [195 of 767] and 31% [94 of 302]), with a small subset with no fellowships (9% [67 of 767] and 10% [30 of 302]). Citizenship status was added to the survey in 2017; approximately 79% (251 of 296) of respondents hold US citizenship or permanent residency. Demographics of the respondents with regard to sex, age, type of medical school, residency training program, and US citizenship are provided in Supplementary Tables 1 through 5.
Update on Job Market Indicators
Rate of Position Acceptance
The percentage of respondents who had accepted a position at the time of the survey has remained stable from the initial 2012 to 2016 survey cohort (74% [233 of 316]) compared with the 2017 to 2019 cohort (69% [517 of 752]; χ21 = 2.643, P = .10; see Table 1). Of note, this represents a snapshot in time at the time of the survey, and not the final percentage of applicants accepting a position—many applicants at this point are actively interviewing, and others have just begun a job search. At the time of the survey, 88% (278 of 316) of respondents had already been invited to at least 1 interview, and of those who had not accepted a position at the time of the survey, 41% (33 of 80) were within the first 3 months of their job search.
Reported Ease of Finding a Position
As shown in Figure 1, across the 2017 to 2019 survey administrations, 38% (85 of 226) of respondents indicated it was Very Easy/Easy to find a position (mean = 2.81 on a 5-point scale; Very Easy = 1, Easy = 2, Moderate = 3, Difficult = 4, Very Difficult = 5), compared with only 20% (100 of 509) of respondents from the 2012 to 2016 benchmark data (mean = 3.45). This is a statistically significant improvement in the ease of finding a position (t225 = −8.212, P < .001). Participants' perception of difficulty finding a position are comparable across the 2017 (mean = 3.01), 2018 (mean = 2.73), and 2019 (mean = 2.67) survey administrations (F2,223 = 1.867, P = .16).
Reason for Perceived Difficulty
Among respondents who answered that it was “Very Difficult” or “Difficult” to find a position, significantly fewer respondents in the current cohort (47% [27 of 57]) cited “too few jobs available” compared with the initial cohort (93% [216 of 233], χ21 = 69.311, P < .001; see Figure 2). It should be noted that, beginning in 2017, the item choice “too few jobs available in my subspecialty choice” was reworded from “too few jobs available” provided on the 2012 to 2016 surveys administrations. Owing to the small number of respondents to this question for the individual survey years, statistical comparisons were not made between 2017 (n = 26), 2018 (n = 15), and 2019 (n = 16) responses.
A 2-way X2 test was performed to compare the length of job search for respondents who had accepted a position at the time of the survey (≤6 months versus >6 months). Significantly more 2017 to 2019 respondents found a position within 6 months of starting their search compared with the 2015 to 2016 benchmark (72% [166 of 231] versus 61% [119 of 196]; χ21 = 5.936, P = .02; see Figure 3). Length of job search was not asked on the 2012 to 2014 surveys.
Characteristics of Accepted Positions
In the current cohort, 93% of respondents were either “Very Satisfied” or “Satisfied” with the position accepted, with the overall mean (mean = 4.50, SD = 0.70; 5-point scale with 1 = Very Dissatisfied, 2 = Dissatisfied, 3 = Neutral, 4 = Satisfied, 5 = Very Satisfied) significantly higher than the benchmark (mean = 4.38, SD = 0.78; t229 = 2.585, P = .01, 95% CI of the difference, .029−.211).
The proportion of respondents accepting academic positions in survey years 2017 to 2019 combined is comparable to the 2012 to 2016 benchmark data (41% [93 of 226] versus 38% [187 of 498]; χ21 = .850, P = .36). Some year-to-year variation was present within the 2017 to 2019 timeframe (χ22 = 6.358, P = .04).
A significantly greater proportion of respondents between 2017 and 2019 reported higher starting salaries, including academic and private practice compensation, than the 2012 to 2016 benchmark (χ27 = 46.440, P < .001; see Figure 4). In 2019, 69% of respondents (n = 54 of 78) reported a starting salary of $200 000 or more compared with 44% (238 of 539) of respondents from the 2012 to 2016 survey administrations.
Respondent Characteristics and Job Search Success
Respondents who completed at least 1 fellowship are more likely to have accepted a nonfellowship position at the time of the survey compared with those who had not completed a fellowship (χ22 = 34.283, P < .001). Sex was not associated with job search success (χ21 = 1.471, P = .22; Supplementary Table 6). In addition, respondents who had or had not accepted positions reported submitting similar numbers of job applications. Respondents who had already accepted a position at the time of the survey had submitted a mean of 5.67 (SD = 3.44) job applications, and those who had not accepted a position had submitted a mean of 5.05 applications (SD = 3.62; t314 = 1.403, P = .16).
International medical school graduates had significantly lower rates of having accepted a position than US medical graduates (68% [n = 67 of 98] versus 79% [153 of 193], respectively, χ21 = 4.192, P = .04). International medical graduates reported having applied to significantly more positions (mean = 6.34, SD = 3.56) than did US medical school graduates (mean = 5.11, SD = 3.37, t289 = −2.878, P = .004). We further compared application rates with advertised versus unadvertised positions. International medical school graduates applied to more advertised positions (mean = 5.67, SD = 3.96) compared with US medical school graduates (mean = 3.88, SD = 3.44, t173.397 = −3.801, P < .001), but similar numbers of unadvertised positions (mean = 1.80, SD = 2.69) for international medical graduates compared with US medical graduates (mean = 1.96, SD = 2.51, t287 = .504, P = .62). Respondents who attended international medical schools also perceived significantly greater difficulty finding their first job compared with US medical school graduates (t218 = −2.870, P = .005, Supplementary Table 7). A 2-way X2 test showed that a significantly greater proportion of international medical school graduates who are non-US citizens compared with those who are US citizens had not accepted a position at the time of the survey (χ22 = 6.416, P = .04). Among respondents who had accepted a position, similar proportions of US and international medical graduates accepted academic versus nonacademic positions (χ21 = 2.418, P = .12, Supplementary Table 8). The proportion of respondents to our survey who are international medical graduates (33% [98 of 299]) appears to correlate well with an approximation of graduating international medical graduates using National Resident Matching Program match data. Between the years of 2012 and 2014 (assuming 4 years of Anatomic Pathology/Clinical Pathology residency and 1 year of fellowship), 1682 postgraduate year 1 matched into pathology, of which 838 (33%) were international medical graduates.9
We show significant improvements in the job market for graduating pathology trainees between the benchmark and current cohorts. We hope that this understanding will enhance the consideration of pathology careers by medical students. Of note, when compared with the benchmark 2012 to 2016 data published by Gratzinger et al,6 respondents indicated that it is easier to find a position and reported a higher satisfaction with the position accepted. Moreover, fewer respondents chose “too few jobs available in my subspecialty choice” as the reason for perceived difficulty in finding a position, and more respondents found a position within 6 months of their job search.
Compared with the 2012 to 2016 benchmark, more respondents between 2017 and 2019 chose “Other, please explain” when asked to indicate the reason for perceived difficulty in finding a position (22 of 57 [39%] versus 52 of 233 [22%]). No distinct themes emerged from the free-text comments, but examples include difficulty obtaining visa sponsorship and positions requiring previous work experience.
A significantly greater proportion of respondents reported higher starting salaries compared with the 2012 to 2016 benchmark. In 2019, 69% (54 of 78) of respondents reported a starting salary of $200 000 or more. As the salary categories are binned, we cannot compare median salaries year to year or the specific increase in relation to inflation. The annual Physician Compensation Report conducted by Medscape in 2019 demonstrated that the average annual pathologist compensation over all career stages was $308 000, ranking higher than internal medicine, obstetrics/gynecology, allergy and immunology, and neurology.10
The results from the study lend support to speculations that the pathology job market for recent graduates is opening up. Although our analysis reveals that the number of fellowships completed has remained stable during the past 3 years, residency directors have noticed in recent years an increase in “unexpected openings” for fellowship positions. This may be an indirect indicator that pathology graduates are finding and choosing employment in lieu of completing an additional fellowship. Timmons et al11 reported data from a residency program directors survey conducted by the Program Directors Section of the Association of Pathology Chairs. The study revealed that in 2017, 96% of pathology graduates obtained employment within 3 years of residency graduation, an increase from 92% in 2013. This is in keeping with the wide majority of residency graduates completing 1 to 3 years of fellowship training.
Limitations pertaining to various forms of bias accompany survey research. For example, selection bias is inherent as respondents are self-selected. Attribution bias may influence results if respondents ascribe personal or dispositional explanations over situational factors. Last, recall bias is intrinsic in all responses due to varying degrees of accuracy in portraying past events. Our study is limited by missing potential non-CAP member responders, and by indirect identification of first-time job seekers using screening questions, approximating the response rate of all first-time job seekers.
Despite a strengthening job market, fewer US allopathic medical graduates are choosing to enter pathology residencies. The CAP has spearheaded multiple initiatives to improve the pipeline of medical students entering pathology. Recently, the CAP Residents Forum Executive Committee created a designated landing page on the CAP website for prospective students entitled “CAP for Medical Students” (https://www.cap.org/member-resources/residents/cap-for-medical-students, accessed June 15, 2020). This webpage includes high-quality information on the profession and job market. Social media outlets, such as Twitter (Twitter, Inc., San Francisco, California) and Instagram (Facebook Inc., Menlo Park, California), have also opened avenues for pathologists to engage medical students and expose them to interesting cases, the broad scope of our practice, and provide opportunities for mentorship. Because pathology instructors and course directors often serve on the frontline of medical student recruitment, their awareness of the decline of medical students entering pathology in addition to the positive employment trends will be instrumental in attracting more students into pathology.
Here, we report positive trends in the job market for pathologists looking for their first nonfellowship position. Graduates are reporting a shorter job search, higher satisfaction with the position accepted, and greater ease in finding a position. The challenge for the field of pathology remains to effectively reach medical students with data-driven publications reporting the positive job market as well as enhance their exposure to the field.
Supplemental digital content is available for this article at https://meridian.allenpress.com/aplm in the September 2021 table of contents.
The authors have no relevant financial interest in the products or companies described in this article.
The views expressed are those of the authors and do not reflect the official policy of the Department of the Army/Navy/Air Force, Department of Defense, or the U.S. Government. The identification of specific products or scientific instrumentation does not constitute endorsement or implied endorsement on the part of the author, Department of Defense, or any component agency.