| Abstract|| |
Background and Objectives: Pathology is a broad subject consisting of various branches, such as hematology, clinical pathology, biochemistry, histopathology, cytology, blood banking, and others. All the subspecialties are difficult to cover in depth in a 3-year MD Pathology course and curriculum. Hence, it was decided to investigate whether the MD Pathology curriculum is able to meet the challenges of today's laboratory medicine practice. So, a survey was conducted among newly qualified pathologists who have passed their exam within last 5 years. Purpose was to know their views about MD Pathology curriculum with special emphasis on challenges they face during their day-to-day practice. Materials and Methods: Study is designed as cross-sectional survey conducted via web-based Google forms questionnaire. Study population is pathologists qualified within last 5 years. A convenience sample of eligible pathologists was taken by sending a web-based Google form to various pathology groups on social media apps. Data were collected in the Google spreadsheet software and various responses were summarized as percentages, graphs, and pie-charts as necessary. Chi square test was used to find the significance of difference in responses from government, private, and deemed university respondents. Results: Different numbers of responses were received to different survey questions. Out of 187 respondents, 65 (34.8%) worked in a hospital-based laboratory, 61 (32.6%) did jobs in a private laboratory, 49 (26.2%) worked in a medical college, and 37 (19.8%) worked in their own private laboratories. Out of 193 respondents, 158 (81.9%) were working in hematology, 149 (77.2%) in clinical pathology, 139 (72%) in cytopathology, 118 (61.7%) in histopathology, whereas 103 (53.4%) worked in clinical biochemistry, and least number of respondents, i.e., 38 (19.7%) were working in blood bank. Almost all the respondents had overlapping work in hematology and other areas. The level of confidence rated by the respondents was best in hematology, followed by clinical pathology; it was least for clinical biochemistry and blood bank. Out of 192 respondents, 64.1% (123) felt that the curriculum does not equip them for lab management and administration, 21.9% (42) felt that the curriculum somewhat equipped them; whereas only 14.1% (27) felt that curriculum equips them for this task. There were 191 responses to the question regarding satisfaction with MD Pathology curriculum; out of which, 51.8% (99) were not satisfied, 24.6% (47) said they may be satisfied, whereas 23.6% (45) were satisfied with the curriculum. There was no significant difference in responses from government, private, and deemed university respondents. Conclusions: The graduating MD Pathology students expressed confidence in reporting routine cases of hematology, clinical pathology, routine cytology, and histopathology. However, there is difficulty in clinical biochemistry, blood banking, and reporting of malignancies. The laboratory management and administration, communication skills, and quality assurance are also other areas of weakness. MD Pathology program needs more focus on these weaknesses, so that newly qualified graduate would feel confident in day-to-day laboratory working.
Keywords: Curriculum, pathology, resident, satisfaction, survey, training
|How to cite this article:|
Kale S, Bindu S, Agrawal R. Whether M.D. Pathology curriculum is sufficient to meet pathology practice requirements in India? A survey of newly qualified pathologists. Indian J Pathol Microbiol 2023;66:118-28
|How to cite this URL:|
Kale S, Bindu S, Agrawal R. Whether M.D. Pathology curriculum is sufficient to meet pathology practice requirements in India? A survey of newly qualified pathologists. Indian J Pathol Microbiol [serial online] 2023 [cited 2023 May 27];66:118-28. Available from: https://www.ijpmonline.org/text.asp?2023/66/1/118/367949
| Introduction|| |
The subject of pathology includes various disciplines and fields, including hematology, clinical pathology (CP), biochemistry, surgical pathology, molecular diagnostics, cytogenetics, cytology, blood banking, and others.
The 3-year MD Pathology curriculum tries to do justice to this problem by allotting rotatory postings of 6-month duration in various disciplines to the pathology residents. But it has been reported that there exists a wide variation in the competencies of postgraduate residents trained in pathology in different institutions across India.
In 3 years, the residents just about get familiar with various disciplines, but this time period appears to be insufficient to develop real mastery over any one discipline. Furthermore, the emphasis of education has shifted from assimilating facts to emphasis on critical thinking and clinical acumen. After qualifying as a pathologist by completing the 3-year course and clearing the final examination, pathologists have broad choices regarding their career. The majority seem to end up as a consultant pathologist – working in private laboratories either owned by themselves or by others. Some do take up a job in a teaching institute, either private or government. There, they again work in all disciplines of pathology as discussed earlier. Only a handful go on to become a specialist and work in a restricted specialized area, such as histopathology, cytology, or blood banking.
At the same time, medical practice is undergoing a rapid change. Patient-centric care, democratization of the “information gap,” and accountability for safety and quality affect the role of the 21st century pathologist and thus challenge the training programs for them. Mary E. Kass et al. conducted a survey in 2007 on adequacy of pathology resident training for employment. They found that newly trained pathologists were highly prepared in general pathology and anatomic pathology (AP), whereas least prepared in CP and administration.
Bhusnurmath et al. have suggested rectification in defining competencies and learning objectives, curriculum development, including emphasis on teaching methods, communication skills, professional behavior skills, etc. On similar lines, the College of American Pathologists and Association of Pathology has published a white paper in 2009 which stated that there are gaps in professionalism, and deficit in communication and interpersonal skills among newly qualified pathologists, which need to be addressed during residency. The Academy of Clinical Laboratory Physician and Scientists (ACLPS) in 2008 has also recommended incorporation of active learning, clinical construction, and competency assessment into CP resident training.
According to Black-Schaffer et al., newly qualified pathologists and their employers reported that MD program inadequately prepared them for some areas, such as laboratory management, molecular pathology, and pathology informatics.
To overcome these challenges, Black-Schaffer et al. proposed a model program of 5 years; where the fifth year will be reserved for advanced training and development as a subspecialist practitioner.
With this backdrop and given the daunting task of mastering many disciplines with their unique challenges, whether the MD Pathology program in India is able to meet the challenges of today's laboratory medicine practice. Also, have the graduating pathologists acquired sufficient skills to function independently as practicing pathologists, immediately after their postgraduation? To answer these questions, a need assessment-based pilot survey among newly qualified pathologists who have passed their final exams during the last five years was conducted. Aim was to know their views about MD Pathology curriculum, with special emphasis on challenges they now face during their day-to-day working.
It is presumed that this survey would help in further improvement of the existing pathology postgraduate training program.
| Materials and Methods|| |
This study is designed as a cross-sectional need assessment-based pilot survey conducted via web-based questionnaire based on Google forms with collaboration of MGM Medical College, Aurangabad and Rajshree Medical Research Institute, Bareilly. The study population is composed of MD Pathologists qualified within last 5 years, i.e., 2016–2020. A convenience sample of eligible pathologists was taken by sending a web-based Google form to various pathology groups using social media apps, such as WhatsApp, Telegram, and online mailing lists such as www.PathoIndia.com. Data collection instrument, i.e., Google form comprising survey questions was designed by all the three authors together. Questionnaire is attached in Annexure 1. Internal validation of the questionnaire was done by peer review and by consultation with the college statistician. Questions were refined and standardized by carrying out a small pilot survey. The data were collected in the Google spreadsheet and various responses were summarized as percentages, graphs, and pie-charts as deemed necessary. Chi square test of significance was used to compare responses of government, private, and deemed university graduates. A certain amount of selection bias could be present in the study because of the “convenience” sampling methods. Participation in the study in the form of responses in the web-based survey was entirely voluntary. No monetary or any other benefits were given to the participants. All the participants' information was kept anonymous and confidential. The survey data will be stored as a soft copy with a password protection for 3 years. Approval from the institute's ethics committee was sought prior to commencement of the study.
| Results|| |
Different number of responses for different questions were received. Out of the 185 respondents, 32 (17.3%) passed in 2020, 32 (17.3%) in 2019, 41 (22.4%) in 2018, 36 (19.5%) in 2017, and 44 (23.8%) in 2016. Thus, there was almost equal distribution of number of responses in 5 years of survey.
Out of 190 respondents, maximum were in the age group between 26 and 41 years. Sex distribution of the respondents was male 28.9% and females 71.1%. So, there was female majority in the sample.
About 52.4% respondents studied in government colleges, whereas 22.2% and 25.4% studied in private and deemed university colleges, respectively. Sixty-five (34.8%) respondents worked in a hospital-based laboratory, 61 (32.6%) did jobs in a private laboratory, 49 (26.2%) worked in a medical college, and 37 (19.8%) owned and worked in their private laboratories.
Out of 193 responses, 158 (81.9%) were working in hematology, 149 (77.2%) in Clinical Pathology (CP), 139 (72%) in cytopathology, 118 (61.7%) in histopathology, and 103 (53.4%) in clinical biochemistry. Least number of respondents, i.e., 38 (19.7%) were working in blood bank. Almost all the respondents had overlapping work in hematology and other areas and reported more than 50 specimens per months in the area of hematology, CP, and clinical biochemistry.
The level of confidence rated by the respondents was best in hematology, followed by CP; it was least for clinical biochemistry and blood bank [Table 1], [Figure 1].
|Table 1: Confidence rating by respondents in various pathology subspecialties|
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|Figure 1: Confidence rating by respondents in various pathology subspecialties|
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The respondents felt that the pathology curriculum equips future pathologists with skills to face day-to-day work in the fields of hematology, cytology, CP, but not in clinical biochemistry and blood bank [Table 2], [Figure 2].
|Table 2: The respondents opinion about ability of pathology curriculum to equip them with skills to face day to day work in various subspecialties|
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|Figure 2: The respondents opinion about ability of pathology curriculum to equip them with skills to face day-to-day work in various subspecialties|
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About 64.1% (123) respondents felt that the curriculum does not equip them for lab management and administration, 21.9% (42) felt that the curriculum somewhat equipped them; whereas only 14.1% (27) felt that curriculum equips them for this task.
And 127 (66.1%) felt curriculum does not equip them for running quality management system such as National Accreditation Board for Testing and Calibration Laboratories (NABL) also, 40 (20.8%) felt it somewhat equips them for this task, whereas only 12.5% agreed that it equips them for the task.
There was wide variation in the need for second opinion, varying from as low as 1 to as high as 400 times a year for some respondents. Most common subspecialties for seeking second opinion were histopathology, cytopathology, malignancies, rare cases, and even sometimes for biochemistry and quality management issues.
Regarding satisfaction with MD Pathology curriculum; Out of, 191 responses 51.8% (99) were not satisfied; 24.6% (47) said they maybe satisfied; whereas 23.6% (45) were satisfied with the curriculum.
A Chi-square test of significance showed that there was no significant difference in satisfaction levels of MD pathology curriculum between the three groups, i.e., government, private, and deemed university responses, χ2 (3, N = 101) = 4.9, p: 0. 29 [Figure 3].
|Figure 3: Responses from government, private, and deemed university graduates about satisfaction with MD Pathology curriculum|
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Also, there was no significant difference in responses with respect to ability of the curriculum to equip the graduates for lab administration in the three groups, χ2 (3, N = 101) = 1.5, P: 0.8. [Figure 4].
|Figure 4: Responses from government, private, and deemed university graduates regarding ability of the curriculum to equip the graduates for lab administration|
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As far as ability of the curriculum to equip the graduates for day-to-day reporting in various fields, such as histopathology, cytology, CP, blood bank, and clinical biochemistry in the three groups was concerned, there was no significant difference in responses. χ2 (3, N = 101) = 2.2, P: 0.9 [Figure 5].
|Figure 5: Responses from government, private, and deemed university graduates regarding ability of the curriculum to equip pathologists with skills to face day-to-day work in the various fields|
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Survey participants were also requested to provide suggestions for improvements in MD Pathology curriculum. A total of 137 suggestions were received. It is not possible to include all the suggestions because of space constraints; however, important suggestions shortlisted are summarized in [Table 3].
| Discussion|| |
Laboratory medicine is undergoing lot of changes because of advances in technology and patient-clinician requirement.
It is a big challenge in front of educators and students to master all of the pathology sub-disciplines in a short span of 3 years; hence, this survey can pinpoint the gaps and help in improvement of pathology curriculum.
Dr. Jaiman in 2009 prepared a questionnaire focused on helping the residents in analyzing his or her career choice in the field of Pathology. He had emphasized on lack of counseling for choosing a right career path following completion of Pathology residency.
Web-based questionnaire of present study received enthusiastic response, with some remarkable suggestions being given for improvement of MD Pathology curriculum. All the suggestions could not be incorporated here but they may help in future direction. There have been number of papers discussing these topics in various journals. Prasad Uma reviewed current scenario about training of postgraduate students in pathology and discussed how it can be improved. Our survey also revealed need for improvement as there was some dissatisfaction on the part of participants regarding MD Pathology program.
Black-Schaffer et al. emphasized core training that provides knowledge in both AP and CP. Survey of present study also emphasized equal importance for AP and CP, as results reveal that clinical biochemistry and blood banking suffer, probably because residency is skewed in favor of surgical pathology. Surgical pathology is being practiced by very few pathologists, probably because they do not get an opportunity for that and/or there is lack of confidence. This has reflected in our survey, where second opinion is most commonly taken in histopathology reporting to the tune of as less as 1 to as many as 400 times a year for some respondents, but this 400 times per year could be an outlier.
In a paper by Bhusnurmath et al., they have lamented about variation in competency of pathology residents in different institutions across India and have highlighted the deficiencies in training facilities and curriculum with respect to well-defined objectives and competencies. Other deficiencies were quality control skills and co-curricular skills such as communication and business practices. Our survey also leads to similar conclusion, as around 66% respondents believed that curriculum does not equip them for laboratory management and administration, along with maintaining quality control and quality management system. Because laboratory management and administration play a pivotal role in the future career of these students, a good amount of weightage needs to be put in this matter in the MD curriculum. This malady is not only restricted to India but is also seen in developed countries such as USA where a similar survey was conducted by Kass et al. in 2007 regarding perceived strength and weakness in pathology resident's training. Their survey found that newly trained pathologists are more prepared for reporting of general pathology and AP; whereas they are less prepared for CP and administration. Our survey also revealed lack of preparedness in laboratory administration. Similar to this study, one more paper from USA also reported lack of sufficient training in communication skills and teamwork and newly trained graduate not being fully ready for independent practice.
An editorial in Human Pathology also discussed ways for preparing residents for future practice, where it emphasized on teaching responsible professional behavior, attitude, and communication skills. A panel of ACLPS also suggested improvement in CP teaching, with emphasis on technical and analytical training through active learning in the laboratory. These are exactly the suggestions put forth by the participants in our survey also. Several pathology surveys conducted in the past decade have identified gaps in preparation of residents for independent practice. At the same time legal aspects of pathology practice also needs to be introduced. Michael Laposata also questioned the ability of the graduating pathologists to manage employees and hospital budget; despite the fact that American Universities have formal hours of laboratory management training.
Smith et al. in a special report have developed a template for curriculum in CP, defining goals and objectives, providing guidelines for instruction methods, and giving examples of outcomes assessed. They also highlight importance of interpersonal skills, professionalism, and informatics, apart from medical knowledge. Overall, our survey echoes similar sentiments among participants; wherein lack of management training has been emphasized by many. With evolution of health care system, pathologists need to be adequately trained as leaders and managers and hence taking this aspect into account, mentor-based laboratory management can be considered. Our study agrees with Hassell et al. where they propose digitalization of images and data as a future trend. This will enhance teaching value pathology expertise.
Our study is one of the first attempts to take a direct feedback from Indian pathology graduates regarding pathology training. Limitation of the study is that this was a purely voluntary survey of limited participants from different parts of India. The training period allotted by different colleges for different subspecialties and availability of qualified biochemists in the lab was not part of this survey. These limitations could be overcome with a larger sample sized and more detailed survey.
| Conclusions|| |
The graduating MD Pathology students are confident in reporting routine cases of hematology, CP, routine cytology, and histopathology. However, there is lack of confidence in clinical biochemistry, blood banking, and reporting of malignancies. The laboratory management and administration, communication skills, and quality assurance are other areas of weakness. MD Pathology program needs more focus on these weaknesses.
There was no significant difference in responses from government, private, and deemed university respondents with respect to satisfaction about MD Pathology program.
The responses received in this survey probably point to the variation in teaching skills, clinical diagnostic skills, research capability, and availability of resources, infrastructure facilities, and quality control of laboratories, institutional support, and above all selection of postgraduate students.
Attempt can be made to improve infrastructure and resources and introduce faculty development programs to improve competency of Indian pathology graduates.
The end users of the pathology services, i.e., the clinicians and the community will benefit more, if the graduating pathologists undergo a standard training program all over the country.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Department of Pathology, MGM Medical College, Aurangabad, Maharashtra
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2], [Table 3]