"Laws" Governing Future Employment; Relevance for Surgical Pathology

A recent blog post by Daniel Jelski proposed three "laws" governing future employment (see: The Three Laws of Future Employment). I found them interesting in relation to the effect that digital pathology may have on the number of surgical pathologists required in the future and the nature of their work. Here's an excerpt from his note:

As a college educator, I am tasked with preparing today’s students for their future careers.
Implicit is that I should know more about the future than most people. I do not - at least not in the sense of specific predictions. But I can suggest some boundaries on the path forward.

• Law #1: People will get jobs doing things that computers can’t do.
• Law #2: A global market place will result in lower pay and fewer opportunities for many careers. (But also in cheaper and better products and a higher standard of living for American consumers.)
• Law #3: Professional people will more likely be freelancers and less likely to have a steady job.

For the most part, surgical pathologists function as knowledge workers. They serve as consultants to the clinicians who submit tissue specimens for interpretation and provide direct services to patients. Theoretically, the duties of the pathologist could be outsourced in the sense that the key knowledge involved can be provided by a pathologist who is not working on-site in a hospital. Gross tissue specimens could be photographed by a pathology assistant working in the hospital and thin tissue sections could be prepared by a histotechnologist and scanned digitally. This is a high-tech vision of the current, common model of sending the glass slides to a surgical pathology reference laboratory for interpretation.

The entire case, in digital format, could also be transferred to a pathologist abroad who could provide diagnostic services, potentially at a lower cost than is available in the U.S. Such a pathologist might be well trained and accredited in the U.S. Within the foreseeable future, it may also be possible for the digital images to be interpreted, at least for a first pass, using imaging algorithms (see: Computer-Aided Tissue Analysis; A Major Step Forward with SIVQ). In other words, computers may substitute for some of the services currently rendered by pathologists.

I don't envision this outsourcing scenario taking place on a large scale, at least in the immediate future. There are two reasons for my skepticism. The first is that the clinicians who submit specimens to their pathologist/colleague place a high value on his or her expertise for rendering the correct diagnosis. They would therefore be reluctant to cede this responsibility to a consulting pathologist abroad, even one with acceptable training. Secondly, surgical pathology services are relatively inexpensive in the U.S., particularly in relation to their value. In fact, the skills of American pathologists are highly admired on a global basis, It is therefore more likely, on a net basis, that widespread adoption of digital pathology will result in more cases being imported to this country than the number of cases diagnosed abroad.

In summary, I don't envision "laws" 1 and 2 above having much effect on surgical pathology in the short-run. However, law 3 is much more likely to have an effect and, in fact, has been widely adopted for many decades. Surgical pathologists have always turned to "freelancers" for consultative services. Here, I define "freelancers" as the marquee pathologists to whom glass slides are physically sent for their "secondary" diagnosis for the most challenging cases. What may be different in the future is that off-site "freelancers" may be rendering primary diagnoses more frequently in smaller hospitals. By this I mean, that such smaller hospitals may contract for their surgical pathology work. These contracting pathologists may be part of the pathology groups in neighboring larger hospitals with a referral relationship with the smaller hospital. This trend will accelerate as older pathologists retire from smaller hospitals and cannot be replaced.

Comments

[Barry Portugal]

Hi Bruce,
I agree that laws 1 and 2 probably won't have a major impact on pathology, but I have a different perspective about law 3.

While there may be some referrals from small pathology groups to pathology groups with greater sub-specialization, I believe another market dynamic will be more prevalent. I believe that there will be a significant number of pathology group mergers over the next few years.

According to industry information, the majority of pathologists working in hospitals practice in groups of five or less. Smaller pathology groups are unable to negotiate effectively with managed care plans, and are often excluded from performing outreach work from plans offered by large insurance companies. Larger pathology groups with substantive sub-specialization and with more geographical diversity will be able to leverage multiple hospital contracts to be included in those networks and compete with national reference laboratories. Additionally, larger pathology groups can compete more strategically relative to the outsourcing of outpatient histology and pathology services to office-based practices.

[Mark Pool]

Excellent post, Bruce. One other way in which the future pathologist would be valuable is to use image analysis tools to provide more actionable information regarding tumor microenvironment, intratumoral heterogeneity, host immune response, etc (at least for cancer and defined inflammatory biopsy specimens). Linking this to genomic and epigenomic information might also be useful.