Less is More

There is a perceived shortage of pathologist manpower in America.1,2,3,4,5,6 To date, reflex solutions to this shortage have revolved around increasing the pool of pathologists by expanding the capacity of pathology residency training programs.4,5,6 This makes sense if we plan to continue practicing pathology the way we have always practiced pathology.

Labor crunches are not unique to pathology. Many, maybe all industries producing products and services experience them from time to time. However, savvy companies resolve their labor shortages not by throwing more people at the problem and not by continuing to operate the way they have always operated. Rather, they innovate. They change their production processes in ways that reduce their need for additional labor. Exemplary innovations that have surfaced over the last few decades include lean production, robotics and outsourcing. Maybe we can learn from them.

What is Lean Production?

Lean production, a term coined by James Womack and heavily promoted by the Toyota Motor Corporation describes a series of processes designed to increase efficiency in the creation and delivery of products and services. 7,8 The secret sauce of lean production is the removal of “waste,” defined as any step in a production process that fails to deliver value to customers. Lean theory defines eight categories of waste, two of which are failure to utilize workers to their maximum potentials and engaging in unessential production activities. Removing these wastes allows companies to increase their production capacity by reducing labor requirements. In other words, they allow companies to "do more with less.” 9

Pathologists can reduce their requirements for professional labor by delegating tasks to other employees, performing only those tasks that they, and only they can do. For instance, many pathology groups employ pathologist’s assistants (PAs) to process gross tissue. 10 That’s a start. Pathologists can offload additional tasks to physician extenders just as their clinical colleagues have offloaded to physician extenders many tasks that they once performed. 11

Figure 1 shows a sample workflow for a hypothetical anatomic pathology case. The figure indicates certain tasks that may be offloaded to physician extenders such as PA’s, histologic anatomists, cytotechnologists, etc. Standardized workflows, templated reports, and team sign outs similar to team rounds conducted by clinicians may facilitate offloading. 12,13 The more tasks that can be offloaded to assistants, the greater the number of cases pathologists can process and hence the more likely it will be for the attendant cost accounting to discourage the need to hire more pathologists.

The figure is not intended to be a template. It is only an illustration of how pathologists might evaluate the feasibility of offloading certain tasks, a process that must be customized to their idiosyncratic practice environments. The assignment titles are arbitrary. Pathology practices must determine who they believe to be the best individuals to perform those tasks. They may have to innovate their search for sources of labor if the pool of available physician extenders shrinks. For instance, identifying histologic anatomists to preview slides may require pathologists to tap academic programs training such individuals. Some pathology practices may choose to financially incentivize employees to enter Pathologist Assistant training programs.

Robotics can help improve efficiencies

Just as robotics have cut the need for labor in manufacturing industries, machine technologies such as digital pathology (DP) and artificial intelligence (AI) may mitigate the shortage of available pathologists. In addition to improving diagnostic accuracy and reducing diagnostic error, machine technology can be programed to perform ancillary tasks like those described for physician extenders above.14 However, routine use of AI and DP may take some time to develop and not provide the immediate relief that some pathology practices require.

Put outsourcing into practice

Reducing the need for labor by outsourcing the manufacture and delivery of products and services has become a mainstay of thrift in most industries.15,16 Our radiology colleagues have long outsourced their night work to distant time zones.17 We can apply outsourcing to the practice of pathology.

For instance, some clinical specialist customers may demand that only pathologists with fellowship training in those specialties examine tissue excised from their patients. This can be an expensive proposition for some pathology groups that do not want to lose the work, but do not possess the caseload to support hiring specialist pathologists or the wherewithal to pay consultant fees on every specialty case.

Pathology groups may solve this problem by contracting specialty pathologists to become remote members of their groups. These new group members can perform for the outsourcing group, all designated specialty work transported to them physically by carrier or electronically by DP. The agreement between the two parties would have outsourcing groups pay the specialist pathologists not consulting rates, but rather wholesale fees. The outsourcing group would then bill payers retail fees. Outsourcing groups might sweeten the deals by allowing specialty pathologists to perform and bill the technical components.18

The arrangement would benefit the specialty group as well. They may envision a profitable economy of scale and repeat this model elsewhere. Outsourcing need not be restricted to specialists. Two or more pathology groups could partner to share caseloads and/or the services of jointly employed or subcontracted pathologists.

In any arrangement, the feasibility of outsourcing-- specialty work or otherwise--is necessarily contingent upon the economic equation demonstrating that the marginal loss of revenue is well compensated by the savings gained in not hiring additional pathologists; by the supplemental retail billing for the professional components of specialists’ interpretations of special stains and other studies; and by the expansion of practices and life styles that the increased capacity of outsourcing affords.

Some efficiencies may not work for all practices. However, offloading and outsourcing may be reasonable options by which pathology groups may alleviate the stress and financial burden that labor shortages impose upon them.


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2. Hayes, E. Steep pathologist workforce decline in U.A. raises alarm. May 31, 2019. Lab Pulse.com. [Cited September 1, 2022] Available from: https://www.labpulse.com/index.aspx?sec=ser&sub=def&pag=dis&ItemID=800127

3. Bhusnurmath S. Industry Voices—The shortage of invisible doctors. October 25, 2019. Fierce Healthcare. [Cited September 1, 2022]. Available from https://www.fiercehealthcare.com/hospitals-health-systems/industry-voices-shortage-invisible-doctors#:~:text=The%20number%20of%20U.S.%20pathologists,according%20to%20Medscape's%202019%20survey.

4. Aldis H. Petriceks, BA and Darren Salmi, MDTrends in Pathology Graduate Medical Education Programs and Positions, 2001 to 2017Acad Pathol. 2018 Jan-Dec; 5: 2374289518765457.Published online 2018 Mar.

5. Robboy A, Weintraub S, Horwath A, et al. Pathologist Workforce in the United States I. Development of a Predictive Model to Examine Factors Influencing Supply. Arch Pathol Lab Med. 137(12) DOI:10.5858/arpa.2013-0200-OA.

6. CAP.org [Internet]. College of American Pathologists. Pathologists Fight Future Medicare Cuts During the CAP’s Annual Hill Day. [Cited September 1, 2022]. Available from https://www.cap.org/advocacy/latest-news-and-practice-data/may-10-2022

7. Womack JP, Jones, DT, Roos D. The Machine that Changed the World. Free Press. New York, London, Toronto, Sydney. 1990.

8. Liker. JK. The Toyota Way. 2nd Edition. McGraw Hill. New York, Chicago, San Francisco et. all. 2021

9. Lemay, P. Production Capacity: Strategies for Improving Productivity and Efficiency. July 31, 2022. Tulip. [Cited September 1, 2022. Available from https://tulip.co/blog/production-capacity-strategies-for-improving-productivity/

10. Hills. D. The Pathologists’ Assistant Profession: a Brief History. September 23, 2020. Nicklas. [Cited September 1, 2022]. Available from: https://www.nicklasstaffing.com/blog/the-pathologists-assistant-profession-a-brief-history

11. Shryock. T. How to boost physician productivity through use of extenders. April 25, 2017. Medical Economics. [Cited September 1, 2022.] Available from: https://www.medicaleconomics.com/view/how-boost-physician-productivity-through-use-extenders

12. Cowan F. How Templates Improve Quality and Efficiency in Surgical Pathology Laboratory Medicine, 28,(4); 1997: 263–267, https://doi.org/10.1093/labmed/28.4.263

13. Huang KT, Minahan J, Brita-Rossi et al. All Together Now: Impact of a Regionalization and Bedside Rounding Initiative on the Efficiency and Inclusiveness of Clinical Rounds. J Hosp Med. 01 March 2017

14. Cui, M., Zhang, D.Y. Artificial intelligence and computational pathology. Lab Invest 101, 412–422 (2021). https://doi.org/10.1038/s41374-020-00514-0

15. Twin A. Outsourcing. June 18, 2022 Investopeia. [Cited September 1, 2022]. Available from https://www.investopedia.com/terms/o/outsourcing.asp

16. Darwish S. Six Reasons Outsourcing Could Benefit Your Business. May 14, 2012. Forbes. [Cited Sept. 1, 2022]. Available from: https://www.forbes.com/sites/forbestechcouncil/2021/05/14/six-reasons-outsourcing-could-benefit-your-business/?sh=6b0a61524a23

17. Goelman A. Telework That Works: Teleradiology and the Emergence of Nighthawk Radiology Firms. Sloan Foundation Industry Studies Annual Conference Cambridge, Massachusetts. April 26, 2007. [Cited September 1, 2022]. Available from: http://web.mit.edu/sis07/www/goelman.pdf

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David A. Novis, MD FCAP, is the CEO and President of Novis Consulting LLC. Dr. Novis received his Doctor of Medicine degree at the University of Vermont and completed residencies in anatomic and clinical pathology and nuclear medicine at the University of California at San Francisco. Dr. Novis is past chairman of pathology and director of clinical laboratories at Wentworth Douglass Hospital in Dover, NH, and York Hospital in York, ME and was the CLIA laboratory director for Oxford Immunotec and Courtagen Life Sciences laboratories. Dr. Novis is a past speaker of the CAP House of Delegates, has served on several CAP committees, councils and the Board of Governors. He is a past adviser to the University of Pittsburgh/CDC Cooperative Agreement Assessment of Best Practices for Standardized Quality Assurance Activities and to the University of New Hampshire Department of Health Management & Policy. Dr. Novis has authored articles on quality and management and an editorial reviewer for the Archives of Pathology. In 2021, Dr. Novis received the CAP Lifetime Achievement Award. Dr. Novis is currently a member of the Practice Management Committee.