New Horizons in Histopathology Training

No matter where in the world you live, histopathology training is demanding. It requires high-quality laboratory machines with regular maintenance and replacement, regular deliveries of quality laboratory supplies, thousands of specimens (ideally showing a wide variety of disease processes in detail), a carefully constructed curriculum with well-defined competencies, an adequate number of competent educators with subspecialty training, hospital settings with multidisciplinary team meetings, and satisfactory salaries for all working personnel. Histopathology training bodies in countries with limited resources face huge challenges in providing and improving training despite the frequent inadequacy of their settings.

The Kitchener School of Medicine was established in Khartoum, Sudan, in 1924. Thirty years later, it was renamed the Faculty of Medicine and became part of the University of Khartoum (U of K). In 1976, the Medical Graduate Board (MGB) was established under the umbrella of the Faculty of Medicine and, four years later, the school saw its first pathology training offering – a Master’s degree in the field. The four disciplines (yes – at that time, pathology had only four branches!) were studied in two years. Later on, training was extended to three years and, finally, to four.

Today, that degree program grants its students a full MD. Trainees study the four branches of pathology during the first two years. For the final two years, students narrow their studies down to only two subjects. But even that can sometimes be too much, and it has become increasingly clear that single-discipline pathology training is essential. Many times, the pathology training board at the U of K has proposed a pathology training program with a single specialty taught over four years. It’s a move that mirrors international trends, and one that follows the recommendations of the Royal College of Pathologists team that visited Sudan in 2006.

By the year 2002, a new training body for medical specialties had been established: the Sudan Medical Specialization Board (SMSB). All of the clinical specialty programs joined the new body – or rather, all but one. Pathology, with the dual identity of being both a basic science and a clinical speciality, had its training confined to the Faculty of Medicine, along with other medical basic sciences. Despite the relegation, rapid global development of pathology as a clinical specialty with many subspecialties has prompted pathologists in Sudan to favor their clinical identity over basic science.

The year 2017 was a landmark for Sudanese histopathology training. On August 24th, by a decree from SMSB, the Histopathology Training Board was established: the first time Sudan had ever had a unidisciplinary program for histopathology alone. The draft curriculum was prepared by experts in pathology training and medical education, and David Bailey – Vice President for Communications at the Royal College of Pathologists – was invited to visit Sudan to supervise the curriculum revision workshop and conduct inspection visits to the proposed histopathology training centers. The final curriculum for the histopathology MD program was approved by the SMSB on 15 March 2018, and the first batch of histopathology trainees will sit the entry exam on 30 June 2018!

A good situational analysis of the country’s previous histopathology training systems will provide a strong start for the new program. And there are plenty of positives: Sudan has 38 years of pathology training experience at both the U of K and Gezira University (which established a similar training program in 1993). Dozens of practicing histopathologists have graduated and are providing good service within the country and abroad. Senior pathologists who have worked in the rich Gulf countries have now returned home and are contributing to training that meets international standards. Efficient inter-institutional cooperations have been set up between medical schools, private laboratories, and the government, so that trainees can benefit from being exposed to a wide variety of experiences. We also have good international collaborations, gained through our participation in histopathology events. The Conference of the Arab Division of the International Academy of Pathology was held in Khartoum in 2012; even then, the international guests were impressed by the activity and eagerness of Sudanese pathology residents. Meeting with pathology educators and trainees from different countries opened new horizons for improving our own training. Sudanese pathologists trained abroad are now also providing services and training at home, allowing us to benefit from other countries’ experiences.

Moreover, we can also gain knowledge without the need for far-ranging travel. The availability of online histopathology resources – especially virtual microscopy – has brought practicing histopathologists living in areas with limited resources up to date with most new developments (in histology, immunohistochemistry, molecular pathology, and more).

On the other hand, the new histopathology training program faces great challenges: limited laboratory infrastructure, limited centers for immunohistochemistry and molecular diagnosis, limited scientific research activities, the urgent need to train the educators themselves, the lack of subspecialists in the field, the lack of autopsies, and – possibly most worrying of all – the absence of quality control measures and auditing in most Sudanese histopathology laboratories. No institution is involved in any form of accreditation program. Tumor boards and multidisciplinary team meetings are scattered and irregular.

It’s clear that there’s a lot of work yet to be done. After all, the new Sudanese histopathology MD program is just the first step on a long road to better training and, ultimately, better services for our patients.