International Medical Graduates and the Shortage of US Pathologists

To the Editor.—The authors of “International Medical Graduates and the Shortage of US Pathologists”¹  cite superseded research in declaring a substantial decline in the number of active pathologists practicing in the United States. This leads them to a substantially inaccurate perspective. It also does not reflect the most recent literature, which shows that pathologist supply has actually been increasing over the years, albeit slowly and likely not enough to meet demand.

In 2020, members of the College of American Pathologists (CAP) found that the data source used in the cited research, the Physician Specialty Data Book from the Academy of American Medical Colleges (AAMC), reported only a subset of pathologists (anatomic, clinical, anatomic/clinical, or chemical pathology) and did not include pathologists whose primary data set classification was in any of 11 recognized subspecialty areas, including blood banking/transfusion medicine, cytopathology, hematopathology, or microbiology.²  The authors estimated that this approach understated US pathologist supply by nearly 40% in 2019. Subsequent research conducted by CAP members and staff from the AAMC confirmed the findings of our 2020 report. It further suggested revisiting methodologies and definitions responsible for tracking the physician workforce in other medical specialties that have undergone increased subspecialization during the past 2 decades, as similar undercounts may exist in other physician specialties.³ 

More recently, the AAMC has made several improvements to provide a more accurate and complete count of active physicians. The AAMC recently launched US Physician Workforce Data Dashboard⁴  with complete data up until 2022. It’s noteworthy that these data show pathologist supply increased to 21 125 in 2022, which is up 3.4% from 20 400 in 2020.

There is little doubt that the number of active pathologists has increased from 2004 to 2020, but this has been accompanied by a substantially greater increase in demand for pathology services. Indeed, the CAP’s 2023 Practice Leader Survey documents the increased demand for pathologists and increasing difficulties practices are having in hiring the pathologists they need.⁴  Thus, we share the authors’ concerns about the current pathologist workforce’s ability to meet demands going forward. The CAP is proactively advocating for solutions to train more pathologists to join the workforce. The authors rightly suggest immigration reform as part of the solution to afford international medical graduates (IMGs) additional pathways to work in the United States following their training. Our research shows that about 25% of pathology practices cite visa regulations as a barrier in considering or hiring IMGs when hiring pathologists.⁴  With nearly all pathology residency slots being filled in recent years, funding is needed to create additional slots as we address the bigger issue of IMGs graduating from pathology programs and being unable to work in the United States because of visa restrictions. The CAP and other physician organizations have sought several legislative solutions to address workforce issues. With regard to the shortage of US physicians, the Resident Physician Shortage Reduction Act would, if enacted, increase Medicare-supported graduate medical education positions by 14 000 during a period of 7 years; if a reasonable proportion of these slots were allocated to training pathologists, this would help to address the shortage. Although much smaller in magnitude, the CAP also supports the Conrad State 30 and Physician Access Reauthorization Act, which would increase the number of visa waivers that allow IMGs to remain in the United States from 30 to 35 per state.