Undermined and Undervalued

I am writing this on behalf of the American Society for Clinical Pathology (ASCP) Resident Council, and in response to articles that have been published previously in The Pathologist regarding pathology education. I also want my colleagues within the pathology and laboratory medicine community to be aware that I have presented this letter directly to John Prescott, Chief Academic Officer of the Association of American Medical Colleges (AAMC) and the Council of Deans (COD) of the AAMC as it is imperative that our concerns are voiced. Specifically, I want to address the current state of pathology training in medical school and the consequences it may have on the field at large.

The ASCP is a nonprofit medical specialty society representing more than 100,000 members, including board certified pathologists, pathology residents, other physicians, clinical scientists (PhDs), certified medical laboratory scientists/technologists and technicians, and educators. We’re one of the largest medical specialty societies in the US and the world’s largest organization representing the field of laboratory medicine and pathology. As the leading provider of continuing education for pathologists and medical laboratory personnel, we place a great emphasis on enhancing the quality of the profession through comprehensive educational programs, publications, and self-assessment materials.

We appreciate the complexities faced by medical schools across the US. We understand the task of teaching the doctors of tomorrow is a great challenge; ensuring that medical students are exposed to and have a basic understanding of each specialty is a significant undertaking.

However, the ASCP Resident Council is concerned that the current trend in transitioning from a traditional two-year, course-based curriculum to a more integrative, systems-based curriculum, may inadvertently underrepresent pathology. As such, pathology education has gone from an intensive course with practical sessions, lectures, and gross pathology labs, to only a limited number of lectures integrated with other clinical subjects. Moreover, evaluation of knowledge has been reduced to a sprinkling of pathology questions lost in a milieu of pathophysiology, pharmacologic, and clinical questions; consequently, passing is easily feasible with little to no knowledge of pathology.

This diminution of pathology is unfortunate and undermines the importance of the field. The diagnoses and laboratory values that pathologists provide are absolutely crucial to patient management. The results provided help guide decisions about whether a patient will undergo surgery or a doctor will initiate a life-saving treatment. As pathologists, our job is to supply accurate results to ensure that medical decisions are based on correct diagnoses and valid lab values, as these results provide a platform to justify medical choices and ultimately a foundation for patient care. Unfortunately, despite pathology’s central role in medicine and patient care, the field is undoubtedly undervalued by fellow clinicians and patients alike. There are many reasons for this. A main contributor is a general lack of awareness of what pathologists truly do. In part, the nature of the profession physically isolates us: we spend large amounts of time sitting at our desks looking through a microscope or in the lab interpreting data, troubleshooting problems, implementing new tests, etc.

The lack of exposure to pathology, coupled with the aforementioned deficiency in medical school pathology training, comes with deleterious effects. Indeed, medical school preparation for pathology residency training is problematic. According to our annual national survey of pathology residents and fellows (1), approximately 80 percent of pathology residents feel that medical school pathology training did not adequately prepare them for residency and 45 percent of residents cite no exposure to pathology or no first-hand pathology experience during medical school. Furthermore, the dearth of pathology instruction in medical school parallels a declining interest in pathology residencies: The National Resident Matching Program reports approximately half of the pathology residency spots have been filled by US allopathic medical students for the last three years (2013–2015). Unmistakably, pathology is no longer viewed as a central component of clinical medicine. The decline in the knowledge of pathology is undoubtedly attributed, at least in part, to the revised curriculum, which has stripped pathology to a bare minimum.

Besides the negative effects on pathology training, the transition to the new, integrated curriculum has also negatively impacted the perception of pathology. For instance, among medical students, fewer students consider pathology to be central to medicine (49 percent in new curriculum vs. 96 percent in old curriculum) or believe knowledge of pathology will be useful in their future careers (52 percent vs. 96 percent) (2). This poor perception persists beyond training and into practice, leading to a decline in communication between pathologists and clinicians as well as a negative impact on patient care. To that end, the Institute of Medicine released a report highlighting an inappropriate utilization of diagnostic testing by clinicians (3). The report emphasizes that pathologists have much to offer in test utilization from test selection to interpretation. Especially with the expansion of molecular diagnostics, pathologists’ role is going to become even more critical in diagnosis, monitoring, risk assessment, prognosis, and predictive aspects of disease process and cancer. Thus, enhanced teamwork among pathologists and treating physicians can only improve diagnostic testing and patient care. However, in order to achieve this goal, the value of pathology needs to be emphasized and taught early on in training.

The time and resources put forth by medical schools across the US to develop and implement the new integrative curriculum are substantial. As such, we realize that drastic revamping or redesigning of the curriculum is not feasible, nor necessarily desirable. However, we hope you agree that the state of current pathology education is in a precarious position. Unless deliberate and conscious steps are taken to ameliorate the situation, the field of pathology as a specialty may be negatively impacted, not only in terms of decreased enrollment of medical students into pathology residencies, but also in perpetuating the perception of pathology within medicine. We encourage the AAMC to revitalize and improve pathology education in medical schools across the nation. Although bringing back traditional pathology courses may not be possible in the current integrative model, we do have some practical ideas that can be implemented to help improve pathology education: 

• Increase in the extent of exposure to pathology
• Ensure that pathology lectures and courses are taught by pathologists
• Review sessions devoted to basic and systemic pathology
• Include gross anatomy laboratories
• Run microscopic/histological sessions 
• Incorporate a mandatory pathology clerkship or a “mini” clerkship within another clerkship (e.g. a week of frozen sections or transfusion medicine during surgery clerkship, laboratory week integrated into internal medicine, cytology week within the obstetrics/gynecology clerkship, a week of biopsy service during dermatology clerkship, spending a week with hematopathology during pediatric clerkship, a week of pathology signout during radiology clerkship to reinforce radiologic-pathologic correlation, etc.)
• Work in concert with pathology and laboratory medicine department(s) to support a pathology student interest group
• Recruit pathologists to be small group leaders or lead problem based learning sessions within the integrated curriculum
• Encourage clinicopathologic correlation early in clinical training prior to clerkships
• Solicit pathology and laboratory medicine department(s) for ideas on how to integrate pathology within the current curricular structure at your institution.

The ASCP Resident Council appreciates the opportunity to present our concerns and our ideas, and we are more than willing to address any questions or concerns that the AAMC or others might have.