Pathology in the East and the West

In January 2017, we spoke to pathologists from Europe and North America, asking them to compare their regional approaches to pathology. The result? A wealth of discoveries about how lab medicine is different on both sides of the ocean, how it is the same – and what lessons each continent can learn from the other.

But what of labs in other parts of the world? The similarities and differences stretch from early education all the way to routine pathology practice – and there is much to be gained from a better understanding of our peers across the globe. To that end, two pathologists who have trained in India and practiced both there and elsewhere share their experiences, contrast the different regions in which they have practiced, and explore what can be gained from adopting one another’s approaches to the discipline.

Shivayogi Bhusnurmath is Dean of Academic Affairs and Co-Chair, Course Director, and Professor of Pathology at St. George’s University, St. George’s, Grenada, West Indies.

Dhaneshwar Lanjewar is Professor of Pathology at the Gujarat Adani Institute of Medical Sciences, Bhuj, India, and Overseas Advisor to the Indian College of Pathologists.

What inspired you to become a pathologist?
Shivayogi Bhusnurmath: I trained in medicine at Bangalore Medical College during the late 1960s and early 1970s. At that time in India, the only “reasonable” options for high-performing students were engineering and medicine – and parental pressure played a major role in career decisions. Because of my academic successes, I had the option of direct admission to either medical school or the Indian Institute of Technology. I opted for medicine because that’s what my friends chose, and I wanted to stay with them. At the time, I was too young to consider the broader ramifications of my choice.

In my second year of medical school, I was bored; I was tired after 18 months of anatomy study; the faculty seemed more interested in torturing than inspiring us. Then I read The Final Diagnosis, by Arthur Hailey – and it was a major turning point in my life. The book’s central character was a chief of pathology and I was impressed by the role he played in critical decisions. A young nurse’s limb amputation due to suspected osteosarcoma; an epidemic of enteric fever; the autopsy that revealed unexpected incidental tuberculosis and prompted the screening of an entire family… These examples are still etched in my mind after five decades. Like the pathologist in the novel, I wanted to be a central figure in clinical decision-making. My intrigue only deepened as I read more pathology texts and learned more about the mysteries of the human body – but the final strike came when I met our head of pathology, Krishna Bhargava, who taught the subject with abundant real-life stories and encouraged active discussion about specimens in the pathology museum. In those days, many clinical questions ended with “maybe, maybe not” – so my drive to eliminate medical uncertainties made pathology a natural choice. 

When I finished my internship, I wanted to pursue a pathology postgraduate program. At the time, candidates had to do one year as a house surgeon in medicine and surgery first – but I was fortunate to have Krishna Bhargava as hospital director. He created a new position at Bangalore’s Victoria Hospital – house surgeon in pathology – and I was the first inductee.

In June of 1974, I learned about the Postgraduate Institute of Medical Education and Research in Chandigarh, which had a great pathology training program. One of my friends had procured an application form (not an easy thing those days due to poor communication facilities), but the deadline had passed. As I read the application out of interest, I discovered that there was still one deadline I could meet: direct admission into a PhD program in pathology. The application asked me to explain how I qualified as an “exceptional candidate.” My naïve response? “Please consider me exceptional because I am greatly interested in pathology and nothing else.” Little did I know then that the Dean in charge of admission exams and interviews was Basant Kumar Aikat, who was also the chair of pathology. He saw my interest for the subject and sent me a telegram that stated, “We regret that we have stopped direct intakes into the PhD program. If interested in the MD Pathology program, we could transfer your application to that pool.” I immediately replied, “Please do.”

The next month, I traveled to Chandigarh, an arduous three-day journey by train and bus, to appear for an entrance exam. My high performance in the entrance examination earned me an interview the next morning. That’s when I lost all hope; India’s culture of favoritism at that time meant that selections were rarely merit-based, and I had no “connections” in this unfamiliar place. When I arrived, all the candidates were seated in a lecture hall, facing two serious-looking senior professors. They called the candidate with the highest merit rank, asked him which discipline he wanted, and directed him to pay his admission fees at the door. That was it. No subject questions at all. I had never seen such fairness!

When my turn came, I said I had applied for pathology. One of the professors (who I later learned was Pran Nath Chuttani, the director of the institute and a professor of medicine) reminded me that, because of my exam score, I could choose any discipline I wanted. When I told him I wanted pathology, he thought I hadn’t understood. Slowly and deliberately, he repeated, “I know you applied for pathology but, because your score is high, you can take any subject. You don’t have to choose pathology.” I said, “I applied for pathology because I am interested in it. Why are you forcing me to join some other program?” He gave up, thinking me a hopeless case. I did not realize then that the gentleman sitting next to him was B.K. Aikat himself – and that he was impressed with my determination to pursue his discipline!

My career has afforded me many opportunities to work outside India. I worked as a lecturer-consultant at Ahmadu Bello University in Zaria, Nigeria, from 1982 to 1985. The HIV/AIDS epidemic was just beginning, and we knew nothing about it – but I remember, while introducing fine needle aspiration cytology, experiencing accidental needlestick wounds and living in fear for many years because there were no diagnostic tests and no treatments available. Fortunately, I escaped infection. I also worked in both the United Kingdom and Japan in the late 1980s and in Canada and Oman in the early 1990s. My final move (so far) was in 1996, when I arrived at St. George’s University in Grenada, West Indies. In India, I had the good fortune to attend almost all of the annual pathology conferences, become secretary of the Indian Association of Pathology and Microbiology, and establish the Indian College of Pathology (becoming its founder fellow and founder secretary) during my tenure.

Dhaneshwar Lanjewar: I was born into a lower-class labor family in Pulgaon, Maharashtra, India. Life in Pulgaon was difficult and there were high rates of poverty and illiteracy. My parents were uneducated and my father had married my mother when they were 15 and 12, respectively. My father died when I was one year old and, because my mother did not remarry, she bore full responsibility for her three sons. She worked very hard – first on the farms and later in the textile industry – so that all of her children could receive a good education.

I matriculated in science in 1969 and wanted to attend a science college. Pulgaon had no such institution and the college in nearby Wardha had a 200-rupee admission fee – too much for my mother. Instead, I traveled hundreds of kilometers to Aurangabad, where a science college for socially and economically disadvantaged students charged me a single rupee to study biology (and to teach me about my social responsibilities and obligations). Eight years later, I held degrees in both biology and medicine, had just married, and was planning to set up a general practice in Pulgaon. I had never imagined taking a postgraduate position – but, when I went to Aurangabad to collect my medical degree, I spotted a notice on the wall advertising a one-year resident pathologist post. I have no idea what came over me, but I applied – and I got the job. From there, my path was set.

In 1985, I accepted my first position at Grant Medical College in Mumbai. Founded in 1845, the school is one of the oldest institutions in Asia. The pathology department, now 140 years old, has housed many of the country’s pre-eminent laboratorians and has contributed significantly to the discipline’s growth in India. When I joined Grant Medical College, Ulhas Laxman Wagholikar was chair of the department; his extensive experience in clinical autopsy and gross pathology made him an excellent teacher and inspired my interest in autopsy.

In June 1988, I performed my first autopsy on a patient with AIDS. The histopathological findings showed opportunistic infections in 18 organ systems – something none of us had witnessed before. That case was the start of a 22-year career in autopsy. My fascination spurred me to work 10 or more hours a day – and that eventually resulted in my promotion to chair of the department, as well as a number of leadership positions in the Indian Association of Pathologists and Microbiologists and the Indian College of Pathologists. Although I retired in 2016, I still serve as overseas advisor to the Indian College of Pathologists.

What does the average workday look like for you?
SB: For the past 25 years, the bulk of my work has involved teaching medical students. With my wife, Bharti Bhusnurmath (also a professor of pathology), I created a unique program called the International Clinical Tutor Teaching Fellowship Program. It started with four recent medical graduates who lived locally, but we now recruit recent medical graduates from across the globe to help us run small groups in our teaching lab. Our course is taught twice a year – involving over 900 students each time – and students come from over 130 countries to join us. We are lucky to have them; although my wife and I (the only full-time pathology professors here for most of our 25 years) could handle lectures for a class of any size, we need high-quality preceptors when we split the class into groups of eight to 10 students for applied clinical learning in the laboratory sessions.

My morning begins with two hours spent training these clinical tutors on the lab exercises for the day, followed by two hour-long pathology lectures for the second-year medical students (which the clinical tutors also attend). After a lunch break, we have four hours of teaching lab sessions, whose preceptors are the clinical tutors we have trained. My wife and I move between small groups, overseeing discussions and assisting if needed. Finally, we meet informally with the tutors at the end of the day to tackle any unresolved issues they have faced in their groups.

I also have administrative duties during the day: faculty and staff recruitment, budget, faculty development, performance assessments, curriculum development, test item generation, item banking, administration of tests, item analysis, and more. I sit on the School of Medicine’s curriculum committee, the committee on academic progress and professional standards, the committee for technology in teaching, the graduation assessment board, the council of deans, and handle tasks including self-study documentation for accreditation, site visits to various international campuses, and one-on-one advising for students who are experiencing difficulties.  The diagnostic services work comes later in the day! We process 60 to 80 patient samples per day – mainly in clinical chemistry and hematology, but we also perform fine needle aspiration cytology and sign out surgical biopsies. Where do we fit this work in? Some of it during our lunch break; the rest after our educational duties are finished for the day.

The cases I see here in Grenada are different to those common in India. Here, I see a lot of sickle cell disease, diabetes, hypertension, human T-lymphotropic virus-related lymph node pathology, prostate and breast carcinoma, dengue, thyroid problems, and seasonal flu following the carnival in August (which brings in a lot of international visitors). In Chandigarh, I saw a lot of liver disease – Indian childhood cirrhosis, Budd-Chiari syndrome, veno-occlusive disease of the liver, non-cirrhotic portal fibrosis, Wegener’s granulomatosis, and alcoholic liver disease (many cases of which may in retrospect have been non-alcoholic fatty liver disease, which was at the time unknown). In Muscat, I saw a lot of Helicobacter pylori, systemic lupus erythematosus, lupus nephritis, and gastric carcinoma.

I also saw a case of Budd-Chiari syndrome in a bear owned by His Majesty the Sultan of Oman and cardiomyopathy with granulomatous lesions in his ostriches!

DL: After my retirement, I joined the Gujarat Adani Institute of Medical Sciences as Professor and Head of Pathology. My workday starts with postgraduate teaching – slide seminars, subject seminars, journal clubs, and discussions over surgical specimens. The rest of my morning is spent signing out surgical pathology cases and discussing thesis projects with residents. After a lunch break, I host lectures and practical classes for second-year medical students two afternoons per week and guide residents as they assist with practical teaching. Every day also features a wealth of administrative work!

The most common cases I see are thyroidectomy, appendicitis, cholecystitis, mastectomy, gastrointestinal resections, splenectomy, hysterectomy specimens, ovarian tumors, placenta, and limb amputations. I have seen a few unusual cases, though…

How does the day-to-day work of a pathologist in India differ from that of a pathologist in North America?
SB: It seems to me that there is much less emphasis on quality control in India, especially in private laboratories. In academic institutions, there is less emphasis on research; although publications matter, their reliability is questionable because of the pressure for promotions and the lack of reliable data. The teaching commitments in India in academic institutions tend to be greater, but – unlike in the US – India has no requirements for recertification or continuing medical education.

There is also much less fear of litigation in India. Many private pathology labs participate in “cut practice” – otherwise known as kickbacks. Referring physicians request more tests than the labs perform, and the overpayment is split between the two. It is difficult to determine the extent of this practice, of course, because it is done under the table and no records are kept. Such practices are rare in North America – perhaps because computerized reporting and shared records are common. This also means that India has fewer consultations by extramural experts, fewer referrals to specialized laboratories, and less use of “checklist”-style reports with ICD and billing codes. Most Indian pathology reports are descriptive and contain few or no codes.

DL: In teaching institutes in India, pathologists manage the clinical laboratory, surgical pathology, cytopathology, frozen section, and autopsy – as well as training and examining undergraduate and postgraduate medical students and those studying to become laboratory technicians. We also have administrative responsibilities.

In private practice, things look a little different. There is no registration or regulation of private pathology laboratories in India – so although some are run by qualified pathologists, many more are led by technicians without medical qualifications. Most laboratories in the country are illegal – by which I mean that the reports they generate do not bear the signature of a qualified pathologist. In private laboratories, 95 percent of the workload is clinical pathology and clinical chemistry; only 5 percent is histopathology – a stark contrast to the US, where most private pathology practice is focused on histopathology.

How does training differ between the two regions?
SB: Training in India is not uniform, but there are three main pathways. The most common is to register as a postgraduate trainee at a medical school. This involves paying tuition fees, attending lectures, and sometimes supervising medical students in labs – but not participating in daily sign-outs. After three years, the program concludes with exams and a dissertation. The second route is through a postgraduate residency program, available only in a few high-end institutions. The (paid) residents rotate through different sections, do grossing, and sign out cases with the faculty. This program is intensive, and residents are involved in the routine management of patients. To finish, they must write a dissertation. The third route involves working in the pathology department of a recognized hospital and taking a national examination conducted by the National Academy of Medical Sciences.

The first two routes result in a medical doctorate in pathology; the third results in the title of Diplomate of the National Board. Nonetheless, all three are considered equivalent for employment purposes.

The quality of training and exams varies considerably among institutions but tends to be better in residency programs. Personal bias and favoritism plague private institutions and university departments, making it easier for popular trainees to do well in their exams and have their dissertations approved. Postgraduate programs also have little national oversight to ensure uniform training and exam standards. Several departments lack facilities for molecular pathology, immunopathology, electron microscopy, medical autopsies, flow cell cytometry, and more – so trainees advance with no experience in those fields. Many departments receive very few representative biopsies from various subspecialties because clinicians send them to private labs for better diagnostic help (or kickbacks), so trainees have limited exposure to cases. There is also little effort to teach laboratory quality control, quality assurance process, and accreditation. Ultimately, the exit exams are poor indicators of readiness to function as a consultant or attending. Most training has one goal: to enable students to attach diagnostic labels to slides.

Unfortunately, there is little impetus to ensure equal opportunity for trainees across India. Leaders in academic pathology have a fair idea of which institutions offer the best training and which are unreliable training facilities; however, there are few concentrated efforts to improve national standards so that all trainees have reasonable access to broad-based, high-quality training. Such a goal could be easily accomplished by cooperation between institutions, national oversight committees, tapping of interested academics in India and abroad who want to contribute to education, and making use of online platforms for education – so I often question why matters have not yet improved.

In North America, the system is very structured. Pathology training is residency-based, overseen by national boards, and involves stringent requirements for the length and breadth of training. There are mandatory sessions for journal article reviews, tumor boards, in-service exams, and final national exams that are well-supervised, well-audited, and completely objective. That is not to say that these programs are perfect; variability remains in the quality of faculty and residents, in entry requirements, and in the emphasis on research and academic activities.

Both regions share four major deficiencies:

1. There are no learning objectives related to professional behavior and communication skills. We try to emphasize this in the training of medical students; it is worthwhile to consider in resident training as well.
2. Little attention is paid to training and testing in the general principles of pathology – a crucial pillar of both our work and medicine.
3. There is little training in how to select laboratory investigations in different clinical scenarios and in intelligent interpretation of test results. Many physicians today are comfortable just clicking on a battery of investigations available on the computer screen without critically reasoning why each one is needed and how the results will aid diagnosis. This increases healthcare costs and can result in unnecessary treatment of asymptomatic patients based solely on abnormal lab values.
4. Both regions must rapidly incorporate digital pathology and artificial intelligence into training programs, lest we be left behind as these trends sweep medicine.

DL: The Medical Council of India regulates the country’s postgraduate pathology training. After medical school and a one-year internship, students may take an entrance examination to qualify for postgraduate study. The three-year program takes the form of postings in various assigned sections, 20 lectures per year (delivered by senior faculty), and activities such as slide seminars, symposia, group discussions, and journal clubs. Resident pathologists rotate through surgical pathology and autopsy (12 months), hematology and laboratory medicine (10 months), cytopathology (eight months), transfusion medicine/blood bank (two months), archiving and record management (one month), and immunopathology, electron microscopy, molecular pathology, cytogenetics, and research methodology (two months in total). Residents must submit a thesis, present at least one poster and one oral paper at a national or state conference, and publish at least one paper during the program to be eligible for the final examination. They must also maintain a logbook, which is periodically assessed, to record their work. Finally, they must teach undergraduate students. The idea behind the program is good, but it has some flaws; for instance, there is no designated person in charge of the program to monitor residents’ performance, and most residents don’t get adequate autopsy training because many institutes don’t conduct clinical autopsies. 

In the US, training requirements are defined by the American Board of Pathology, which examines and certifies pathologists at the end of their training. There is also an official Director of Residency Program in every institution who is responsible for monitoring every candidate’s performance based on evaluations from faculty members – and who makes sure that training requirements are satisfied.The training takes four years – two in anatomic pathology and two in clinical pathology. Residents gross surgical specimens, conduct tumor board meetings, and perform a minimum of 50 autopsies prior to board certification. They have a six-month rotation in clinical chemistry and another in the blood bank, where they take calls and handle quality assurance. Even microbiology rotations are a minimum of one to two months.

Do both regions face similar difficulties with staffing and recruitment?
SB: It is good for pathologists trained in India to work in North America. It will help address any deficiencies in their training and make them better pathologists. Most Indians never leave India in their hearts and minds even if they move physically to seek out better prospects and working conditions. Almost everyone regularly visits family and friends at home and most feel a strong desire to “give back” – a cost-free feedback loop that enhances education and facilities in India. Some who have moved up the academic ladder in North America even invite trainees from India to observe in their departments as guests. The only drawback is that these individual efforts are spotty and uncoordinated. We have formed the Association of Indian Pathologists in North America to streamline this energy and enthusiasm so that we can help upgrade pathology education, practice, and research in India.

Staffing and recruitment are not major problems in India because of the many certified pathologists who graduate each year. However, the quality of those pathologists is variable due to the lack of national standards. The salary in teaching institutions cannot compete with private laboratories – so, unfortunately, those who choose to teach are usually those who cannot find positions at high-end laboratories (although there are exceptions). It is a tragedy; institutions that train postgraduate residents cannot attract top academic talent, perpetuating issues of quality and inconsistency.

DL: In India, filling the posts of retired faculty is not a priority – and new recruitment also takes time, so many pathologists are overburdened. Although some Indian pathologists move to the US for work or study, that migration doesn’t limit the country’s ability to train new pathologists. Each year, over 80,000 students are admitted to medical colleges in India – of whom over 1,700 become full-fledged pathologists.

How do labs in India differ from those in North America?
SB: The only Indian laboratory in which I have worked is the Postgraduate Institute of Medical Education and Research in Chandigarh, where I practiced from 1974 to 1992. It is one of the best labs in the country – so perhaps not representative of Indian labs as a whole. However, I have visited many labs in both India and North America.

In India, labs in academic institutions (excluding the top few national institutes) generally lack funding, equipment, quality control, and – worst of all – faculty motivation to excel. The quality of testing and reporting is variable, but rarely reliable. As a result, diligent clinicians often send their patient samples to large multinational laboratories that offer better-quality reporting – kickstarting a vicious cycle in which the local labs receive fewer and fewer samples and thus have fewer and fewer opportunities to learn and improve.

DL: At government medical colleges, resources are limited. Even though the technology is modern, we don’t have a regular supply of reagents – so we often can’t perform necessary tests. Laboratory staff also lack regular training, so their knowledge is often outdated – and, in many institutions, those who retire are not replaced, so laboratories run on skeleton crews. Sadly, it seems that laboratory safety is not always a priority.

Because there is no regulatory agency in India, very few labs are quality-conscious. NABL 15189:2012 accreditation is purely voluntary; less than 1 percent of labs are accredited. Without efficient, credible, and quality-conscious diagnostic reports, the future of healthcare in India will continue to languish. We need a set of binding rules and regulations for pathology labs.

In the US, on the other hand, the Centers for Medicare & Medicaid Services regulate all laboratory testing (except research) performed on humans via the Clinical Laboratory Improvement Amendments. All clinical laboratories must be properly certified to receive Medicare or Medicaid payments. Many US labs have state-of-the-art technology and place a high priority on safety.

How widespread are newer technologies like digital and molecular pathology in India?
SB: They are available in only a few select laboratories and institutions.

DL: Awareness of molecular diagnostics is increasing in India, where there are now more than 20 molecular pathology labs. Most are in tertiary care hospitals and research centers. In 2011, a group of enthusiastic Indian experts formed the Molecular Pathology Association of India to promote and cultivate the study and practice of molecular pathology.

Although interest in digital pathology is growing among Indian pathologists, there are still impediments to its adoption. Recently, the Department of Pathology at Mumbai’s Tata Memorial Hospital surveyed pathologists’ knowledge, attitudes, and practices toward digital pathology. The results will provide a roadmap for digitization in the Indian pathology community. At the moment, only one laboratory in India offers web-based consultations with national and international pathologists using whole-slide images.

What are the biggest challenges pathology faces in India? What are the biggest challenges it faces in North America?
SB: In India, the main challenge is the variable quality of training, practice, and research. There is also a lack of collaboration between the “haves” and “have-nots” who could facilitate one another’s growth, little oversight of training and quality, and little access to advanced technologies. The practice of kickbacks robs trainees of the opportunity to see interesting samples, whereas the lack of advanced mentoring robs them of potential career opportunities. These things, coupled with the overall lack of uniformity in testing and training, mean that two young Indian pathologists might have completely different backgrounds, educations, and skill sets after completing their training.

In North America, the opposite is true. Pathology is becoming dependent on a “checklist” philosophy that may lead to a lack of independent and creative thinking. Many pathologists are entrenched in subspecialty silos, impacting their ability to be good diagnosticians across the full spectrum of surgical pathology. I feel that some pathologists may even rely too much on adjunct techniques, denying the humble H&E-stained slide the respect it deserves. Most importantly, US pathologists often engage in defensive practice to avoid litigation. Excess caution may seem like a good thing but can lead to unnecessary testing and overtreatment.

DL: In India, the biggest challenge is quality control. How sure are you that your lab results are accurate? Indian pathologists need to organize and make quality a priority across labs, with restrictions on who can start and run a lab. Technology has improved in clinical pathology, but histology lab quality is still largely substandard. Even tests as basic as immunohistochemistry are too expensive for routine use.

The decline of the autopsy has confronted us with the challenge of providing adequate training and experience for new pathologists. Growing administrative duties have increased our workload and responsibilities – including the need to comply with various regulatory bodies. Issues such as accreditation, internal and external quality assurance, continuing professional development, performance indicators, continuous audit activities, revalidation, and participation in clinical governance activities are just a few of the tasks expected of medical professionals nowadays.

In North America, pathologists generally subspecialize, which carries its own set of challenges:

• Decreased staffing flexibility in comparison with more general laboratories.
• Increased operational overheads (every subspecialty operates as a separate unit).
• Difficulty measuring workload equity between staff on different subspecialty teams.
• Difficulty evaluating the efficiency of pathologists’ work due to weights and indicators that vary from one subspecialty to another.
• The need for more staffing – still the biggest factor hindering subspecialization.

Technology is also a double-edged sword for North American pathologists; although molecular tests are becoming more readily available, their cost is affecting hospital budgets.

What can North American and Indian pathologists learn from one another?
SB: North American pathologists often think that their Indian colleagues are poorly trained or have had few opportunities for training – when, often, this is not the case. Indian pathologists, on the other hand, believe that all North American pathologists are rich, well-trained, and otherwise superior to their Indian colleagues.

We can both learn from one another. India must adopt North America’s focus on lab management, quality control and assurance, accreditation, communication skills, and mandatory continuing medical education or other forms of professional development. In return, India can teach volumes about how far down the diagnostic pathway one can go with just a simple H&E-stained slide and how to be truly selective when ordering additional tests.

DL: The one thing I would like North American pathologists to learn from their Indian counterparts is the skill of making a diagnosis with limited resources. We may have suboptimal sample or stain quality and lack ancillary stains, such as immunohistochemistry, but we still make diagnoses.

In India, there is no culture of laboratory inspections and quality assurance. Therefore, one thing I would like our country to take from North America is the strict adherence to quality assurance protocols and the value of accreditation and regulation.