Examining the Entrance to Elysium

At a Glance

• In the UK, pathologists at all stages of their careers have observed a backlog of alented trainees making it into practice
• Many have cited difficulty in passing the FRCPath Part 2 examination as the primary cause
• Trainees have identified problems with the structure, content and marking of the examination, or with the conditions under which the test is taken
• Though RCPath has taken in feedback from their examinees and seen an increase in pass rates, for many issues, no clear way forward has yet been agreed

In order to enter the Greek underworld, the souls of the dead must first pass through its gates, which are guarded by the multi-headed hellhound Cerberus. The discipline of pathology in the United Kingdom is much the same – only in this case, Cerberus takes the form of the Fellowship Examination of the Royal College of Pathologists (FRCPath) Part 2.

Many young pathologists would agree that the hound, with his serpent’s tail, mane of snakes and lion’s claws, is an appropriate representation of the FRCPath Part 2. The exam consists of surgical pathology, diagnostic cytology and autopsy in various formats over the course of two days (1). It’s designed to test the limits of your ability – the Royal College of Pathologists (RCPath) states that “the overall aim of the examination for medical trainees is to provide external quality assurance that a trainee is on course to […] practice as an unsupervised specialist in the specialty.” But some feel that the exam isn’t a fair test of trainees’ abilities, and others are concerned that it may be adding to a shortage of pathologists that is already impacting patient care (2). One senior pathologist says, “The numbers that are coming through are not high enough. There have also recently been problems with the exam; they were getting 20-odd percent pass rates, which was making a big backlog of trainees that weren’t coming through the other side.” In fact, RCPath is aware of the issues, acknowledging in a statement that “in December 2013, a survey was commissioned by the Histopathology College Specialty Training Committee (CSTC) following concerns about the declining pass rate in the FRCPath Part 2 examination in histopathology. Over 400 College members replied to the survey, including over 100 trainees.”

Unfortunately, both trainee and consultant pathologists continue to express concerns about the test – its structure, its contents and its administration. One trainee, Christine Evans, spoke for many, saying, “I can’t hope to figure out how many hours we’ve all spent complaining, crying and stressing over this exam. The worst part is realizing that it does not test us as pathologists. It tests whether we can pass an exam; whether we know the tactics for passing.” They described the effect the test and its poor pass rates – historically as low as about one-fifth of test-takers in some cases – have, not only on the pool of new consultants, but on the expectations of the trainees themselves. “It means absolute heartbreak,” Evans says. “Realizing that one could function perfectly well as a practicing pathologist, but the exam is not representative of real life, where you don’t sign out in a vacuum. In real life, you talk to colleagues, clinicians; you don’t rush things. With the exam, we’re expected to come to a definitive diagnosis in most cases. And in 10 minutes. Based on one representative slide.”

Investigating infrastructure

One major problem these young pathologists have is with the testing infrastructure itself. Trainees face not only the costs of sitting the examination, but also the expense of travel and accommodation on short notice when they learn to which testing site they will be assigned. A trainee from outside the UK points out that “for those who have to travel from outside the country, this is inconvenient, at best, and prohibitively expensive at worst.” According to RCPath, the intent is to provide candidates with at least six weeks’ notice of examination dates and venues, but they include the caveat that this is not always practical. “Where an examination is offered across multiple centers, a number of logistical factors need to be taken into consideration to avoid conflicts of interest between candidates and examiners.” Because there are limitations on where candidates are permitted to sit their exams, and on where the exams can be held – for instance, in smaller specialties where exams can’t be organized until there are enough candidates, or in larger ones where candidate numbers must be finalized in advance in order to find a large enough venue – it may not always be possible to provide candidates with six weeks’ notice of their exam location.

It’s not just the travel expenses that frustrate candidates, though; tales of unfortunate testing circumstances abound. Many trainees have complained about the quality of the microscopes provided at exam sittings, or about the difficulty of bringing their own, especially if traveling from overseas to some of the more remote locations within the UK. One trainee reports, “There was one autopsy exam that started an hour late because they lost some of the exam cases and were still setting up the furniture.” Another had a horror story of “the time when it was in a hotel, next to a busy room in which there was – I kid you not – some kind of bell-ringing demonstration. While the door kept opening and closing.” Situations like these haven’t escaped the attention of the College though. “Whilst every effort is made to ensure the suitability of external examination venues,” they explained, “we realize that there are occasionally events which occur on the day which create less than ideal examination conditions for the candidates and are out of the control of the examination organizers.” This may be of little help to candidates sitting those examinations, but at least they can be reassured that, if enough of them make RCPath aware of the issue, they can avoid future problems with those testing locations. “Depending on the level of concern raised by this,” the College says, “it may be that that venue will not be used as a center again.” If pathology trainees are truly concerned by the conditions under which they sit the FRCPath Part 2 exam, it seems that the best course of action is to present a united front when raising those concerns with the College – the more candidates speak out, the better their voices can be heard.

Geographic discrepancies?

There are also differences in the ways various countries train their pathologists, which can have a knock-on effect on those candidates’ chances of success in the FRCPath Part 2. Jemima Renner, a pathologist from Ireland, reports, “There are significant differences in training between the UK and Ireland, and I believe a lot of this has to do with the difficulty of the exam. UK trainees are encouraged to sit the exam after four years, while Irish trainees are sitting it after five years or more.” She further comments, “UK training seems almost entirely exam-focused. They perform some limited service-work, but the consultants perform most of the day-to-day work, following up cases and going to multidisciplinary meetings. I was very taken aback to learn that you can successfully complete your training without ever attending a multidisciplinary meeting.” This raises the concern that simply passing the exam does not, in and of itself, prepare trainees for the reality of working as a consultant. Renner says, “Irish training is almost entirely service-focused. Irish trainees are essential to the day-to-day running of a lab. In most labs they perform all cut-up, all postmortems, have all cases screened with a provisional report composed before consultant review, and follow up all additional investigations to completion. They prepare and present multidisciplinary meetings. Unfortunately this is at the expense of exam preparation. No exam courses are provided. Centers routinely refuse study leave in order to prioritize service provision. So an Irish trainee struggles to learn the exam techniques needed to pass the FRCPath, even if they are competent and confident with the lab‘s daily workload. Make no mistake, passing the FRCPath involves exam techniques that cannot be learned during routine reporting. The exam should only represent one aspect of becoming a well-rounded, competent consultant. I think the difficulties in passing have skewed training priorities, particularly in the UK.” This sentiment is not unique to trainees from Ireland; Evans says, “A friend of mine who continued her training in the US said that she’s relieved she never had to sit the FRCPath.” When asked whether American training is easier, she replied, “Easier is maybe not the word, but fairer, perhaps.”

Questioning content

Many trainees see problems with the way the FRCPath Part 2 exam is structured – but that doesn’t mean that the content is flawless. Cytology was a popular target for complaints; Evans observes that “the cases in recent years have been incredibly difficult and cytology is not practiced by all pathology consultants. The emphasis on passing cytology seems disproportionate, especially when the case number is so small. I don’t think that’s a fair test of anyone’s cytology skills.” Another trainee disagrees with the choice of cases, commenting, “They say that it’s not supposed to be esoteric stuff and yet an examiner once commented that he hadn’t seen an example of a particular case for over twenty years.” Though cytology received the bulk of the attention, one pathologist raised concerns about the autopsy component of the test, and about students’ preparation for that section. “In Ireland you cannot practice as a consultant histopathologist without the autopsy part,” Roberta Downey says. “In the UK it is not necessary now because of the shortage of pathologists in general, and the thinking that a lot of pathologists dislike autopsy. There is a huge emphasis on the surgical and cytology components of the exam as it is. I believe the autopsy component is often overlooked. Because it is now an option, the exam is becoming more difficult to pass as only people who ‘like’ autopsy will sit it in the UK. We all have to sit it in Ireland, and training needs to be provided with this in mind.”

There’s some doubt as to whether this criticism is fair, though. In response to these and other statements, RCPath states that “the selection of the cases to be used in the Part 2 examination is the responsibility of a panel of experienced examiners, including specialist and general diagnostic pathologists. Cases are not accepted unless there is consensus that they provide an appropriate basis on which to determine whether or not a candidate is able to demonstrate a safe approach to diagnosis and management.” Additionally, there was extensive discussion of a potential modularization scheme that would allow candidates to sit, or to pass, different sections of the test at different times. Referring to the survey commissioned by the Histopathology CSTC, the College says, “The survey found that there was support, although not universal, for a degree of modularization of the exam. In particular, many respondents wanted histopathology and cytopathology to be separated for examination purposes. A number of options were discussed including complete separation of diagnostic cytology from histopathology with independent examinations. However, it was felt that this would be inappropriate and that competence should be demonstrated in histopathology and cytology contemporaneously.” The suggestion that a pass in one section could be carried forward to the next sitting was raised, but will require consideration of many factors (including part-time trainees, overseas candidates, and administrative and logistical arrangements) before any plans for this kind of modularization can be made – especially as, in order to ensure parity between examinations, the College must then consider modularizing all 19 of the specialties in which the FRCPath tests are offered.

Mastering marking

“I would suggest,” says Downey, “that modularization is a step forward, but the marking system needs to be overhauled to facilitate a real improvement.” This sentiment was met with great accord by trainees and consultant pathologists alike. Though the original intent of the closed marking system was to allow marks ranging from 1.0 to 4.0 for a single surgical short case (3), Renner doesn’t feel that this truly applies. “In practice,” she says, “the examiners decide whether they feel a case is ‘easy’ or not. If they think the case is simple, they move the maximum mark obtainable to 2.5, a bare pass, or 3.0. However, if you get the answer wrong, the lowest possible minimum mark remains at 1.0. Essentially, a closed marking system within a closed marking system has been introduced, which is obviously unfair and ridiculous. Why have these cases at all unless they are all subject to the same marking system?” Her words are strong, but supported by others – one trainee, for instance, says, “I understand, intellectually, the reason for closed marking; it’s critical to get pathology diagnoses right out in the real world – but there is something deeply demoralizing when you realize that merely getting a correct diagnosis will give you a bare pass and, in some cases, it is impossible to get more than 2.5 out of 5.” Renner adds yet another concern in that candidates aren’t informed of which cases are capped at a maximum mark of 2.5, so they are unable to allocate their testing time accordingly.

It’s important to note, though, that RCPath doesn’t make a monolithic decision as to how each case will be marked – rather, the panel responsible for selecting the cases prospectively decides the model answers and marking schemes. Two examiners mark each paper independently against the agreed marking scheme, and the papers are then independently moderated by a third and possibly even fourth examiner if there’s a significant discrepancy between the original two marks, or in the case of a borderline fail. Where candidates are very close to a pass, the College assures them that every effort is made to scrutinize the marks to ensure that the correct result is given. Though the FRCPath Part 2 has suffered from historically low pass rates (3), things in that respect may be looking up – the pass rate for the most recent set of exams was 68.6 percent.

In examinations set by RCPath, candidates are not provided with detailed information about their results. Nor are they permitted to make appeals that challenge the academic judgement of the examiners, an unpopular policy but one in line with those of other royal medical colleges. (More information on RCPath’s complaints (4) and appeals (5) procedures can be found online.) But the complaint and appeal systems, too, are a source of unhappiness for trainees anticipating the exam, with one commenting, “Even secondary school exams have the right to appeal. The lack of transparency is just one of many worrying things about the setup.” Candidates worried about the impact of this policy on borderline marks – one, having failed the surgical section by a single mark, was unsatisfied with the lack of information provided to explain the result. “If you fail, you’re told which components you’ve failed – which is only a recent development. You get a comment on whether it was a narrow fail or a big fail. And now, through your trainer, you can get a breakdown of your marks. But it’s numbers, not helpful comments. The advice I was given in my generic failure letters: needs more experience in x, where x is dermatopathology or cytology or something along those lines.” Clearly, pathologists who take the test are concerned about the level of transparency provided by the College – and perhaps, with more detailed information about exam results both good and bad, trainees might sit fewer times and be more satisfied with the procedure as a whole. “They say that repeating the exam makes for better pathologists,” says Evans, “but I disagree. It’s made me angrier, sadder and poorer, but I don’t think it has made me better.”

Facing the future

It’s clear that pathologists – both those who have found their way to Elysium and those who have yet to cross the river and gain entrance – have strong feelings about the FRCPath Part 2 examination and would like to see it change in the future. Their ideas are fairly solid, too. Many would like to see the exam modularized, the cases more reflective of everyday lab work, and the marking system reformed. They’d like to have better opportunities to appeal unfair results. And they’d like to be able to get a firmer grip on the test procedure itself – where they’ll be going to sit their exam and what they can expect to find on their arrival. At the moment, though, progress isn’t without its stumbling blocks. RCPath has discussed the outcomes of the Histopathology CSTC survey at length, but has stated that “any changes to an examination system of this nature must be approved by the General Medical Council, who have specific time frames for these submissions. At present, no clear way forward has been agreed, and until we are confident that a fair, feasible and workable solution can be submitted for consideration, the examination will continue in its current format.”

Hopefully, the changes will come soon enough for today’s pathology trainees, whose frustrations are beginning to build. “If someone told me tomorrow that I could give up pathology and medicine and still be financially secure,” says one young pathologist, “I’d do it without a second thought.”

* Please note that those interviewed wish to remain anonymous, hence their names have been changed for the purpose of this article.