What Is Most Important In Pathology Training?

Cellular pathology (histopathology and cytopathology) has traditionally had an apprenticeship model, in which trainees gradually build up their experience through exposure to an increasing range and volume of diagnostic cases. In the earlier years of training, and when examining rarer cases later in professional life, the typical strategy used will be to assess a case using a hypothetico-deductive model. This is an important bridge between being a complete novice, a time when what is seen under the microscope doesn’t fit into any recognised pattern (particularly for graduates of undergraduate curricula in which exposure to histology is sparse), to the later stage in which most cases are diagnosed using a rapid pattern recognition strategy. In my opinion the experience gained by attempting to diagnose increasing numbers of cases, with subsequent feedback (preferably in person) from an expert pathologist, is central to the development of the trainee from novice to independent practitioner.

I was interested to find out whether trainee pathologists and their trainers shared this view, and to see how other aspects of training programmes were valued by both groups. In order to explore this, I conducted a survey examining the importance placed by consultants and trainees on a variety of educational activities that may be present as components of a post-graduate cellular pathology training programme. The results confirm the continued perceived importance of double-headed reporting by both trainees and consultants.

This study surveyed trainee and consultant cellular pathologists, as part of a study with local National Health Service research ethics committee and Royal Free Hampstead NHS Trust Research and Development Department approval, relating to post-graduate pathology education. The survey was conducted predominantly online. Email invitations to take part in the survey were sent out to all trainees and consultants at the Royal Free Hospital, to personal contacts who are trainee or consultant cellular pathologists practicing in Great Britain, and a link to the survey was also included in the email newsletter of the Royal College of Pathologists. A small number of paper copies of the survey were completed in private and returned anonymously. These responses were added by the author to the online survey. It is acknowledged that this method of sampling could introduce some bias, and that it is not possible with this methodology to reliably ascertain a survey response rate, however I would consider an estimate of approximately 10% to be plausible. Fifty seven cellular pathology consultants and 25 trainees responded to the section of the survey described in this report.

Respondents were asked to rate the importance for training of the following activities on a scale of 1-5 (1 – unimportant, 2 – slightly important, 3 – moderately important, 4 – important, 5 – very important): double headed reporting, autopsies, independent reading, black box sessions (meetings at which trainees are asked to discuss the diagnosis of educational cases), small group tutorials, teaching performed by the trainee, independent review of archival slides, inquest attendance, conference attendance, research activities, lectures, and journal clubs.

Both consultants and trainees reported very similar levels of perceived importance for the various activities (figure 1 and tables 1, 2, and 3). Both trainees and consultants rated double-headed microscopy reporting as the most important activity (both groups giving a mean score of 4.84/5). No consultant and only one trainee gave double-headed reporting a score of less than 4/5, demonstrating the consistency of the perceived value of the activity within and between the groups.

Independent reading, black box sessions, and autopsies were also considered very important by both groups, although autopsies were given a slightly higher importance rating by trainees than consultants (4.36 vs. 3.93/5). Both groups gave a mean importance rating of between 3 and 4 for small group tutorials, independent review of archival slides, teaching performed by the trainee, conference attendance, lectures, and inquest attendance.

Both trainees and consultants gave relatively low importance ratings to journal clubs and research activities, although the trainees gave a higher importance rating to research than did the consultants. Trainees were not subdivided into those with academic and those with non-academic career aspirations, and it is likely that the relative importance of research for an individual would depend on their career aspirations.

It is of interest that both trainees and consultants considered double-headed reporting to be more important than lectures, which may support the importance of the apprenticeship model of pathology education, in which supervised exposure to increasing numbers of cases is the core component of educational activity. The Royal College of Pathologists ‘Curriculum for speciality training in histopathology and related subspecialties’ document states that the majority of the curriculum (for histopathology postgraduate training) will be delivered through ‘work-based experiential learning’.¹ Similarly, the ‘Future Doctors Policy Statement’ published by the Postgraduate Medical Education and Training Board has also emphasised the importance of trainee doctors developing their skills in front-line settings that provide them with relevant experience.² While acknowledging the importance of other learning opportunities, the survey reported here demonstrates that double-headed reporting of cases, a core component of experiential learning in cellular pathology, is considered educationally very important by both trainees and consultants.

In my opinion, although additional learning tools can make an important contribution to cellular pathology training, the core activity of supervised reporting of cases is still vital to the development of the diagnostic skills required to become a consultant cellular pathologist.

REFERENCES

1. Royal College of Pathologsts website. Royal College of Pathologists Joint Committee on Pathology Training. Royal College of Pathologists; 2008. http://www.rcpath.org/resources/pdf/g051_histocurriculum_aug08.pdf [accessed 22/2/2010].
2. Postgraduate Medical Education and Training Board. Future doctors a statement on the future of postgraduate medical education and training. London; Postgraduate Medical Education and Training Board: 2009.