Strong Job Market for Pathologists: Results From the 2021 College of American Pathologists Practice Leader Survey

The CAP Policy Roundtable included a series of questions about the job market in its 2021 Practice Leader Survey (Table 1).

All board-certified pathologists with 5 or more years in practice received the invitation to participate, with the instruction that only the individual best suited to represent the practice should respond. Of 13 285 pathologists invited to participate, 375 practice leaders responded.

The survey also asked demographic questions about the practices in order to assess practice settings and other variables.

Respondents were from 44 states. Given the most current estimate from the CAP of about 1000 to 1200 practices in the United States (written communication from T. Smith, September 20, 2021), the response rate was about a third of practice leaders.

Of the 375 survey respondents, 282 provided data on whether or not they were hiring a pathologist in 2021. Overall, 128 responding practices (46.2% of the 277 respondents who provided information on hiring and data on practice size) had fewer than 6 full-time equivalent (FTE) pathologists (Table 2). In contrast, only 39 responding practices (14.1%) had 26 or more FTE pathologists. Nearly all (242 practices, or 85.8% of the 282 practices) were based in 1 of 4 settings (Table 3): nonacademic health center hospitals unaffiliated with an academic health center (N-AHC; 75 [26.6%]); academic health center hospitals (AHCs; 62 [22.0%]); nonacademic health center/hospital owned by, managed by, or affiliated with an AHC (Affiliated; 54 [19.1%]); and independent laboratories (I-Lab; 51 [18.1%]). The median practice size for each setting ranged from a high of 20.0 FTEs in AHC settings to 1.7 FTEs in practices based in “other miscellaneous settings” (eg, central laboratories, physician offices laboratories not owned by pathologists, forensic laboratories/medical examiner offices, or other settings; Table 3).

A higher percentage of practices sought to hire pathologists in 2021 than in 2017. In 2017, a total of 116 of 256 responding practices (45.6%) sought to hire, jumping to 157 of 282 practices (55.7%) in 2021 (Table 4).

Filling newly created positions suggests either growth in the demand for pathologists or a reallocation of resources to different pathology services (eg, genomic pathology or informatics; Table 5). The ratio of newly created to preexisting positions increased between 2017 and 2021: The newly created positions increased from 95 of 246 FTEs (38%) in 2017 to 175 of 385 FTEs (45.5%) in 2021, with the percentage of positions to fill vacancies in existing positions dropping from 62.0% in 2017 to 54.5% in 2021. The average number of pathologists sought per hiring practice rose from 2.1 in 2017 to 2.4 in 2021.

The hiring increase was evident across practice settings. AHCs continued as the leading setting most likely to hire, as the percentage of AHCs hiring at least 1 pathologist rose from 41 of 57 (71.9%) in 2017 to 51 of 62 (82.3%) in 2021 (Table 6). The share of affiliated practices hiring dramatically increased from 17 of 43 (39.5%) to 34 of 54 (63.0%) during this same period. The share of I-lab and N-AHC practices hiring also increased but to a lesser extent. The only decrease occurred among government practices, falling slightly from 10 of 17 (58.8%) to 8 of 15 (53.3%), but that difference may not be significant because of the small number of respondents.

The AHCs continued as the setting predominantly hiring pathologists (Figure 1). About half of all open positions were in AHC-based practices, although the share dropped slightly from 52.8% to 47.8% during the 4-year interval. Furthermore, in both 2021 and 2017, about three-quarters of all pathologist positions that respondents sought to fill were in hospital-based settings (AHC, N-AHC, or Affiliated), at 77.2% and 75.5%, respectively.

General anatomic and clinical pathology (AP/CP) was the most sought-after skill set, followed by specialty anatomic pathology (AP) (Figure 2). Hiring into dedicated leadership positions (ie, a chair, program director, or medical director) was also common. Fewer respondents sought general AP, general clinical pathology (CP), or specialty CP.

For the categories of general AP/CP, general AP, and general CP, about 60% of 290 responses across these 3 settings were comfortable with hiring pathologists with fewer than 2 years of experience (after training; Figure 3). For specialty AP and specialty CP, slightly more experience was desired. Only for “Leadership Expertise” did most respondents (71 of 100 respondents, or 71%) require 3 or more years of experience, with most desiring at least 6 years of experience.

The survey also asked about the extent to which pathology practices were able to fill open positions. In 2021, 97 of 150 responding practices (64.7%) that sought to hire pathologists were able to fill all positions, compared with 73 of 107 practices (68.2%) in 2017 (Table 7). In terms of specific numbers of positions, of the 385 open FTE positions in 2021, practices were able to fill 283.5 (73.6%); 101.5 FTE positions (26.4%) remained unfilled (Table 8). Unfortunately, we did not collect analogous data for 2017, so we cannot judge whether these numbers represent a strong supply of pathologists or a potential supply shortage.

Hiring plans during the next 3 years are expected to exceed those in 2017. Employers report they plan to hire many new pathologists across the full spectrum of practice settings (Table 9). As in 2017, in 2021 most planned hiring was in hospital-based settings (AHC, N-AHC, and Affiliated): 328.9 of 452 projected FTE openings (72.8%), with most of the other FTE positions (n = 140.9) in I-labs.

Further, in 2021, more hires were expected for newly established positions (262.5 of 451.9 FTE positions [41.9%] in 2021, compared with 210.5 of 297.5 FTE positions [29.2%] in 2017), suggesting that practice leaders anticipated an increased demand for pathologist services. Among those settings that expect to hire more than 20 pathologists in the next 3 years, the percentage is highest in the I-lab and AHC settings, where more than half of projected positions are “new.” By contrast, among the 14 respondents in government settings, more FTE pathologists are anticipated to retire (15) than be hired (12), resulting in a net loss of 2 (−16.7%) positions. Because there were only a small number of government or military hospital or laboratory (Govt) respondents, the finding may not represent all practices in this setting.

For more than 2 decades, pathology has been beset by conflicting perspectives on the job market for pathologists. One side of this argument has espoused the concern of whether there are jobs in pathology. This concern likely stemmed from the 2006 elimination of the “credentialing” year of pathology residency training, which effectively was a fifth year.¹⁷  Consequently, 2 classes of graduates simultaneously became eligible to enter the job market in the same year, thereby flooding the market and creating a glut of new pathologists¹⁸  that led to many of these graduates engaging in fellowship training. In addition, the 2008–2010 economic recession may have further compounded the problem, leading to financial strains on practices and decisions at that time by some older pathologists to delay retirement.

Conversely, others have predicted a pending pathologist shortage. Robboy et al³  had a projection of a retirement cliff, taken in concert with a concurrent decrease in the number of pathologists being trained annually in the last 2 decades compared with those trained in prior years (1960–1980s)¹ ; this indicated a long-term future decrease in pathologist supply potentially beginning in 2015 and progressively decreasing through at least 2030. Although Metter et al⁸  reported that the supply had already dropped by 17% between 2007 and 2017, Robboy et al¹⁴  showed that their data source, which many others also used, dramatically undercounted pathologists by 40% by ignoring (rather than counting) subspecialist pathologists.

So, where are we? Is there an excess or a shortage of pathologists relative to current demand? Our results demonstrate that in 2021, the need for pathologist services was strong and had expanded more vigorously than it had in 2017.⁶  Others, too, have found graduating trainees, by and large, are pleased with their ability to find the jobs they want,¹⁸  suggesting that demand at least matches supply. Compared with 2017, our 2021 survey reveals that a greater percentage of practices are seeking to hire pathologists (157 of 282 practices [55.7%] in 2021 versus 116 of 256 practices [45.3%] in 2017), and those practices are seeking to hire a greater number of pathologists (2.4 pathologists per hiring practice in 2021 versus 2.1 pathologists per hiring practice in 2017), with solid demand across practice settings. It also shows a growth in pathologist demand above and beyond mere replacement of existing vacancies. Finally, it shows a willingness to hire new-in-practice pathologists as well as those with more experience, which is consistent with other literature showing an easing job market for new-in-practice pathologists.^19,20  Practice leader projections of hiring needs for the next 3 years foretell a continuing robust demand for pathologists, exceeding that projected in 2017, with 451.9 FTE pathologists needed by 245 practices, or an average of 1.84 pathologists per practice, compared with 1.30 pathologists estimated per practice in 2017.

In terms of pathologist supply, several publications have raised concerns about whether there will be enough pathologists to meet demand.^{7,8,14,21–24}  This survey revealed that 39 of 150 open pathologist positions (26%) were unfilled. This figure, by itself, is not sufficient to determine whether we are in, or about to enter, a pathologist shortage. However, if demand continues at this rate, it may very well become more challenging to fill these positions. For the past 2 decades, only about 600 pathology residency positions have opened each year,²⁴  and not all 600 physicians who enter residency will practice pathology in the United States after training. A slight majority of current trainees are graduates of international medical schools,²⁵  and at least some portion of that number are expected to practice in other countries. Furthermore, some trainees will become physician-scientists who work in research laboratories or industry (eg, the biopharmaceutical industry) rather than go into clinical practice; some may never even complete pathology residency. In other words, no more, and likely fewer, than 600 new pathologists enter practice in the United States each year.

Although our survey results can only forecast demand, a straight-line extrapolation of the data in Table 9 to all the US-based practices (1000 practices at the low end of our estimate) suggests that demand for 700 pathologists per year could reasonably be expected soon. (A straight-line extrapolation based on an assumption of 1200 practices in the United States, the high end of our estimates, would require 20% more pathologists, or 840 new pathologists per year.) These findings are consistent with, or may even understate, other evidence of the demand for pathologists in the United States in 2021. In a December 2021 Laboratory Economics survey of pathology groups and practices, “pathologist shortages” were cited as a growing concern by 20% of respondents, compared with only 3% of respondents citing this as a concern in 2020.²⁶  In the first three quarters of 2021 alone, Pathology Outlines listed 987 job postings, with the second- and third-quarter listings (345 and 375, respectively) being the most listed for any quarter to date.²⁷  This total is an underestimate of the number of jobs available. Some of these listings advertise for multiple jobs, and some positions, particularly specialized positions, are not advertised in Pathology Outlines.

Further, other pathologist positions are filled informally (eg, an academic department hiring 1 or more of its trainees or a community practice informally inquiring with a local pathology training program to identify job candidates). But again, even if demand continues at or near the current surveyed level, the number of pathology residency training slots is inadequate. Quite simply, 600 new graduates per year are insufficient to meet current market needs.

A shortage of available pathologists has profound implications for the future. Some of this deficit may be mitigated in the short term as trainees opt to reduce the number of years of fellowship from 2 or more years to 1 (or even zero). Anecdotal reports suggest that an increasing number of pathology trainees are forgoing a second year of fellowship training to enter the job market, but we do not yet know the magnitude of this shift. However, this is only a temporary supply increase, as a pathologist who enters the job market earlier than expected is not available to enter it in a future year.

Another significant change we anticipate is a further emphasis on subspecialization. At least 1 study has concluded that a pathologist is more productive if practicing as a subspecialist in a single or a limited number of areas instead of a generalist involved in many areas.²⁸  This includes not only expertise in all of the reporting and regulatory requirements for each organ system but also a higher level of expertise and hence lesser need for peer consultation. The emphasis of pathologist practice groups on hiring specific subspecialist-trained pathologists aligns with the behavior of pathologist trainees in getting subspecialty fellowship training.

Broad subspecialization across all practice settings may result in a general increase in pathologist productivity. In addition, new forms of instrumentation will affect productivity, and thereby may affect the demand for pathologists, albeit in unpredictable ways. Computer-assisted technologies, including (but not limited to) AI, promise to impact the practice of pathology in ways that could enhance practice efficiencies while also bringing new roles and responsibilities for pathologists. Specific to the use of AI, we note that there are multiple additional justifications for AI-assisted practice beyond whether there will be a shortage of pathologists, including enhanced quality and safety, and enhanced identification of key diagnostic findings.^29,30  The potential impact of AI-assisted diagnosis and other emerging technologies on pathologist efficiency will merit continued study, just as there will be continued need to monitor the pathologist workforce supply.

Although AP subspecialization is a potential strategy for enhancing per-pathologist productivity, there might be separate market stress in the identification of suitably trained subspecialty pathologists. We recognize, of course, that in future years some exogenous and unpredictable factors, such as changes in technology or consolidation in health care, may decrease or reverse the recent trends that have been leading to an increased demand for pathologists. But the fact remains that, as late as 1994, about 200 more pathologists were being trained per year than in 2005,³  with annual trainee numbers remaining at the lower level of about 600 per year since 2005. As pathologists from the 800-per-year era continue to retire during the next 10 to 20 years, there simply will not be enough newly trained pathologists to replace them. This simple fact, along with the growing and aging population,²¹  portends a continued increase in demand for pathologists regardless of AP practice paradigm. This line of reasoning is separate from the additional increased need expected for laboratory medicine services as the population ages, and for the pathologists required to deliver those services.

Finally, any shortage of pathologists will accentuate threats to infringements on the pathologist's scope of practice. Allen³¹  previously reported on how physician shortages or reductions in the physician workforce could lead to a scope of practice creep, noting that it is cheaper for hospitals to grant privileges to lesser-trained professionals than to financially support the training of new physicians. In addition, Allen noted that although pathologists' assistants, histotechnologists, cytotechnologists, laboratory technicians, and PhD clinical laboratory staff currently work closely with pathologists on a day-to-day basis with “well-defined job descriptions,” those boundaries are likely to be tested if it is hard to find pathologists in the future. In short, for the foreseeable future, we predict a good job market for pathologists seeking positions. We recognize that, for a prior generation of pathologists-in-training, great concern had been raised about there being “too many pathologists”⁶ ; this concern may have had a significant impact on the market appeal of pathology as a profession. Our purpose in writing this paper is driven by the perceived need to understand the pathologist workforce far better than had previously been available. As has been clear from the narrative of this article, reaching such an understanding has been a challenging process. In this specific paper, combined with a recent similar analysis,⁶  current market demand trends are clearly demonstrated. The task now will be to implement strategies to better meet this demand.

The authors would like to acknowledge Melissa Austin, MD, and Aidan DeLisle, MPP, for their contributions in the preparation and development of this manuscript.