Avoiding the Ripple Effect

The classic role of the pathologist in medical school education was quite diverse not so long ago. We often served as course directors, responsible for crafting learning objectives, creating content and designing test questions. We regularly found ourselves teaching lectures to eager medical students, or spending afternoons in gross or microscopic pathology labs, explaining disease processes. Clinical presentations, gross pathologic findings and histology were often combined and explained alongside one another, creating a seamless picture of the pathobiology of a disease. This fairly simplistic model worked pretty well back then. But the great strides that have been made in disease research in recent years means that our knowledge has soared, and as a result, so too has the mountain of information that could potentially be taught to medical trainees. So today, we’re often left with the job of distilling that knowledge, and deciding what is important for the undifferentiated future physician to learn and what will fail to make the cut – not an enviable task. 

Change is happening

Recent trends in medical education have moved toward (or, in some cases, gone back to) the concept of integrated, or “modular,” curricula – i.e., instead of discipline-based courses (such as pathology or microbiology), they are integrated and organ-based. This model has the benefit of presenting a coherent picture of basic structure and function working alongside pathophysiology and treatment. This way, students are exposed to one organ system at a time, covering everything from histology to pharmacotherapy and microbiology specific to the system. And it seems to have worked; migration to this circular structure has been shown to increase performance on standardized examinations (1) – exams that seem to dominate the psyche of medical students more with each passing year. In the United States, a major checkpoint of this distillation and passage of information is the USMLE Step 1 exam. This single test has become the focal point of the preclinical medical school years. If information is not commonly tested on this exam, it is often deemed superfluous. While these changes in curriculum have led to more efficient medical education with an emphasis on high-yield topics, they have also required a change in the role of the pathologist as a medical educator.

Importantly, this transition has meant that much of the control of course content has shifted from specific (such as pathology or microbiology) departments within colleges of medicine to whole committees of the colleges of medicine. The result? Standardized education, more staff support and an infrastructure that likely substantially exceeds that which a department could provide alone. How can pathologists ensure that they have significant input into this new teaching model? Ideally, by serving on curriculum committees and giving input into what pathology should be taught, and how. But is this happening in the real world? Or is there a danger that pathologists will be phased out of undergraduate medical student education? Sadly, unless something is done, I think the answer to that is, quite possibly, yes.

The “disappearing pathologist”

Overall, this loss of discipline-based courses has the net effect of decreasing the pathologist’s role in designing, creating and, sometimes, delivering educational instruction to preclinical trainees. There’s also a very real risk that traditional material taught by pathologists (i.e., histology) could be culled in the interests of efficiency. If pathologists are not involved at the earliest levels of planning, we run the risk of losing the opportunity to teach what we love. In fact, many of us have already witnessed in some capacity the presentation of a pathology lecture by a clinical colleague – for example, an oncologist or internist.

The “disappearing pathologist” may become a reality as the material we deliver and the contact hours we have with students are eroded. This phenomenon has the potential to cause ripples that may loom over the entire field of pathology in the coming years. As many pathologist educators have experienced, the pathophysiology course at a medical school is a (if not the) predominant driver of interest in pathology as a career. Many medical students have their first interaction with pathologists via these courses, and inevitably some choose pathology based on this interaction (as was certainly the case for me). And these courses also provide students with a faculty contact, which is very important, in particular for those who are potentially interested in pathology as a career. Worryingly, loss of these courses, if uncompensated, could lead to a decrease in interest in the field.

Bucking the trend

Here at the University of Arkansas for Medical Sciences, we are working hard to buck this damaging trend. We have reinstated our pathology interest group (with support from extramural grants from the Intersociety Council for Pathology Information and our department of pathology), and we’ve established a summer preceptorship, both of which have increased student awareness and interest in pathology as a career. But we haven’t stopped there… We’ve partnered with other disciplines to integrate pathology into medical student education from the very start of their undergraduate training.

It’s important to recognize that the opportunity to teach pathology is everywhere, and pathologists must explore new avenues to continue to be at the forefront of preclinical medical education. One, mostly underutilized, resource for pathology education, which we have taken advantage of, is the collaborative integration of pathology into other courses. This, of course, does not have to be limited to pathology, but may involve any interested subspecialty. At the University of Arkansas for Medical Sciences we have an expansive collaboration occurring within the first-year gross anatomy course between anatomy (David Davies), radiology (Sharp Malak) and pathology (me). This collaboration has led to a greatly enriched learning experience for medical students in their first weeks of medical school. What could be better than starting the journey of medical education working with scientists and clinicians teaching anatomy, radiology, histology and disease process from day one?

Our approach explained

The way it works at our institution is as follows: pathology attendings and residents are present during selected gross dissection lab sessions; these sessions usually include dissection of the chest, abdomen and pelvic organs. The pathologists, usually five to six in number, rotate among the 35 dissection teams, which are composed of five students. The role of the pathologist is to answer questions, identify and explain grossly evident disease and to assist the teams in taking of biopsies; each team is allowed to take up to seven. Discernment of which areas to sample is left to the students, which plays an important role in emphasizing self-directed learning. Additionally, it stresses resource utilization and clinical decision-making development. Clinical decision-making is further enriched by allowing the dissection group time to research their differential diagnosis before taking samples.

As the students obtain biopsies, they are processed by the histology department, and slides are returned to the students so that they may begin evaluating them. Obviously, medical students in their first month of school may lack the foundation to critically evaluate slides, or, in some cases, describe expected normal histology, so a network of educational resources has been put into place. Students have access to pathologists and microscopes and are encouraged to ask questions during laboratory sessions. Additionally, they are referred to online resources for help with histologic and pathologic features.

These resources allow them to explore the slides as a team and develop and refine their differential diagnosis. The ultimate resource they are allowed to utilize is a 15-minute pathology consult with an attending pathologist. At this consult the students review their slides at a conference microscope, and the attending pathologist identifies and describes the disease processes present in the biopsy material. In general, the pathologist lists “take-home points” that could be ascertained from the biopsies, and gives possible causes of death for the students to consider and research as they move into the next phase of the project, the abstract and presentation.

Thinking creatively

In developing this curriculum, it was determined that “meaningful” documentation of the findings was necessary to reinforce learning. Clearly, when working with pathology slides, photography is an ideal way of presenting and archiving findings; however, the manpower needed to help medical students photograph hundreds of slides would easily overwhelm most departments. To counter this, cell phone camera mounts were purchased for the microscopes and students were given a brief tutorial on how to use a microscope and slide photography. The photographs that the students obtained could be easily shared with group members and inserted into abstracts and group presentations. Use of the students’ own phones helped to generate interest and buy-in to the process of pathologic evaluation of biopsies.

Following the pathology consult and group evaluation of their material, the students are required to produce a scientific abstract, composed of an introduction, methods, findings and conclusion. They are urged to focus on the suspected cause of death, a disease process the group found interesting, or, in the case of a normal cadaver, the histology and physiology of an organ system of their choosing. This abstract acts as an outline for a 15-minute oral presentation that each group delivers to their peers and faculty judges at the end of the course. The presentations are graded for content and group professionalism and provide an opportunity for the faculty to provide narrative assessment of the group’s progress. Truly, the entire process, from the lab to the presentation, helps to anchor gross anatomy, histology, radiology and pathology in clinical context and provide a deep learning experience for each group.

What do the students think?

Of course, the success of a major change in curriculum depends heavily on the attitudes of those who take part in it, both teachers and students. This project was deployed in addition to an already packed schedule, which many new students find intimidating. In its pilot year, significant concern existed as to whether students would be able to tolerate the increased workload associated with the course. To evaluate the impact of the project and student attitudes, a detailed survey was given to the students. Impressively, there was strong and universal praise for all facets of the experience, despite the resulting large increase in workload (see Infographic). While the pathologists were not formally evaluated on their perception of the project, their attitude was enthusiastic and many faculty and residents signed up for additional time slots after their first visit to the lab. Many pathologists expressed enjoyment because they were teaching in a lab and at a microscope, as opposed to in a lecture hall. In addition, resident pathologists appreciated the additional opportunity to gain formal experience in teaching medical students, an experience that has become sparse at our institution in the last few years.

I would urge any interested pathology educator to use this article as a blueprint, follow a similar model and take the earliest possible opportunity to ensure that pathology is taught to first-year medical students, impressing upon them the true awesomeness of pathology.

Charles Matthew Quick is Associate Professor of Pathology at the University of Arkansas for Medical Sciences, Little Rock, USA.