The Clinical Laboratory Workforce: The Changing Picture of Supply, Demand, Education, and Practice

July 2005

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Executive Summary | Introduction | Project Objective and Research Questions | Report Outline | Methods | Description of the Clinical Laboratory Workforce | Pathways to Becoming a Clinical Laboratory Science Worker | Factors Related to Supply of Clinical Laboratory Science Workers | Data from the Educational Program Survey | Perspectives on Supply from Key Informants | Factors Related to Demand for Clinical Laboratory Workers

Findings on Demand from the ASCP Wage and Vacancy Survey | Perspectives on Demand from Key Informants | Imbalance Between Supply and Demand of Clinical Laboratory Science Workers | Shortages by Types of Workers | Shortages by Type of Work Setting | Shortages by Geographic Area | Impact of the Shortage of Clinical Laboratory Science Workers on the Health Care System | Key Findings | Conclusion | References

Executive Summary

Overview

For a number of years there has been a growing concern among educators and the health care industry, primarily hospitals, that there is a shortage of clinical laboratory workers. These workers perform critical functions in health care delivery through the collection and analysis of bodily fluids and tissues. Yet the profession has suffered from a lack of public recognition, declining enrollment and education program closures, relatively little real wage growth, and a lack of career development opportunities within and outside the laboratory setting. To study these issues, the U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, National Center for Health Workforce Analysis issued a grant to the University of California, San Francisco, Center for California Health Workforce Studies.

Study Goals
The objective of the study was to produce a report to inform the health professions educational community, the health care community, and the public about issues related to the clinical laboratory workforce. Research questions addressed the size of the workforce, demographic characteristics, role of various types of clinical laboratory workers, educational requirements, scope of practice, magnitude of any workforce shortage, key factors impacting the supply of and demand for workers, and issues that are expected to influence the future of the workforce.

Methods
The research team partnered with the American Society for Clinical Pathology, a professional organization that has studied clinical laboratory workforce issues for several years and has longitudinal data on wage and vacancy rates, educational programs, and job tasks. The research team utilized quantitative and qualitative approaches including a literature search and review, an analysis of secondary labor market data, a wage and vacancy survey, an online survey of educational programs, key informant interviews, and an analysis of longitudinal data from a cohort of clinical laboratory workers.

Summary of Major Findings

1. Qualitative and quantitative data suggest a shortage of clinical laboratory workers in the past several years although the most recent data indicate that the shortages may be easing at least for some types of workers and in some settings and geographic areas.
2. Increasing wages and the use of sign-on bonuses indicate that the market is responding to a shortage of clinical laboratory workers. The increased use of per diem and contract workers and overtime may conceal the severity of the current shortage.
3. Though the pipeline to employment in the clinical laboratory sciences has deteriorated – mostly due to closures in hospital-based training programs – student interest is rising. Local or regionally driven efforts to restart training programs, or develop new ones, in locations currently experiencing labor shortages, have capitalized on renewed student interest to meet local workforce demand.
4. New and developing technology, including the automation of many common tests, will have an impact on the demand for clinical laboratory workers; yet much of that change is emerging more slowly than once predicted.
5. Medical technologists (MTs) will not move into consultative roles on clinical teams without a strategy to make this happen.

Introduction

The clinical laboratory workforce plays a vital, but often overlooked, role in the health care system. Clinical laboratory practitioners help in detecting and diagnosing disease or pre-disease states, as well as in monitoring the progress and results of treatment. General job responsibilities include the collection, examination, and analysis of body fluids, tissues, and cells for signs of infections, chemicals, abnormalities, and other indications of disease or precursors to disease. [1],[2],[3] Most consumers are familiar with the person who draws their blood but are not aware of the personnel who analyze those specimens behind the scenes, using techniques ranging from automated machines to complex visual analysis and report the findings back to medical personnel.

In recent years there has been a growing concern among employers, educators, professional associations, and policymakers that there is a significant shortage in the number of clinical laboratory workers. The perception that the shortage will worsen in the next decade as older workers retire, and vacated and new positions are not filled due to an insufficient number of new graduates, is of even greater concern. The Bureau of Labor Statistics (BLS) projects about 138,000 openings for medical technologists (MTs) and medical laboratory technicians (MLTs) by 2012.[5]Many hospitals, which had been the primary site of educational programs in the clinical laboratory sciences, closed their programs during the 1970s and 1980s due to both declining reimbursements and enrollments.

In response to these concerns, the Bureau of Health Professions, National Center for Health Workforce Analysis, issued a grant to the University of California, San Francisco (UCSF), Center for California Health Workforce Studies, to study issues of education, scope of work, supply and demand, and the impact of technological changes on the clinical laboratory workforce. For this study, the Center for California Health Workforce Studies developed a partnership with the American Society for Clinical Pathology (ASCP), a professional organization whose Board of Registry certifies laboratory workers, as well as surveys and collects data on the laboratory workforce, employers, and educational programs on an ongoing basis.

Project Objective and Research Questions

The goal of the study was to address 10 major research questions, including an assessment of educational requirements and a scope of practice for each of six types of clinical laboratory practitioners, a description of the size and demographic characteristics of the workforce, key factors influencing the current and future supply of and demand for workers, an assessment of the magnitude of any shortage and its impact on the health care system, and suggestions for addressing an imbalance between supply and demand. Research questions included the following:

1. What are the roles and activities of various clinical laboratory workers and what is the potential for substitution of workers and tasks?
2. What are the educational requirements for each type of position?
3. How is the scope of practice (job duties and responsibilities) of different clinical laboratory workers affected by the type of education (diploma, associate degree, on-the-job training)?
4. What are the demographic characteristics of the clinical laboratory workforce in the U.S. and regionally?
5. What are the key factors influencing current and future demand for key clinical laboratory sciences personnel?
6. What are the key factors influencing current and future supply of clinical laboratory sciences personnel?
7. What is the current and future utilization of key laboratory sciences workers in their primary work settings?
8. To what extent can the magnitude of any shortages among clinical laboratory workers be quantified?
9. What is the impact, if any, on the health care system of any shortages of key clinical laboratory personnel?
10. What recommendations from the clinical laboratory professions address supply/demand imbalance and underlying factors?

Report Outline

In this report we first describe the clinical laboratory workforce, its primary roles and responsibilities, educational pathways to the field, and certification and licensure processes. We then discuss the supply of and demand for clinical laboratory workers, using data from the project surveys and key informant interviews. In the final section, we present major findings of importance to educators, industry, government, and policymakers.

Methods

We utilized quantitative and qualitative approaches to study the clinical laboratory workforce. The collaboration between UCSF and the ASCP allowed us to utilize existing surveys and respondent databases. Because these surveys have been conducted by the ASCP for a number of years, we were able study longitudinal data from the same cohort of individual practicing clinical lab technologists. The following specific data sources were employed in this study.

1. Wage and Vacancy Survey

The ASCP Wage and Vacancy Survey of Medical Laboratories is a biennial survey conducted by the ASCP of clinical laboratory directors throughout the U.S. The 2002 survey was sent to 9,349 clinical laboratories in hospitals, private clinics, and industry from a mailing list maintained by the ASCP. There were 1,788 surveys returned for a response rate of 19 percent. Survey items address current vacancy rates and wages for certified and non-certified personnel in a variety of clinical laboratory settings. The ASCP 2002 Wage and Vacancy Survey of Medical Laboratories was conducted in collaboration with UCSF and Morpace International.[5] In the 2002 version of the survey, items were added for the purpose of collecting information on the number of lost positions, difficulty in filling positions, and strategies used to recruit new workers.

2. Survey of Educational Programs

A survey of educational program directors is conducted annually by the ASCP and is addressed to directors of all educational programs in the ASCP database. The 2002 ASCP Board of Registry Annual Survey of Medical Laboratory Science Programs was sent to 632 directors of educational programs for medical technologists and medical laboratory technicians, specialists in blood banking, histotechnologists and histotechnicians, cytotechnologists, and phlebotomists. There were 491 completed surveys for a response rate of 77.7 percent. The 2002 Program Survey was changed in two important ways from previous years. First, the survey was expanded to include items on student recruitment, the number of faculty full time equivalents (FTE), faculty hiring and turnover, and curriculum changes. Second, the survey was conducted online rather than by mail. Program directors were contacted via e-mail with a link to the survey and a password, along with instructions on how to complete the survey. It was estimated that the survey took about 15 minutes to complete online.

3. Analysis of Longitudinal Cohort Survey Data

The ASCP conducted a longitudinal study of a cohort of medical technologists from 1993 to 2002. The survey began in 1993 with an initial mailing of the survey to 1,797 medical technologists. There were 1,156 responses for the initial survey, a response rate of 64 percent. The survey was conducted annually with a set of items that varied somewhat from year to year but included questions about job responsibility, job mobility and advancement, job satisfaction, and basic demographic information. By 2002, 186 respondents had remained in the cohort the full 10 years. These respondents are included in the analysis for this report.

4. Key Informant Interviews

Project staff researched and identified prominent organizations and professionals in the field of clinical laboratory science and identified individuals who were recognized experts in the field to contact for key informant interviews. These individuals represent a variety of perspectives on the field, including those of educational programs, the health care industry, professional associations, certifying bodies, accrediting bodies, regulatory agencies, and health care systems. We then sent letters to these potential informants describing the study and its purposes, and followed up with telephone calls to obtain verbal consent and schedule interviews. We identified and contacted 36 subjects, and conducted in-depth structured interviews with 31 (86 percent) of them. There were two refusals and three individuals with whom we made, but subsequently lost, contact with and thus were unable to interview. Interviews lasted from 30 minutes to 1.5 hours.[1]

[1]The perspectives of the individuals interviewed do not necessarily represent the views or positions of key stakeholder agencies, organizations, and institutions with which these individuals are affiliated.

Description of the Clinical Laboratory Workforce

The clinical laboratory workforce includes several categories of laboratory science practitioners, who have various levels of education and training ranging from on-the-job training to associate, baccalaureate, and graduate degrees. The general job responsibilities of clinical laboratory workers involve the collection and analysis of body fluids, tissues, and cells in order to diagnose and monitor diseases and medical conditions.[6],[7],[8] Through these processes, clinical laboratory practitioners help in detecting and diagnosing diseases, or pre-disease states, as well as in monitoring the progress and results of treatments.

The clinical laboratory professions addressed in this report include phlebotomists (PBT), generalist medical laboratory technicians (MLT) [also called clinical laboratory technologists (CLT)], and medical technologists (MT) [also called clinical laboratory scientists (CLS)], as well as specialized practitioners such as histotechnologists (HTL) and histotechnicians (HT). These latter two practitioners specialize in the preparation of thin slices of body tissues such as bone or organs for analysis.[9],[10] There are also specialists in blood banking (SBB), who are trained in the functions of blood banks and transfusion services, and cytotechnologists (CT), who specialize in the study of cells for infections and abnormalities.[11] For example, CTs screen and analyze the Pap smear test for cervical cancer. Table 1 contains descriptions of the different types of clinical laboratory workers, their general job responsibilities, and typical work settings in which they are found.

Table 1

Types of Clinical Laboratory Workers

Sources: American Medical Association, Health Professions: Career and Education Directory, 30th Edition, 2002-2003; AMA Press. Bureau of Labor Statistics, Occupational Outlook Handbook, 2004-05 Edition.

[2] The two largest groups of clinical laboratory workers are each referred to with two interchangeable titles by practitioners, educational programs, and professional organizations. The higher-educated group is known as both “medical technologists” (MTs) and “clinical laboratory scientists” (CLSs). The lesser-educated group is known as both “medical laboratory technicians” (MLTs) and “clinical laboratory technicians” (CLTs). For the purposes of this paper, we will primarily refer to MTs and MLTs, unless otherwise indicated (i.e., unless in the context of a direct quote or in reference to an institution/organization that employs the other titles).

Work Setting

Clinical laboratory practitioners work in a variety of settings, most often hospitals, but also in physicians’ offices, independent laboratories, universities, colleges, community colleges, and the biotechnology industry.[12] Figure 1 presents Bureau of Labor Statistics (BLS) data showing the percent of clinical laboratory workers who work in each type of setting.[13]

Figure 1

National Employment of Laboratory Workers by Industry Setting, 2002

D

Source: Bureau of Labor Statistics, Occupational Employment Statistics, 2002 National 4-digit NAICS Industry-specific estimates, 2002

These data are for both medical laboratory technologists[3] and medical laboratory technicians, which are the only categories of clinical laboratory workers represented in the BLS. Not surprisingly, a majority of these workers are in hospital settings, with the remainder found primarily in physicians’ offices and medical or dental laboratories. Only 12 percent of these workers are in non-medical settings, such as industry (research and manufacturing), education, or government.

[3] The BLS uses the non-standard classification “medical laboratory technologist” rather than the more commonly used “medical technologist.”

Figure 2 shows a comparison of employment setting for a cohort of ASCP-certified medical technologists, certified with the ASCP in 1993. This cohort was surveyed annually from 1992 through 2002, and the data presented here are for a subset of individuals who participated in each round of the survey.[4] The categories of laboratory setting in the survey included small and large hospitals, independent laboratory, academic laboratory, and other.

[4] Due to possible biases related to self-selection into this subset of the original cohort, generalizations from these data should be made with caution.

Figure 2

ASCP Cohort Data: Employment of Laboratory Science Workers by Industry Setting in 1993 and 2002[5]

D

Source: American Society for Clinical Pathology, Longitudinal Study of Medical Technologists, 1993, 2002

[5] Small hospitals are defined as those with 300 or fewer beds; large hospitals are defined as those with 301 or more beds. Independent laboratories are privately owned clinical laboratories that provide outsourcing services to hospitals, physicians, and health care facilities, and direct testing to consumers. Academic laboratories are those found in university hospitals. Laboratories in the “other” category would tend to be found in doctors’ offices, or in industrial research facilities.

Within this cohort, overall employment in hospitals decreased between 1993 and 2002, while it increased in academic labs and the “other” category. Employment in independent laboratories has remained roughly the same. Neither biotechnology nor industry were included in the response categories on the survey, therefore these employment settings are included in the “other” category.

Historical Growth of the Workforce

The clinical laboratory science professions arose from the science of clinical pathology.[14] In the early 1900s, during outbreaks of infectious diseases such as tuberculosis and typhoid, laboratories began to hire bacteriologists to detect the presence of pathogens in samples of sputum, throat cultures, and feces.[15] The work was low paying and offered little opportunity for advancement, thus it was regarded as most suitable for women. As medical technology became more sophisticated, the need for these workers increased and their numbers began to rise. These laboratory assistants or technicians trained on the job to perform routing testing procedures.

In 1920, the American College of Surgeons began requiring trained technicians to supervise hospital laboratories. At this time, clinical pathology itself was an undefined medical science, hardly acknowledged by the American Medical Association. Yet its practitioners foresaw that laboratory testing could potentially revolutionize the power and scope of medical diagnosis.[16] The first formal recognition of the profession came in 1922, when a group of 39 physicians laid the foundation for the American Society for Clinical Pathology (ASCP) with the objective “to promote the practice of scientific medicine by a wider application of clinical laboratory methods to the diagnosis of disease.”[17] A primary goal of the ASCP was to create a formal program to ensure the competence of laboratory workers through certification. In 1928, the ASCP established a Registry of Medical Technicians (later renamed the Board of Registry, or BOR) and solicited technicians to apply for certification. Initially, applicants were certified on a case-by-case basis, but by 1933 the ASCP-BOR began to require that applicants meet educational prerequisites and pass both written and practical examinations to obtain certification.

The field of clinical laboratory science has grown remarkably since its beginnings, and continued growth is assured. In 1930, the first year that the ASCP issued certificates, just over 400 technicians were certified.[18] There were 2,453 MTs newly-certified in 1960 by the ASCP, and the number certified each year grew steadily throughout the 1960s likely due in part to the advent of Medicare in 1965, and increases in other third party payments for laboratory testing (see Figure 3). Growth in the profession led to the development of other professional and certifying agencies such as the National Credentialing Agency, which was founded in 1978. The NCA certifies laboratory professionals including clinical laboratory scientists and technicians, and phlebotomists. In terms of overall employment in the field, in 2001, there were approximately 150,000 MTs and 147,000 MLTs employed in the United States.[19] The Bureau of Labor Statistics projects that there will be 179,000 MTs and 176,000 MLTs employed by 2012, which in both cases represents an increase of about 19 percent from 2002.[20]

Demographic Characteristics

The clinical laboratory professions are female-dominated and, in the aggregate, are representative of the U.S. population with regard to ethnic or racial background.[21] However, given the general tendency for minorities to be underrepresented in higher income health professions, it is likely that, in fact, ethnic or racial minorities are underrepresented among the higher skilled, higher paid clinical laboratory science professions such as cytotechnologist or clinical laboratory scientist.[22] Despite the frequently cited concern in the clinical laboratory science field that a critical number of workers will retire from the field over the next 5-10 years, Current Population Survey (CPS) data show that the median age of clinical laboratory workers[6] in 2002 was 41.[23]

Table 2

Race/Ethnicity and Sex of Laboratory Science Workers and the U. S. Population in 2001

Source: Current Population Survey, Bureau of the Census, Outgoing Rotations, 2001

[6] The OES category used for the CPS is “clinical laboratory technologists and technicians,” and CPS does not provide details about which workers fall into this category. Thus, for MTs and MLTs there may be measurement error associated with this statistic.

Wages

Nationally, hourly wages for clinical laboratory workers range from a low of $10.55 for staff phlebotomists to $29.00 for cytotechnology supervisors, who are followed closely by MT managers at $28.50. Hourly wages by job category, therefore, demonstrate a relationship between compensation and both educational level and job experience. The educational requirements for different categories of workers are discussed in more detail in the section on pathways to becoming a clinical laboratory science worker.

Table 3

Median Hourly Wage by Job Category, 2002

Source: ASCP Annual Wage and Vacancy Survey, 2002

Geographic Concentration of the Workforce

Table 4 displays the State ratios per 100,000 persons medical laboratory technologists and technicians, expressed as a percentage of the national ratio of these workers to the population. This measure describes the concentration of workers by State, compared to their concentration nationally. The table also contains values for registered nurses and radiation technologists and technicians, allowing comparisons to be made across health care professions.

Table 4

Clinical Laboratory Science Workers per 100,000 People: State Ratios Compared to the National Ratio, 2001

*States that require licensure of MTs are in bold

Sources: Bureau of Labor Statistics, Occupational Employment Statistics, 2001; Bureau of the Census,State & County Quick Facts, http://www.census.gov

Washington, DC has the highest concentration of medical laboratory technologists and technicians in the Nation, at over two times the national average. North Dakota and Tennessee have the highest ratios of all the States, at 58 percent and 61 percent higher than the national average, respectively. Nevada has the least workers per population of all the States, at only 61 percent of the national average.

The requirement for licensure may be related to the number of workers in each State in that licensure could be perceived either as a barrier to entry or an attraction to workers if licensure offers the benefi