Pathology's Workforce Crisis - Impact on acute healthcare in Australasia

Pathology is a critical part of the medical process. Without high quality pathology services, healthcare would degenerate and services could eventually grind to a halt.

Despite the critical role pathologists and pathology play in medicine, very few people understand what Pathology is all about.

Considered the ‘backroom’ specialty of medicine, pathologists are seldom directly seen by patients and rarely acknowledged today by health administrators and politicians as the important medical specialists that they are.

Unfortunately, unless a medical specialty is hitting the headlines in some way (like surgical waiting lists and waiting times in emergency departments) politicians don’t listen and funding does not follow.

Pathology is in such crisis because of a shortage of trained professionals for this valuable discipline.

The Royal College of Pathologists of Australasia (RCPA), the body responsible for training doctors to become pathologists in Australasia (i.e. Australia, New Zealand, Hong Kong, Singapore and Malaysia) is extremely concerned about the impact the crisis in pathology will have on the healthcare system.

Indeed, the RCPA is so concerned about the potentially devastating impact of the crisis that it has undertaken an active campaign to raise awareness of the situation with governments, heath departments, health administrators, other medical practitioners and the general public across Australia and New Zealand.

Pathologists are the specialists who diagnose all known cancers in the world. They are involved in diagnosing infectious diseases such as Golden Staph, influenza and SARS. They play an important role in diagnosing and monitoring diseases such as diabetes and rheumatoid arthritis. They play an integral role in blood transfusion services and they are at the cutting edge of using genetics in diagnosing disease.

More than 70% of all diagnoses will involve pathology tests. Add to that the important role pathology plays in monitoring disease, and it is all too apparent why this profession is so critical.

Pathology itself is the specialty that looks at the underlying cause of all diseases.

In fact, the RCPA says “Medicine is Pathology”.

Pathologists themselves work in different ways through their sub disciplines which include Anatomical Pathology, Chemical Pathology, Haematology Cytopathology, Immunopathology, Microbiology, Genetic Pathology, Forensic Pathology and General Pathology.

Given its importance, why is this critical area of medicine such an endangered species?

Over the last 10 years in Australia, at least 70 training positions have been cut out of the system by stressed health administrators trying to balance budgets for the short term. There was no imperative to plan for the longer term.

There are currently 1290 pathologists in active practice in Australia and 20% of these are over the age of 60. 130 are over the age of 65.

Currently in Australia, only 55 new pathologists are produced each year on the funding made available by government.

This is quite frightening considering the age profile of pathologists and the fact that there are more than 70 vacancies in the system for qualified pathologists that cannot be filled.

The situation in other countries where the RCPA provides training is even worse.

In Australia, the pathologist per head of population ratio equates to one pathologist for every 15,500 people. In New Zealand this number is one pathologist per 20,250 people. In other words, New Zealand would require another 63 pathologists to bring it to the Australian ratio - and Australia itself is in crisis.

If we then turn our attention to number of pathologists in Hong Kong, Singapore and Malaysia, the figures are worse again.

In Hong Kong, there are 260 pathologists for a population of 6.9 million people, a per head of population ratio of one pathologist per 26,500 population.

In Singapore, there are 92 pathologists for 4.5 million people, a ratio of one pathologist per 48,900 population.

Finally, in Malaysia, in 2004, there were 242 pathologists in practice for a population of 25 million, a ratio of one pathologist per 103,300. There is an active campaign in Malaysia at present to increase the number of training positions in pathology to reach a target of one pathologist per 75,000.

As the crisis in pathology workforce is worldwide, importing appropriately qualified pathologists to fix the problems in Australasia is not an option.

In Australia, the government-convened Australian Medical Workforce Advisory Committee (AMWAC), recommended in 2003 that Australia needed an extra 100 training positions per year for at least five years. Despite the fact that all State, Territory and Commonwealth Health Ministers signed off on this report, we are now in year three, and there should be 300 positions - only 52 have been created... far short of requirements.

The RCPA has looked at numerous options to solve the problem.

Many health administrators suggest workforce substitution when trying to address the workforce crisis in general. In Pathology, this has already occurred.

Pathology is very much a team effort, with pathologists working very closely with scientists and laboratory technicians. There are few additional areas where further delegation can occur. In addition, there is a serious shortage of scientific staff in Australasia, so even if there were tasks to delegate, there is nobody to delegate them to.

The problem in Australia, at least, is purely one of the governments not funding training positions.

There are more medical students wanting to do pathology than there are training positions. There are plenty of laboratories that are accredited by the RCPA for training that are ready and willing to train – there is just no funding from governments to provide these extra positions.

In other countries, lack of training positions is one of the contributing factors. But there are other issues such as insufficient staff to train new pathologists and insufficient medical practitioners available to train in pathology. It is interesting to note in Hong Kong however since the SARS epidemic, there has been a great deal of interest among young doctors to train in the pathology disciplines of microbiology and virology.

This crisis is not looming, it has arrived.

The RCPA’s efforts to redress the situation are being largely ignored by governments. Action is required now to prevent the crisis from worsening.

There is a real risk that overworked, tired pathologists are more likely to make misdiagnoses. While there are very good quality systems in place to try to prevent this, mistakes in such environments are much more likely.

Specific examples of the impact on the healthcare system are as follows:

• Without Anatomical Pathologists, there would be delays in cancer diagnosis with patients not being able to get access to the required treatment in a timely fashion, thus leading to higher mortality rates

• Without Microbiologists, infectious diseases may not be able to be diagnosed nor treated appropriately, leading to further spread of the illnesses, with patients suffering and the healthcare system having to cope with more sick people

• Without Haematologists, blood transfusion would not be able to proceed safely and surgery would be a life threatening “throw of a dice” as would the management of emergency trauma cases

• Bed blockages in hospitals would occur as would emergency department blocks when pathology results are not available

• Without Chemical Pathologists, patients’ heart attacks, diabetes and kidney failure would not be diagnosed promptly and managed appropriately

• Without Immunopathologists and other pathologists, patients with HIV/AIDS would not have tests available to them to monitor and titrate the toxic drugs they require for treatment

• Without Genetic Pathologists, serious genetic conditions may not be screened for and thus prevented, adding further burden to both patients and the healthcare system

• Finally, though more in the administration of justice, if there are no Forensic Pathologists autopsies and burials would be delayed, causing families great stress and in some cases criminals may literally “get away with murder”

These scenarios are very frightening.

The RCPA is very concerned that if action does not occur, Australasia’s extremely high quality pathology services will not be sustainable into the future.