A Connected Future for Pathology

For international medical students and graduates seeking to build a life and career in a new country, getting started can feel like an impossible task. This is particularly true for those who are beginning their medical careers in a new language, with a new alphabet, or in a medical system completely different to the ones they’ve grown accustomed to during training. To overcome the many obstacles a move to the United States presents, we conceived CMG23PathGroup – a virtual pathology interest group to help with residency applications and promote workforce diversity, equity, and inclusion.

Who are CMGs?
 

Chinese medical graduates (CMGs) currently represent a small portion of the active US physician workforce (less than 1 percent in 2017), but one whose top practicing specialty is pathology (1). And the numbers are only increasing – in 2017, 571 (10.8 percent) of all US-based CMGs were pathologists (2), but by 2022, this had increased to 1,520 (19.4 percent). 

CMG applicants for pathology residency training fall mainly into three categories: i) candidates with an advanced graduate degree after completing medical education in China, ii) candidates who practiced pathology or other specialties in China, and iii) fresh medical graduates and medical students. We refer to all Chinese applicants as CMGs. Regardless of their background in medicine, these candidates develop their passion for pathology in their research or clinical work and then pursue a career in the United States for a variety of reasons.

Challenges and opportunities
 

Like other international medical graduates (IMGs), CMGs face challenges when applying for US pathology residency, including educational, linguistic, and cultural differences; limited US clinical experience; and issues with visas or work permits.

In China, medical school takes five to eight years, depending on the specific program’s training track. Pathology is typically introduced in the second year after anatomy and histology courses, but medical students do not evaluate slides under microscopes in real clinics and, as with many US undergraduate medical programs, pathology clerkship is not mandatory (3). These factors limit students’ exposure to pathology and may contribute to the misperceived idea that pathologists are “not doctors” (4,5).

A key difference between Chinese and US pathology is the scope of clinical practice. Pathology graduate medical education in the US consists of anatomic pathology (AP) and/or clinical pathology (CP) but, in China, “pathology” typically refers to the AP arm only. CP professionals in China – including biochemistry, microbiology, transfusion, and coagulation – are trained in a separate laboratory medicine track and are not considered “pathologists.” In medical school, CP is primarily taught in laboratory diagnosis and internal medicine courses. These differences narrow the scope of pathology in China and generate confusion when CMGs apply for pathology residency in the US.

Another challenge for CMGs is language. In China, pathology courses (and medical curricula in general) are taught in Chinese, which generates a significant language barrier for those who hope to practice in the US – for instance, when preparing for the USMLE exams and during clerkship training (6).

Finally, CMGs, like other IMGs, have limited access to US mentorship and clinical rotation opportunities. US clinical experiences and letters of recommendation from these experiences are two key documents for residency application that CMGs often lack. The COVID-19 pandemic further decreased the availability of US clinical experience and prevented international travel, even though the need for health care professionals increased worldwide during the pandemic (7). Another consequence of the pandemic is the permanent cancellation of the USMLE Step 2 clinical skills (CS) exam. IMGs are now required to undergo the Pathways for ECFMG Certification, including passing the Occupational English Test and a structured clinical examination, instead. For example, Pathway 6 requires that the applicant’s clinical skills be evaluated through six clinical encounters by at least three licensed physicians using ECFMG’s Mini-Clinical Evaluation Exercise. These new evaluations add additional layers of uncertainty, as well as financial and time costs, for IMGs.

But challenges and opportunities come hand in hand. To overcome the barriers and help CMGs match into US pathology residency programs, we initialized the CMG23Path Group, a virtual pathology interest group for all CMGs applying for residency in the 2022–23 cycle. The group aims to encourage pathology learning, shared observership opportunities and experiences, and residency preparation. Our long-term goal is to promote the pathology profession and bring in new perspectives and skills to enrich the diversity of the US pathology workforce.

CMG23Path Group achievements
 

The group has two subgroups, PathStudy and PathConnection. The PathStudy team is responsible for scheduling weekly group study sessions via Zoom. The sessions, which take place most Saturdays at 10 pm EST to accommodate both US- and China-based participants, typically last one to two hours. The topics and format are flexible. For example, we review textbook chapters covering bone marrow, soft tissue, liver, brain, and so on. Members are encouraged to share their clinical experience (for instance, tips on specimen grossing). We also hold group case studies in which attendees are encouraged to describe the microscopic features and give diagnoses to the unknown slides. Residents and faculty are invited to join and teach as well – for example, we invited Mengxue Zhang, a PGY-1 pathology resident at the University of Chicago, to host a medical renal unknown conference. The flexibility in format and content allows speakers to deliver or discuss topics of personal interest. Live question-and-answer sessions are encouraged and unanswered questions are addressed in the group chat after the meeting. This peer-to-peer group learning has been interactive, engaging, and fruitful!

The PathConnection team is responsible for connecting with peers, residents, fellows, and faculty members. For example, in July 2022, we invited Guannan Zhang, a PGY-2 pathology resident at the University of Miami/Jackson Health System, to host a live session to answer pathology residency application questions. In September, we invited Kamran Mirza, an associate professor of pathology at Loyola University, to give a mentoring session on “Demystifying Pathology Residency Interviews” (see Figure 1). These invited talks attracted and served audiences worldwide, with attendance numbers up to 80 per session – about 12 percent of total IMG applicants (8).

The PathConnection team also organized a program search during the application season. Each volunteer selected between five and eight programs and filled out an informational form, including USMLE Step score requirements, year of graduation cutoff, number of open positions, and more, using the programs’ official websites and cross-referencing online databases such as FREIDA and medmap.io. The forms are updated if additional information is explained in the program’s open house and serves as a reference for group members to promote individualized application and reduce costs.

Through these activities, CMG23Path Group members develop a robust collegial relationship, which is maintained and strengthened after entering residency and beyond.

Where are we heading?
 

CMG23Path Group is growing and attracting IMGs from other countries. In August 2022, we opened the CMG23Path Group to all aspiring pathologists interested in learning, sharing, and connecting. CMGs, IMGs, and US medical students and graduates (UMGs) are all welcomed and we have expanded our social media groups to different platforms, including WeChat, Twitter, and WhatsApp. Our group has therefore become more inclusive. We kept the name CMG – but the “C” took on a new meaning: Connected.

CMG23Path Group is now working on a number of things to herald a supportive community. First, we propose collaborating with Path_Sig, a virtual pathology student interest group founded by Kamran Mirza. CMG23Path Group and Path_Sig complement each other; CMG23Path Group members are mostly IMGs, whereas Path_Sig members are mainly UMGs. Collaboration between the two groups can only promote diversity, equity, and inclusion within pathology education and the workforce. Second, we plan to collaborate with the Pathology Outreach Program (POP) founded by Ahmed Aadil and co-ambassadored by Casey P. Schukow. POP aims to engage and empower high school students to learn about pathology. Collaboration with POP can enrich current applicants’ volunteer experience and enhance the future pathology workforce in the long run. In our opinion, the more connected aspiring and early-career pathologists become, the better our discipline will be for years to come.