Reevaluation of the US Pathologist Workforce Size

IMPORTANCE

There is currently no national organization that publishes its data that serves as the authoritative source of the pathologist workforce in the US. Accurate physician numbers are needed to plan for future health care service requirements.

OBJECTIVE

To assess the accuracy of current pathologist workforce estimates in the US by examining why divergency appears in different published resources.

DESIGN, SETTING, AND PARTICIPANTS

This study examined the American Board of Pathology classification for pathologist primary specialty and subspecialties and analyzed previously published reports from the following data sources: the Association of American Medical Colleges (AAMC), the Accreditation Council for Graduate Medical Education (ACGME), a 2013 College of American Pathologists (CAP) report, a commercially available version of the American Medical Assoication (AMA) Physician Masterfile, and an unpublished data summary from June 10, 2019.

MAIN OUTCOMES AND MEASURES

Number of physicians classified as pathologists.

RESULTS

The most recent AAMC data from 2017 (published in 2018) reported 12 839 physicians practicing "anatomic/clinical pathology," which is a subset of the whole. In comparison, the current AMA Physician Masterfile, which is not available publicly, listed 21 292 active pathologists in June 2019. The AMA Physician Masterfile includes all pathologists in 15 subspecialized training areas as identified by the ACGME. By contrast, AAMC's data, which derive from the AMA Physician Masterfile data, only count physicians primarily associated with 3 general categories of pathologists and 1 subspecialty category (ie, chemical pathology). Thus, the AAMC pathology workforce estimate does not include those whose principal work is in 11 subspecialty areas, such as blood banking or transfusion medicine, cytopathology, hematopathology, or microbiology. An additional discrepancy relates to the ACGME residency (specialties) and fellowship (subspecialties) training programs in which pathologists with training in dermatopathology appear as dermatologists and pathologists with training in molecular genetic pathology appear as medical geneticists.

CONCLUSIONS AND RELEVANCE

This analysis found that most sources reported only select categories of the pathologist workforce rather than the complete workforce. The discordant nature of reporting may pertain to other medical specialties that have undergone increased subspecialization during the past 2 decades (eg, surgery and medicine). Reconsideration of the methods for determining the pathologist workforce and for all workforces in medicine appears to be needed.

Characteristics and Frequency of Children With Severe Obstructive Sleep Apnea Undergoing Elective Polysomnography

OBJECTIVE

To determine the prevalence and demographics features of pediatric patients with severe obstructive sleep apnea (OSA) who would not undergo preoperative polysomnography (PSG) under current American Academy of Otolaryngology (AAO) guidelines.

STUDY DESIGN

In this retrospective cohort study, we identified patients from the electronic medical record who underwent elective polysomnography for evaluation of sleep-disordered breathing between 2012 and 2018.

SETTING

Urban tertiary safety net hospital.

SUBJECTS AND METHODS

A total of 456 patients with a mean (SD) age of 5.7 (3.2) years (263 male, 193 female). Demographic factors (age, sex, race, language, insurance status) and clinical findings (symptom severity, tonsil size) were recorded. The data were analyzed by univariate analysis.

RESULTS

Of 456 patients identified, 66 (14.5%) were found to have severe OSA. African American patients had 3.7 times the odds of severe OSA compared to white patients (95% CI, 1.2-10.8). Patients aged 2 to 3 years had 2.2 times the odds of severe OSA compared to patients aged 4 to 6 years (95% CI, 1.2-4.0). Sex, ethnicity, language, and insurance type were not significantly associated with severity of OSA. The presence of apneic episodes and tonsil size were not found to be statistically significant.

CONCLUSION

Up to 14.5% of healthy pediatric patients with sleep-disordered breathing may have severe OSA; young age and African American race are statistically significant predictors. Clinical findings, such as tonsil size and symptom severity, were not found to be statistically significant predictors.

Prevalence and natural history of obstructive sleep apnea in pediatric patients with laryngomalacia

OBJECTIVE

Laryngomalacia is the most common cause of infant stridor, and obstructive sleep apnea (OSA) is sometimes found concurrently in patients with laryngomalacia. OSA has been shown to improve after surgical treatment of laryngomalacia, but the majority of laryngomalacia patients have spontaneous resolution of symptoms. It is unknown whether their comorbid OSA also resolves. This study seeks to define the incidence of OSA in laryngomalacia and assess for resolution of OSA with polysomnography data.

METHODS

Retrospective cohort study at a tertiary care academic medical center. All pediatric patients with diagnoses of laryngomalacia or stridor were reviewed, and patients with laryngomalacia confirmed by Otolaryngologist exam were included. All patients with laryngomalacia were recommended to undergo polysomnography.

RESULTS

A total of 108 patients had laryngomalacia confirmed by an Otolaryngologist. Of those patients, 56 completed a polysomnogram, and 44 (79%) were diagnosed with OSA. Among the OSA patients, 34 had no surgery, 5 underwent supraglottoplasty, and 5 underwent adenoidectomy or adenotonsillectomy. Follow-up polysomnograms were performed for 9 non-surgical patients, 4 supraglottoplasty patients, and 4 adenoidectomy or adenotonsillectomy patients. Mean change in AHI was -2.81 without surgery, -8.18 after supraglottoplasty, and -2.94 after adenoidectomy or adenotonsillectomy.

CONCLUSION

OSA is often present in patients who have laryngomalacia, and the proportion in this population was higher than previous reports. The only significant predictor for obstructive sleep apnea was race, specifically Black/African American. Among patients with follow-up polysomnograms, the largest OSA improvement was in supraglottoplasty patients, but all patients improved.

Evaluation of Acupuncture's Efficacy Within Otolaryngology

OBJECTIVES

Acupuncture is a form of Traditional Chinese Medicine that has minimal side effects, is cost-effective, can be easily administered, and may serve as a useful non-pharmaceutical therapy for certain conditions. However, studies and clinical practice guidelines are inconsistent in conclusions and recommendations about acupuncture. This qualitative review addresses the evidence available for acupuncture use in otolaryngology.

METHODS

A literature review was completed using EMBASE, PubMed, and The Cochrane Collection for conditions within otolaryngology that have used and studied the comparative effects of acupuncture. Thirty studies ultimately fit the inclusion criteria and were used for this qualitative review.

RESULTS

Studies included in this review contained a variety of conditions within otolaryngology, including allergic rhinitis, chronic rhinitis, tinnitus, sudden sensorineural hearing loss, post-viral olfactory dysfunction, dysphonia, and tonsillectomies.

CONCLUSION

Given its safety profile, cost, and perceived benefit, recommendations and guidelines supporting acupuncture as an alternative or adjunctive therapy are surfacing for certain conditions such as allergic rhinitis. However, stronger conclusions with specific recommendations are limited by varied methodology between majority of the studies. Additional high-quality randomized control studies with low risk of bias are required to continue to assess the effects of acupuncture in the field of otolaryngology before stronger recommendations can be made on other conditions.

The State of the Job Market for Pathologists: Evidence From the College of American Pathologists Practice Leader Survey

CONTEXT.—

Disagreement exists within the pathology community about the status of the job market for pathologists. Although many agree that jobs in pathology were harder to come by earlier this decade, recent evidence suggests improvement is occurring.

OBJECTIVE.—

To assess the state of the job market for pathologists.

DESIGN.—

We analyzed data from the 2018 College of American Pathologists Practice Leader Survey. This survey contains data from 253 practice leaders on practices' hiring (and retrenchments) in 2017, the skills and level of experience being sought, success in filling those positions, and expectations for hiring in the next 3 years.

RESULTS.—

Among the surveyed practice leaders, 115 (45.5%) sought to hire at least 1 pathologist in 2017, and together tried to fill 246 full-time equivalent positions that year, of which 93.5 full-time equivalents (38%) were newly created. This hiring was not limited to larger, academic-based practices, but also occurred among smaller practices and practices based in nonacademic hospitals, independent laboratories, and other settings. Although some practices retrenched (60 full-time equivalents in 2017), the net increase was a healthy 187 full-time equivalents. Practices most frequently sought pathologists who had at least 2 years of experience, but the level of experience identified with the "optimal" candidate varied by desired areas of subspecialty expertise. Practice leaders also reported expected growth in hiring, with the number of positions they hope to fill in the next 3 years exceeding those vacated by retirement.

CONCLUSIONS.—

Our findings support the proposition that the demand for pathologists is strong, at least at the current time.

Improving Cancer Diagnosis and Care: Patient Access to High-Quality Oncologic Pathology

Drawing on discussions at a workshop hosted by the National Cancer Policy Forum, current challenges in pathology are reviewed and practical steps to facilitate high‐quality cancer diagnosis and care through improved patient access to expertise in oncologic pathology are highlighted

Outcomes of Children with Mild Obstructive Sleep Apnea Treated Nonsurgically: A Retrospective Review

Objective

Obstructive sleep apnea (OSA) is characterized by partial or complete obstruction of the upper airway and is commonly caused by adenotonsillar hypertrophy in children. Accordingly, adenotonsillectomy is considered first-line treatment. However, in cases of mild OSA, nonsurgical management has been proposed as an alternative. The purpose of this study was to determine the outcomes of pediatric patients with mild obstructive sleep apnea (OSA) treated without surgical intervention.

Study Design

Case series with chart review.

Setting

Tertiary care university medical center.

Subjects and Methods

The medical records of children ages 2 to 18 years with OSA at Boston Medical Center from January 2000 to April 2017 were reviewed. Children with mild OSA (apnea- hypopnea index [AHI] between 1 and 5), who were managed nonsurgically and had serial polysomnograms, were included. Serial sleep studies were compared to assess for patterns of change.

Results

Of the 201 patients with mild OSA who were identified, 104 (52%) opted for initial nonsurgical management. Of those, 91 had a follow-up sleep study to reassess their OSA. Forty-two (46 %) had a greater than 20% decrease in AHI and 38 (41%) had a greater than 20% increase on the second sleep study. The remaining 11 had changes less than 20% in either direction. There was not a significant difference in the proportion of patients with an increase vs decrease in AHI on follow-up sleep study ( P > .05).

Conclusions

Mild pediatric OSA has approximately equal chances of worsening or improvement over time without surgical intervention, which is useful for counseling parents on treatment options.

Inferior Turbinate Hypertrophy: A Review of the Evolution of Management in Children

Background

Historically, there has been uncertainty in the treatment of inferior turbinate hypertrophy (ITH) in children. Although management always begins with medical therapy, the decision to offer surgery in resistant cases is becoming more widely practiced. In the pediatric population, turbinate reduction can be achieved with turbinectomy, electrocautery, lasers, submucous microdebridement, and radiofrequency volumetric tissue reduction (RVTR). However, there remains a lack of consensus on the preferred approach to treatment.

Objective

To compare how the efficacy, duration, and complications of different surgical methods has changed the management of inferior turbinate hypertrophy in children over time.

Methods

In March 2018, a comprehensive literature search was performed in PubMed for all inferior turbinate hypertrophy management-related studies in children. Inclusion criteria included children (age, 1–17 years). Exclusion criteria included reviews and abstracts.

Results

Each technique has experienced a period of popularity over the last 30 years in parallel with the technology available at the time as well as evidence from studies in adults. The literature for ITH management in children has largely followed these trends, with a recent improvement in the quality of studies mirroring the overall increase in surgical practice. Of all methods currently used, RVTR and submucous microdebridement offer the least invasive and most efficacious relief of nasal obstruction.

Conclusion

This review provides an overview of the evolution of ITH management in children and, based on historic and current evidence, proposes the following graduated recommendation to treatment: (1) a 3-month trial of medical management, (2) evaluation for adenoid hypertrophy for consideration of concurrent adenoidectomy, and (3) RVTR or submucous microdebridement as the first-line surgical approach.

The Role of the Pathologist in Population Health

CONTEXT.—

As part of its value-based care initiative, the College of American Pathologists has pursued research to better understand the role pathologists can have in population health.

OBJECTIVES.—

To answer the following questions: (1) what is the impact of population health and population health management on pathologists; (2) what roles are pathologists playing in population health management; (3) is population health something that pathologists in both larger and smaller settings can engage in; (4) are pathologists in a position to analyze laboratory data for population health, and, if so, what are the key information sources those pathologists must access; and (5) what steps can a pathologist take to become involved in population health?

DESIGN.—

We conducted 10 semistructured interviews with pathologists and other medical laboratory leaders who have been active in population health. These interviews were supplemented with a review of the medical literature.

RESULTS.—

Pathologists have demonstrated that laboratory data can provide unique value-added contributions to improving the health of populations. These contributions are not limited to pathologists in large, integrated settings. However, pathologists need to be proactive to contribute to health systems' population health efforts and may need to both enhance their own skills and the quality of their data to maximize the value of their contributions.

CONCLUSIONS.—

Although not necessarily a definitive summary of the roles that pathologists are playing in population health, this article identifies some of the promising and innovative activities occurring among pathologists and laboratorians.

Genomic Landscape of Adult and Pediatric BCR-ABL1-Like B-Lymphoblastic Leukemia Using Parallel DNA and RNA Sequencing

BCR-ABL1-like B-Acute Lymphoblastic Leukemia (B-ALL) is a subset of B-ALL with a poor prognosis that is found in all age groups. Definitive identification of these patients is difficult in routine clinical practice as gene expression profiling, the gold standard test, is not widely available. Comprehensive genomic profiling performed on 450 patients with extensive fusion profiling revealed a wide range of genomic alterations which were consistent with a classification of BCR-ABL1-like B-ALL in 29% of cases. This manuscript highlights a clinically available alternative method for identifying a large subset of patients with BCR-ABL1-like B-ALL.

Evidence-Based Alignment of Pathology Residency With Practice: Methodology and General Consideration of Results

Few medical specialties engage in ongoing, organized data collection to assess how graduate medical education in their disciplines align with practice. Pathology educators, the American Board of Pathology, and major pathology organizations undertook an evidence-based, empirical assessment of what all pathologists need to learn in categorical residency. Two challenges were known when we commenced and we encountered 2 others during the project; all were ultimately satisfactorily addressed. Initial challenges were (1) ensuring broad representation of the new-in-practice pathologist experience and (2) adjusting for the effect on this experience of subspecialty fellowship(s) occurring between residency and practice. Additional challenges were (3) needing to assess and quantify degree and extent of subspecialization in different practice settings and (4) measuring changing practice responsibilities with increasing time in practice. We instituted annual surveys of pathologists who are relatively new (<10 years) in practice and a survey of physician employers of new pathologists. The purpose of these surveys was to inform (1) the American Board of Pathology certification process, which needs to assess the most critical knowledge, judgment, and skills required by newly practicing pathologists, and (2) pathology graduate medical education training requirements, which need to be both efficient and effective in graduating competent practitioners. This article presents a survey methodology to evaluate alignment of graduate medical education training with the skills needed for new-in-practice physicians, illustrates an easily interpreted graphical format for assessing survey data, and provides high-level results showing consistency of findings between similar populations of respondents, and between new-in-practice physicians and physician-employers.

A Survey of the Prevalence and Impact of Reporting Guideline Endorsement in Pathology Journals

OBJECTIVES

To determine the prevalence of reporting guideline endorsement in pathology journals and to estimate the impact of guideline endorsement.

METHODS

We compared the quality of reporting in two sets of studies: (1) studies published in journals that explicitly mentioned a guideline vs studies published in journals that did not and (2) studies that cited a guideline vs studies that did not. The quality of reporting in prognostic biomarker studies was assessed using the REporting recommendations for tumor MARKer prognostic studies (REMARK) guideline.

RESULTS

We found that six (10%) of the 59 leading pathology journals explicitly mention reporting guidelines in the instructions to authors. Only one journal required authors to submit a checklist. There was significant variation in the rate at which various REMARK items were reported (P < .001). Journal endorsement was associated with more complete reporting (P = .04). Studies that cited REMARK had greater adherence to the REMARK reporting guidelines than studies that did not (P = .02).

CONCLUSIONS

The prevalence of guideline endorsement is relatively low in pathology journals, but guideline endorsement may improve the quality of reporting.

Breastfeeding Infants with Ankyloglossia: Insight into Mothers' Experiences

INTRODUCTION

Breastfeeding difficulty from ankyloglossia can affect both the mother and baby in a breastfeeding dyad. With renewed emphasis in today's culture on breast milk, mothers may feel increasing pressure to breastfeed, and the inability for some to do so may cause significant distress. Recently, online parenting forums have seen exponential growth; these forums allow mothers to connect with peers undergoing similar life transitions. The purpose of this study was to review online discussions regarding ankyloglossia to understand mothers' experiences with breastfeeding.

MATERIALS AND METHODS

We performed an ethnographic content analysis of 76 online threads and 501 posts regarding ankyloglossia based on six domains: (1) initial expectations, (2) breastfeeding complications, (3) questions, (4) diagnosis, (5) treatment, and (6) outcomes.

RESULTS

About one-fourth of women who participated in online forum discussions had initial expectations to breastfeed, however, many found it impossible due to poor latch or pain. Concerns were frequently exacerbated by healthcare providers who reportedly missed or overlooked ankyloglossia. Although these complications made breastfeeding a challenging experience, mothers often described both subjective and physical improvements after frenotomy.

CONCLUSION

Breastfeeding difficulty was a commonly voiced concern in online ankyloglossia forums. Forum analysis is an effective way to gain insight into patients' experiences, which allows providers to anticipate concerns and provides more effective counseling.

The Pathologist Workforce in the United States: II. An Interactive Modeling Tool for Analyzing Future Qualitative and Quantitative Staffing Demands for Services

CONTEXT

Pathologists are physicians who make diagnoses based on interpretation of tissue and cellular specimens (surgical/cytopathology, molecular/genomic pathology, autopsy), provide medical leadership and consultation for laboratory medicine, and are integral members of their institutions' interdisciplinary patient care teams.

OBJECTIVE

To develop a dynamic modeling tool to examine how individual factors and practice variables can forecast demand for pathologist services.

DESIGN

Build and test a computer-based software model populated with data from surveys and best estimates about current and new pathologist efforts.

RESULTS

Most pathologists' efforts focus on anatomic (52%), laboratory (14%), and other direct services (8%) for individual patients. Population-focused services (12%) (eg, laboratory medical direction) and other professional responsibilities (14%) (eg, teaching, research, and hospital committees) consume the rest of their time. Modeling scenarios were used to assess the need to increase or decrease efforts related globally to the Affordable Care Act, and specifically, to genomic medicine, laboratory consolidation, laboratory medical direction, and new areas where pathologists' expertise can add value.

CONCLUSIONS

Our modeling tool allows pathologists, educators, and policy experts to assess how various factors may affect demand for pathologists' services. These factors include an aging population, advances in biomedical technology, and changing roles in capitated, value-based, and team-based medical care systems. In the future, pathologists will likely have to assume new roles, develop new expertise, and become more efficient in practicing medicine to accommodate new value-based delivery models.