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There exists a wide variation in the competence of the postgraduate residents trained in pathology in different institutions across India. This results in strong disparities in the clinical diagnostic skills, teaching skills, research capabilities and the managerial skills of the graduates. The end users of this training, namely the community, clinicians and health care institutions would benefit from a more uniform and better trained pathologist. The article reviews the reasons for the variation in the quality of the training programs. The main deficiencies include, lack of well-defined criteria for recruitment of residents, training facilities, faculty resources, curriculum with well-defined learning objectives and competencies, hands-on experiences in diagnostic and research activities, diagnostic specimens and medical autopsies, exposure to molecular pathology, pathology informatics, electron microscopy, research experiences, communication skills, professional behavior and bioethics, business practices in pathology and quality assurance. There is also a lack of defined career tracks in various disciplines in laboratory medicine, standard protocols for evaluation and regional and national oversight of the programs. The steps for rectification should include defining the competencies and learning objectives, development of the curriculum including teaching methods, facilities and evaluation strategies, communication skills, professional behavior skills, teaching skills, legal aspects of practicing pathology and the various career pathways to sub-specialtiesin pathology. The training should include defined exposure to molecular pathology, electron microscopy, quality control and assurance, laboratory accreditation, business aspects of pathology practice, review of literature, evidence-based medicine, medical autopsy and medical informatics. Efforts should be made to share human and laboratory resources between regional cooperation. The oversight and accreditation policies should be evolved and well-documented. Web-based platforms need to be developed for easy interaction among residents, faculty and administrators on a national level.IntroductionThere is a wide variation in the way different institutions select students for postgraduate training. The matriculating candidate may have various reasons for joining the field of pathology and the desire and aptitude may play only a minor role in the decision. The institutions are varied in terms of faculty, laboratory support, infrastructure facilities, evaluation standards, quality control of the laboratories and the program and the institutional support. The products coming out of these programs are thus trained in a variety of fashions and may have varied capabilities to deliver the expectations from a competent pathologist. Some of these factors may be out of the control of individual faculty or the heads of departments in pathology. We have a choice in "letting things slide" as they are currently or take a bold step in planning for a better graduate for the future. "The best way to predict the futures is to invent it". The article explores the various options available and provides some guidelines for those who want to pursue this path. The authors have made the observations and recommendations on the basis of the insights they have gained through their work and interactions related to this program in several countries across continents, including India, over the last 36 years.Deficiencies in the Current SystemAdmissionsThe admission policy on the quality and the number of residents in a given department is often quite outside the purview of the head of the department or faculty. There may be students who opt for pathology as a last resort because they could not get into any other clinical program. Such students may not be motivated to actively learn and enjoy the practice of pathology.The number of postgraduates enrolled in a program may be determined by monetary considerations by the Institution and may not correlate with the training resources within the department including faculty, laboratories, number of specimen/samples, physical space and interactions with the clinical departments.Training FacilitiesThe department may lack the quality and quantity of laboratory infrastructure, research programs, research laboratories, teaching space, adequate number and variety of pathology samples processed in the laboratory, and medical autopsies.Faculty ResourcesThe faculty teaching in the program may not have adequate training in the educational technology, content training in the discipline, communication skills, overall vision, clinical perspectives or evaluation strategies. Some faculty may be in the position not out of choice but because they had no other choice. Some faculty may not be able to provide adequate time and attention to the training of residents because of their private practice or other affiliations.Learning Objectives and CompetencesVery few departments if any have written learning objectives or outcome objectives for their postgraduate program. It is generally assumed that the student must learn "everything" about pathology including all the sub-specialties within the defined time span of 2-3 years. Others assume that the textbooks of pathology and monographs of sub-specialties liked by the head of department constitute the objectives. This assumption sends mixed signals to the trainee on what competences he is expected to gain.CurriculumThe department may not have a defined curriculum of the postgraduates. The sessions specifically directed at them like lectures, biopsy sessions, slide seminars, clinicopathological conference (CPCs), etc., may vary greatly at different institutions. In some departments the curriculum may be restricted to what the local faculty knows or feel is important. Some programs over emphasize on the technical components of the laboratories like tissue processing, section cutting and staining which should be the domain of medical technologists. What are the minimum exposures needed for surgical pathology, clinical pathology, hematology, immunopathology, cytopathology, etc.?Residency Training Versus Postgraduate TrainingSome institutions provide for residency training with employment cum training programs. This includes hands-on training in processes like grossing of specimens, signing out slides, performing processes like frozen section, fine needle aspiration cytology, bone marrow biopsies, electron microscopy, participating in biopsy rounds and CPC. Other institutions run a postgraduate teaching program which includes lectures, review of collection of slides with very little hands on activities by the students in the day-to-day diagnostic and interactive activities of the department. This leads to accumulation of theoretical knowledge with little practical competences.Lack of Medical AutopsiesMost institutions do not have this facility. The autopsies are one of the best resources in the training of a pathologist.Molecular Pathology, Electron MicroscopyMost of the institutions do not have these facilities. Most of the current faculty are not trained in it and feel uncomfortable to learn it and hence cannot teach these aspects.Communication Skills and ProfessionalismThere is not currently any effort to teach and evaluate these in the training program although these are valued as necessary attributes of any good doctor.Opportunities for Research and PublicationThese vary tremendously between institutions. There is also a tendency to use an inadequate database just to write a thesis or publish where these activities are mandated.Business PracticesA large majority of the trained pathologists enter in the private practice in their own laboratories or commercial laboratories. There is no training on the special business management skills beyond the knowledge of pathology that is needed for such practice.Teaching Methods and TechniquesVery few institutions involve the postgraduate students actively and constructively in the teaching of medical students. Often it is treated as a chore and some of it may be passed on to the postgraduates in the concepts of education.Electronic and Online Learning ToolsVery little of these opportunities are actually utilized in many programs.Evaluation MethodsMany institutions use subjective methods in reality even if they go through the process of including slides and specimens in the process. Undue control may be exercised by the heads of departments in the outcomes without any input from all the faculty members. Undue importance may be given to the extra-curricular activities of the residents throughout the training program. The external examiners may not be able to maintain objectivity expected of them in evaluating the examinees.Extramural Oversight of Training and EvaluationThis supervision is either non-existent or gets only lip service on paper. History tends to repeat itself in the form of the entire program and the outcomes being almost exclusively in the hands of the local heads. There is very little effort to change and evolve.Defined Career Tracks in Branches of Laboratory MedicineVery few trainees may eventually practice surgical pathology. Do they need so much training in that segment? How much training is provided in clinical pathology which would be the bread and butter for most practicing pathologists? What are the community needs?Lack of exposure to special components like electron microscopy, molecular pathology, quality assurance, pathology informatics, business practices in pathology, communication skills, professional behavior, evidence based medicine.Why is the Urgent Need to Change?The frontiers of medical practice are ever expanding and the speed of evolution has grown geometrically in the past few decades. Pathologists are involved not only in making accurate diagnosis but also in providing, influencing the decision regarding the type and extent of therapy to be given and subsequently objective evaluation of the effect of the therapy. It is estimated that over 70% of all decisions in patient care and medical research involve the pathology laboratories and decisions of the pathologists. The pathology trainees no longer stay at the local institution or the local region. There is widespread movement across the states, the nation and the globe. The programs must develop a graduate who is comprehensive in skills and current and relevant to the present practice of medicine and be ready to adapt to the evolving practices of healthcare. The "mantra" is "think globally and act locally." India is emerging as a leader in health care and the preferred location for medical tourism. We cannot afford to continue to produce pathologists who are not ready for the current demands of health care. The postgraduate training programs in North America have evolved continually based on the development in the field. Japan has also documented similar progress. We also cannot afford to have graduates of different qualities coming out of different institutions. The market forces and the global economy will look upon unfavorably at the centers that cannot guarantee quality graduates. The mentors and leaders in pathology education need to actively analyze the situation and plan for the immediate future to stay relevant in the health care practices.Opportunities and Areas for ImprovementAdmissions/Enrollment to the ProgramThe faculty and the heads should define the competencies they desire from an incoming trainee. This should include knowledge but not be restricted to it. There should be a process to evaluate these competences like interest in the discipline, attitude, dedication, communication skills among the short listed candidates for final decisions on enrollment. The tests of knowledge should not be in pathology because that is what they are entering the program for. The tests should concentrate on the knowledge of a good intern or a good undifferentiated physician within the clinical context.All the departments may not have full control over the enrollment but developing a list of prerequisites as above and providing the same to those responsible for the enrollment could be the first step.Define the Core CompetencesThe Accreditation Council for Graduate Medical Education (ACGME) in the USA advocates six well-defined competences in medical education including patient care, medical knowledge, practice-based learning and improvement, professionalism, interpersonal skills and communication and system-based practices. All of these are applicable in drawing up a curriculum for postgraduate training in pathology although traditionally there has been a greater emphasis on medical knowledge and patient care. These need to be incorporated in the curriculum.Defining Career Tracks in PathologyThe great emphasis currently is on surgical pathology. How many of the trainees eventually end up practicing that in their professional career? It would be a minority who are based in a hospital or big laboratories. The bulk of practice generally involves clinical pathology that needs to be emphasized so that the community at large is served better. There should be a general year of rotations through all branches and the subsequent years should be spent more on what the candidates desire to practice.Cognitive Component of the Curriculum(i). Providing a list of learning objectives in a sequential manner and evaluating their achievement in a step-wise process: There should be an opportunity for both the trainee and the faculty to determine the progress regularly. A review of this nature at the end of the first 3 months might give a good perspective to both. The objectives in these months should include a recapitulation of the applied aspects of anatomy, histology, elements of the blood, cell biology and some basic techniques of tissue preservation, processing and staining.An evaluation at this step can decide if the trainee has achieved these basics and can move on or needs to repeat these steps. If warranted, there could be decisions taken on remedial measures at this stage before moving onto the next stage of the program. Similar building blocks or stepping stones in the form of learning objectives can be constructed sequentially for each component of the pathology program and evaluations carried out before training at the next higher level. In this way there could be a sequential development and documentation of learning objectives for the entire program. This will make the direction and targets clear to both the student and the examiner.(ii). Hands on training: The trainee should be involved in supervised participation in all the diagnostic and interactive activities of the pathology laboratory such as grossing of specimens, frozen section, signing out of cases, performance and interpretation of special tests and procedures, discussions with clinicians and biopsy rounds, CPCs, consultations, etc.(iii). Interaction with patients: The trainee should have supervised interaction with patients like fine needle aspiration cytology, bone marrow biopsy, venepuncture for blood samples, etc. Communication skills need to be taught, practiced and evaluated.(iv). Ward rounds (clinical exposure): The training program should include opportunities to go for ward rounds with clinical teams to discuss the laboratory issues related to patient management (indications for tests, collection and transport of appropriate samples, interpretation of tests results, additional tests needed, etc.) This will also provide an insight to the trainees on what questions the clinicians expect answered in the pathology report.(v). Discussion on the quality of pathology reports: The faculty should provide examples of incomplete, inaccurate, inappropriate laboratory reports and hold discussions with the residents on the construction of good quality reports. Indian college of pathology (ICP) may be encouraged to come up with templates for completeness of surgical pathology reports on specific types of specimen including tumors.(vi). Sensitization to applications of molecular pathology and genomics: The current practice of medicine involves the routine use of several techniques. All the departments may not have the faculty or the laboratory resources to practice and demonstrate them to the trainees. An attempt could at least be made to discuss the basis for the techniques and the common diagnostic and therapeutic applications of the common ones. If there is a regional laboratory that performs these tests, the trainees should be encouraged to go and observe them.(vii).Research methodology and statistical analysis: These should be an integral part of any postgraduate training program. They should be taught and tested as modules. Their applications should be reviewed in regular journal club sessions where the trainees and faculty discuss the critique of pathology publications in peer-reviewed journals. Emphasis should also be placed on evidence-based medicine.(viii).Exposure to experimental medicine/pathology laboratories: Most departments do not have the facilities for animal experimentation or tissue cultures. An attempt should be made to arrange visitation by trainees to centers where these are available to get a concept on how they run.(ix).Clinical correlations: Many pathologists feel that writing a good report is the total activity of a pathologist. The trainees should be encouraged to think about the patient whom the pathology sample represents. They should learn to explain etiology, pathogenesis, the basis for the symptoms, signs and investigations for the patient. They should be able to aptly describe the gross, microscopic and molecular features of the disease process and predict the usual course and complications. They should be able to suggest the broad lines of management based on the pathology.This should be a part of the daily sign-outs, group discussions and other teaching sessions. The trainee should develop the competence to build a clinical story based on a pathology image and vice versa. This should be a part of teaching and testing. Training in clinical pathology is very important but not much emphasized currently.(x). Electronic portfolio (e-portfolio): The trainees should be encouraged to develop an e-portfolio of their learning activities. They should add to it and enhance it regularly. The e-portfolio could be one vital segment of the overall evaluation of the trainee.(xi).Developing algorithms for various observations: The algorithms can be computerized. This is more helpful than jumping to diagnostic conclusions. This method should be taught, records maintained and evaluated formatively and summatively (Example-pigment in hepatocytes, fatty changes in hepatocytes, villus atrophy-Develop an algorithm and draw a chart to step-wise distinguish the diagnostic possibilities).Communication Skills and Professional BehaviorThese are vital functions of anyone involved in the health care provided by the specialists. A conscious effort must be made to develop objectives related to this and the list should be provided to the trainees. They should be evaluated on an ongoing basis throughout their program. This area might be difficult for some faculty to conceive. Some examples would be-coming to work on time, wearing the appropriate attire to work, compassionate attitude to patients, patient's relatives and colleagues, respect to peer and faculty, showing restraint when angry or provoked, handling professional disagreements without ill-feeling, actively listening to another's opinion, clear and concise speech at biopsy rounds, CPCs, responding accurately, briefly and politely to any queries, showing care for the laboratory area, instruments, slides, specimens, copies of reports, maintaining confidentiality, team-player spirit, leadership qualities, volunteering for community service, etc.Business PracticesA curriculum model needs to be developed for training the students on the issues involved in setting up a private laboratories and how to handle them. Legal aspects of the practices of pathology also need to be introduced.Involvement in the Teaching of MBBS StudentsThe trainees should be involved actively in the laboratories sessions to help the medical students learn clinical correlations. This will also teach the trainees the art and science of education and evaluation.Quality Control and Quality AssuranceThe trainees need to be aware of these issues in a laboratories so that they can set up or work properly in the diagnostic or research laboratories after their qualifications. The program could arrange for mock inspections of laboratories of cooperating departments/hospitals so that the residents can go through an A-Z check list for compliance.Exposure to Autopsy Pathology and CPCsMedical autopsies and the study of pathology material obtained is one of the best learning tools in pathology. It provides an opportunity to touch, feel and study diseased organs and correlate with histopathology and all the clinical and radiological features. Efforts must be made to include as a part of the program a few weeks of exposure to autopsy pathology at other institutions where it is available. It could also involve archived autopsy material with the specimens, slides and the clinical files.Online Electronic ResourcesEfforts should be made to include several electronic resources for the learning of pathology. Several sites such as pathology outlines, Path Xchange, Medscape, Med MD, United States and Canadian Academy of Pathology (USCAP), several hospital and medical school websites like the national cancer Institute, John Hopkins Hospital, Tulane University, etc., offer several modes of learning through images, virtual microscopy, clinicopathological exercises, lectures, textual information, quizzes, continuing medical education (CME) exercises. Most of these are free and a few may need institutional membership at nominal charges. The medical informatics or pathology informatics is an essential component of residency training in the US. The residents should be encouraged to develop an e-portfolio and keep adding to it and modifying it as they progress in their training. It can also be an invaluable tool for evaluation.Inter-institutional CooperationEach and every department does not have all the resources needed to fulfill all the requirements in terms of faculty resources, laboratories, teaching set-ups, pathology specimens, etc. It would be worthwhile to work on a regional basis where institutions can support with the training activity for most of the trainees of that region. The trainees could have rotational postings in those institutions to get trained and evaluated there for those aspects. This is already happening to some extent in some regions for the training in autopsy pathology. The cost could be shared between the institutions and the trainees. Some of the commercial and national medical and educational bodies could be tapped for such funding. The exchange process could be established on a national level too. The cost would be well-worth when compared to the benefits accrued to our national graduates. Some of the computer experts in pathology, faculty and postgraduates could be encouraged through the Indian Association of Pathologists and Microbiologists (IAPM) to set up a dedicated website to pathology postgraduate training. Telepathology is a great tool for teaching, learning and clinical service. There could be contributions online to this site by experts in the field through podcasts, slide seminars, quizzes, CPCs, autopsy data analysis, QA/QC measures, etc. There could be sections on the same site of different sub-specialties for pathology. It could provide opportunities for communications between faculty at various sites, trainees at various sites and a dialogue between faculty and trainees at various locations.International CollaborationInternational organizations like the College of American Pathology (CAP), USCAP, Indian Association of Pathologists from North America (AIPNA), International Academy of Pathology could be requested to assist in the electronic learning and testing through the website created. Their members and alumni pathologists from any college in India could provide teaching material for the site. The site could archive teaching material, slides and quizzes for future generations of trainees. The faculty could use the site for self-learning.National Oversight of the Training Program (National Committee for Postgraduate Training in Pathology)There needs to be a formal body charged with the oversight of the postgraduate training program in pathology across the country. It could set the curriculum, the standards of education and evaluation in addition to the quality control of the laboratories that are involved in this educational process. It could have a regional branch each for North, South, East and West or pass the charge to the state chapters of the IAPM and the ICP should move toward voluntarily establishing such a body and write the constitution and remit of this committee. The process will be long drawn and is likely to have some political and financial obstacles. Steps need to be taken right away so that the program gets started with out delay. Every meeting of the Annual Conference of IAPM Conference (APCON) should have at least one day dedicated to the meeting of this NCPTP along with faculty involved in the training programs and representatives from the postgraduate residents. The committee could deliberate electronically on a monthly basis and the news and developments transmitted through an electronic newsletter on the website dedicated for pathology postgraduate training.EvaluationsThe evaluations should be in multiple stages, at the end of first three months, first 6, 12, 18 and 24 months. A greater value should be attached to the in-course evaluation to reduce the tensions and subjectivity of an all or none final examination. The in- course assessment should monitor the communications skills and professional behavior in addition to cognitive skills. The faculty members should also be evaluated by the trainees regularly and should have regular meetings with the residents to discuss and resolve issues related to training.Looking at the FutureThe programs now offer a fixed duration of training, at the end of which, the trainee must pass an examination to qualify. This system does not take into consideration the individual learning abilities and the competence of the students. The conclusions are made on a set of slides and specimens and a grand viva under a trying experience for the examinee. Factors other than competence may play a major role in the outcome.We could think of a system where we define the skills and competences to be achieved by the trainees. They could be evaluated on a continual basis in course for the achievement of these competences. Some may achieve these quickly and others may take a little longer. Thus instead of defining the period of training one could define the competences and make the learning and evaluation individualized. This will lead to more competent pathologists for the community, but it needs a reorientation of the educational philosophy behind the pathology residency training program.ConclusionsThe authors have contributed to the postgraduate residency training programs in pathology in eight countries across Asia, Middle East, UK and North America in several institutions over 35 years. They have also attended and participated in several seminars that discussed the postgraduate training programs in the medical field and pathology in particular. They have visited several medical schools across India and interacted with pathology residents in various teaching sessions.This background offered a unique opportunity to take a global view at how the programs can be improved in India to train and graduate a pathologist who has competence acceptable anywhere in the world.The article documents the lacunae and categorizes various areas on which efforts need to be made locally, regionally and nationally with international cooperation to improve and enhance the program. There is a certain degree of urgency to this quest for our nation to remain competent in the international health care scene.Source: How can the postgraduate training program in pathology departments in India be improved? Bhusnurmath SR, Bhusnurmath BS