Immersive Pathology Experiences
Creating a realistic perception of pathologists to medical students
Shivayogi Bhusnurmath, Bharti Bhusnurmath | | Longer Read
Many medical students still perceive pathologists as hermits in the basement of a hospital – screening slides, assigning diagnostic labels, and sending reports up to the wards for the clinicians to manage patients. This perception leads students to believe that pathologists have no patient contact and are more like basic scientists than clinicians – having little or nothing to do with actual patient management. Could this be the reason behind the general disdain for pathology careers among medical graduates?
Unfortunately, many medical school educators themselves hold this view of pathology, making it difficult for their students to envision the exciting life of a pathologist in patient management and the advancement of medicine. In our quest to improve perception of the field, we have taught medical students across several countries over the past four and half decades and have tested a number of methods. Based on the opportunities within each curriculum, we varied the steps and our approach at different medical schools – but the scope is wide enough to offer something for everyone.
1. A two-week rotation in the pathology department. Every student had a posting in pathology during their rotation. On day one, each student was taken around the histopathology, cytology, immunology, hematology, and electron microscopy labs and were tasked with writing up 10 patient stories on the samples processed in these labs during their posting. They had to discuss with the medical technologist the process of preparing slides, making a diagnosis, and justifying it; study the slides; and discuss interesting samples with the consultant. They then went to the wards or outpatients to study the case files, examine the patients if they were available and consented, and note down their observations and clinical summary. Finally, they completed a write-up on the clinical problems that needed to be addressed based on the signs and symptoms and explained how the laboratory test results helped finalize the diagnosis and patient management decisions. The logbook was scrutinized and signed by a pathology faculty member to signify successful completion of the rotation.
2. Observing procedures with patient contact. Students posted in the pathology department accompanied us to the wards and outpatient departments when we performed fine needle aspiration (FNA) cytology on the lumps and bumps identified in patients. The students examined patients, studied case files, and observed us performing FNA. They then returned to the pathology lab with the slides, observed the staining, and joined us on a multiheaded microscope to learn about sign-out. We believe they appreciated the patient interaction and the short time it took us to solve clinicians’ diagnostic dilemmas and enable appropriate patient management.
3. Attending biopsy rounds. Students attended the biopsy rounds we held with teams from hematology, surgery, internal medicine, pediatrics, and obstetrics and gynecology on multi-headed microscopes. In these sessions, our colleagues presented the clinical features, differential diagnosis, and reason for the biopsy or cytology; we presented the biopsy and explained the diagnosis. The sessions reinforced pathology’s vital role in the clinical care team.
4. Weekly clinicopathological conferences. Exploring cases chosen by pathologists, these were attended by faculty, residents from all departments, and medical students. The take-home messages the sessions illustrated created excitement and interest in pathology among the students.
5. A one-month pathology elective for final-year medical students. This was especially designed for students planning to apply for pathology residency. The activities included rotation through a pathology diagnostic lab, participation in teaching small groups, reviewing collection slides with professors, a weekly review of a published article in a peer-reviewed pathology journal, and a detailed write-up (with literature review) on five cases they encountered in the lab.
6. Designing learning objectives in pathology small group sessions, starting with altered morphology and function to create clinical vignettes. Students were given pathology images and had to individually fill out a rubric, followed by a presentation of their write-up to the group under the mentorship of a trained preceptor. The rubric consisted of identification of the organ or tissue (a recap of anatomy and histology), description of any abnormalities and, based on the structural alterations, a suggested diagnosis. Students then had to imagine the patient from whom the lesion was taken, consider their altered functioning (physiology), and suggest three signs and symptoms they might be experiencing. After this, they suggested three laboratory tests (physiology, biochemistry, immunology, and microbiology) that could help confirm the diagnosis and suggest important associations and possible complications. Finally, they wrote up a clinical vignette with a multiple-choice question on etiology, pathogenesis, altered morphology, clinical features, lab investigations, and complications. By the end of the 16-week course, each student had generated 400 clinical vignettes based on images through this rubric. This exercise demonstrated that the entirety of clinical medicine is based on a sound knowledge of pathology.
7. Exploring clinical cases. Students were given 120 brief clinical cases with built-in short-answer pathology questions to work through during the 16-week course. They were required to discuss their answers in small group sessions under the mentorship of a preceptor. This was another exercise that emphasized the necessity of applying the principles of pathology to analyze and solve clinical dilemmas.
8. Modified exams. Test items for midterm and final exams were almost exclusively designed to use pathology knowledge to solve clinical situations – and rarely required only recall of information.
9. Modified essay questions. We provided students with about 10 questions each week for self-study. The questions laid out clinical situations and asked students to write solutions in one or two words. If more than two words were included in the answer, they scored zero. This encouraged students to think critically and move away from multiple-choice questions – thereby excluding guesswork and more closely mimicking real-life situations.
10. Teaching lab situations using real patients with chronic diseases. Students were encouraged to take a history of the patient and, by rotation in groups, ask them specific questions. After all questions were exhausted, the patient was asked to leave. Each student group was then asked to justify their choice of question and what they learned from the response. In the end, the faculty steered students toward suggesting lab investigations to encourage them to apply their knowledge of pathology to patient situations.
11. Analysis of clinical vignettes to explain basic science concepts. In the pathophysiology course that followed pathology, we designed lecture sessions such that multiple clinical vignettes were presented and the students had to analyze each component (symptoms, signs, lab investigations) using knowledge acquired in basic science courses. They had to provide the possible differential diagnosis for each component and select the most appropriate one with justification. This was, in a way, the opposite of the pathology course in that students used altered morphology to create a clinical vignette. Employing pathology and pathophysiology sequentially prepared the students to think “up” as well as “down” to link pathology and patient problems. This created greater interest in pathology as a decision-making platform for everyday clinical analysis, solutions, and patient care.
In recent years, about 20 students from each class have opted to become pathologists in the US medical system. If pathology educators function as clinicians in their teaching and direct students’ learning and assessments toward pathology as the basis of clinical medicine, it should be possible to negate pathology’s negative stereotypes and motivate more medical students to consider a career in our field.