Toward a cardiovascular pathology training: Report on the forum held in Vancouver, March 6, 2004, Society for Cardiovascular Pathology

Cardiovascular pathology is a subspecialty of anatomic pathology that requires both clinical education and expertise in contemporary physiopathology. The Society for Cardiovascular Pathology sponsored a special workshop within the frame of the USCAP Annual Meeting, held in Vancouver, March 6-12, 2004, to address the present and future role of cardiovascular pathology in research, clinical care, and education. Clearly, the recruitment and training of young pathologists are crucial to this aim. The forum tried to answer a series of questions. First, is there room for cardiovascular pathologists and clinicopathologic correlations in the era of extraordinary advances of in vivo human body imaging? What is the evolving role of the autopsy? How can the cardiovascular pathologist simultaneously be an autopsy prosector, a surgical pathologist, a molecular pathologist, and an experimental pathologist? Is there a specific domain content for training in cardiovascular pathology and does it meet the constellation of market needs and demands? What are the experiences in Europe, North America and elsewhere? What is the influence of cardiovascular pathology in departments of pathology? Is the subdiscipline still a Cinderella in the anatomic theatre or a Princess with a double helix coat of arms? The Society for Cardiovascular Pathology is strongly committed to optimizing the academic and professional profile of the future generation of cardiovascular pathologists. This article reports the outcome of the forum and directions that may lead to a vibrant future for well-trained cardiovascular pathologists.     

Expectations and essentials for the community practice of pathology

In 3 surveys during the past 10 years, community hospital pathologists were asked what they want, need, or look for when employing a pathologist and, more specifically, what skills and knowledge a newly minted pathologist should have to be successful in the community practice of pathology. The most recent survey, done in spring of 2005, cited surgical pathology diagnosis, frozen section diagnosis, gross dissection, cytology, and fine-needle aspiration as essentials in anatomic pathology. For clinical pathology, knowledge of clinical medicine and test strategies that use the laboratory for clinical problem solving was paramount. New expectations in the latest survey were knowledge of molecular pathology and experience in quality assurance procedures. New pathologists generally meet the expectations of the community hospital workplace; however, there were some deficiencies: they were not proficient in gross pathology or autopsy pathology, they were slow, and many lack the clinical knowledge and experience to be effective consultants. The principal attribute that determines success in the practice of pathology, however, is skill in communication and interpersonal relations, and this remains the major deficiency of the fledgling pathologist.     

The tasks of pathological anatomy (pathology) in the medical college and the possible means for their resolution

The course of pathologic anatomy in medical students' training is unsatisfactory as it doesn't cover many aspects of present-day human pathology. The graduates lack necessary knowledge in general and special pathology. The existing system of pathologist training is deficient, it should last for at least 4 years (subinternship, internship, clinical internship). Coordinated plans of advanced training of both the teachers and the pathologists are necessary. The relationships between chairs and bureaus of pathology should be systematized and creation of educational-scientific-practical complexes validated.     

Osler's pathology

Sir William Osler, one of the giants of clinical medicine, had his initial training as a pathologist. He was one of the physicians responsible for the impact that autopsies have had on medicine. He also contributed to the development of laboratory medicine. Osler made significant discoveries in anatomic pathology and hematology. His expertise was restricted not just to human pathology, but also to veterinary pathology. His mentors played a fundamental role in his achievements in academics.     

Pathologists overseas: coordinating volunteer pathology services for 19 years

Pathologists Overseas is a nonprofit organization that has been coordinating the efforts of volunteer pathologists and technologists for 19 years to improve and provide affordable pathology services to underserved patients worldwide. This is accomplished by aiding and establishing pathology laboratories, providing diagnostic pathology services, and training local physicians as pathologists. Projects have been completed or are currently active in Kenya, Eritrea, Madagascar, Ghana, Nepal, Bhutan, Peru, El Salvador, and St Lucia. The main challenge is finding enough volunteers to provide uninterrupted service to maintain a project. Our goal is to build on these experiences and continue to both support existing and establish more pathology laboratories worldwide.     

Practicing pediatric pathology without a microscope.

This article highlights changes in the field of pediatric pathology that have resulted from technical advances in prenatal diagnostics, immunohistochemistry, cytogenetics, and molecular genetics. The relatively new and growing need for specialized training in fetal pathology is used as an example. Comprehensive evaluation of human fetuses has become a requisite skill for many diagnostic pathologists, in part because contemporary prenatal diagnostic techniques have shifted the demographics of many congenital conditions from spontaneous term delivery to mid-gestation termination of pregnancy. The information provided by the pathologist has a tremendous impact for families and clinicians as they consider recurrence risks in future pregnancies. As most specimens from therapeutic terminations have gross dysmorphology, which may or may not constitute a recognizable pattern of human malformation, their analysis requires additional skills and methods that were traditionally the domain other specialists (e.g., medical geneticists). The pathologist must learn to identify syndromes, to be aware of their underlying etiology and pathogenesis, and to utilize advanced cytogenetic methods (e.g., fluorescence in situ hybridization), flow cytometry, or specific mutational analysis when appropriate. At a minimum, important anatomic details must be well documented and appropriate tissue samples should be obtained and stored to facilitate more specific diagnostic testing in the future.     

Challenges for pathologists in clinical laboratory medicine]

The number of pathologists in hospitals has been increasing and they are responsible for both surgical pathology and clinical laboratory medicine. In the future they will also play important roles in the modernized reform of the central laboratory as it establishes its own importance in improving the quality and safety of medical activities. As a pathologist, the author reports on challenges faced since assuming the present directorship of the department of laboratory medicine in 1995 including (a) establishing a decision-making system in collaboration with technologists, (b) improving expertise in the department through joining a variety of seminars, conferences and research activities, (c) publishing an annual department report, and (d) introducing both internal and external quality assessment. In the future, for young pathologists training in both pathology and laboratory medicine will be essential.     

Pathology graduate medical education (overview from 2006-2010)

Graduate medical education of pathologists has undergone considerable changes since 2006. The "Outcome Project" and reduction of basic anatomic pathology/clinical pathology training to 4 years are major changes. With implementation of the 80-hour week, it now takes 16,000 hours to train a pathologist who is competent to sit for the American Board of Pathology examination and practice independently. Reduction of the training time from 5 to 4 years has produced a perception (or reality) of mandatory fellowships. Changes are discussed, and trends are updated. Recent data is compared with data reported by the author in 2001 and 2006, and is updated through 2010.     

The boundaries of cellular pathology: how pathologists see their clinical role

There has been much recent public attention on the effects of the practices of cellular pathology on patients and their relatives. It is important to establish clearly pathologists' views about their professional relationships to clinicians and patients. A national postal questionnaire survey was performed to investigate how cellular pathologists perceive their role in clinical practice and whether there are important differences between different groups of pathologists. Responses were received from 773 pathologists, of whom 167 were trainees. On the basis of responses to 25 attitude statements, it appears that the profession shares a core belief that pathologists are clinicians rather than scientists and sees diagnosis as its main clinical responsibility. However, the role that each pathologist feels clear about differs significantly between pathologists, with a stronger consensus over function, responsibility, and professional image than on the clinical practice of pathology, job satisfaction, and the impact of technological change. Academic activities are a minority interest, although academic pathologists express better job satisfaction and more radical views of professional practice. Young trainees are more likely to work in teaching hospitals, to be female, to have trained outside the UK, and to have had experience in other specialties. They have, however, a more restricted view of the clinical role of pathology than accredited pathologists. Most cellular pathologists see themselves as clinicians with a special role in diagnosis, but how this is interpreted and the extent to which pathologists involve themselves in clinical decision-making is inconsistent. This professional dilemma should be addressed by research to obtain more systematic knowledge of the clinical impact of cellular pathology and especially the ill-defined links between diagnosis and clinical decision-making.     

Residency training in anatomic pathology: looking forward in the 21st century

Residency training in anatomic pathology in the United States elicits a wide range of fundamental questions and conflicting opinions. This paper reflects the author's opinion concerning 4 questions that are often integral to these discussions and impact the outlook on training in the current century. (1) What are the goals of residency training in anatomic pathology? (2) In the face of exponential growth of information in anatomic pathology, how are residents to be trained? (3) What changes are likely to occur in the practice and training of anatomic pathology? (4) Is combined training in anatomic and clinical pathology a viable program for the 21st century?     

Current tasks of institutional pathology departments in training physicians in the system of postgraduate education]

The difficulties in the postgraduate training of pathologists are analyzed and the leading role of the pathology chairs of the institutes for postgraduate medical training is outlined. Measures for retaining and improving the existing system for the training of pathologists are discussed. The importance of the physician's attestation in their qualification categories, and other possibilities in improving the postgraduate pathologist training are considered.     

Pathology in the U.S.A. A glut of pathologists, the role of the autopsy and the future of the "clinical pathology"]

This analysis deals with selected questions regarding the status of pathology in the United States. For a long time, the number of pathologists, both in practice and in training, had been deemed inadequate, but present trends indicate the existence of a considerable surplus of specialists in this discipline. The autopsy is still an important field of endeavor for the American pathologist even tbhough autopsy rates have drastically declined everywhere and the exact role of this procedure is being reevaluated. The concept of "clinical pathology" which seeks to encompass a whole conglomerate of heterogeneous disciplines and still dominates the practice of pathology in North America has come under attack; some observers plead for the total separation of laboratory medicine from pathology as well as for the systematic and intensive development of subspecialties within the field of pathology.     

Some characteristics of the community practice of pathology in the United States. National Manpower Survey of 1987

An evaluation of 629 pathologists engaged in community hospital and private laboratory practice and representing 601 pathology practices of varying size shows surprising uniformity in the distribution of professional effort. On average, pathologists in community practice distribute their effort as follows: surgical pathology, 34.6%; autopsy pathology, 6.7%; cytology, 8.8%; clinical pathology, 18.0%; teaching, 6.0%; research and development, 2.3%; laboratory administration, 17.5%; hospital administration, 2.9%; and other, 3.2%. The average community pathologist is male, 52 years of age, and a graduate of an American medical school (60%). When surveyed in 1986, community pathologists worked an average of 50 hours per week and retired at an average age of 62 years.     

Critical values in anatomic pathology

Similar to critical values (CVs) in clinical pathology, occasional diagnoses in surgical pathology and cytology could require immediate notification of the physician to rapidly initiate treatment. However, there are no established CV guidelines in anatomic pathology. A retrospective review of surgical pathology reports was recently conducted to study the incidence of CVs in surgical pathology and to survey the perceptions of pathologists and clinicians about CVs in surgical pathology, with a similar analysis of CVs performed in cytology. The results indicated that CVs in surgical pathology and cytology are uncommon but not rare and that there is a wide range of opinion among pathologists and between pathologists and clinicians about the need for an immediate telephone call and about the degree of urgency. It was obvious from the study that there is a lack of consensus in identifying what constitutes surgical pathology and cytology CV cases. Since the Institute of Medicine's report on medical errors, there has been an increasing number of initiatives to improve patient safety. Having guidelines for anatomic pathology CVs could enhance patient safety, in contrast to the current practice in which CV cases are managed based on common sense and on personal experience. Therefore, a discussion involving the pathology community might prove useful in an attempt to establish anatomic pathology CV guidelines that could represent a practice improvement.     

Gynecologic pathology as a hybrid subspecialty

Gynecologic pathology is a discipline that encompasses the pathologic changes of the female genital tract and placenta. As a field, it may encompass 30-50% of the overall case load of surgical pathology. Five pathways of study that may lend to a career concentrated in gynecologic pathology are reviewed. Pathology training, with pathology board certification in anatomic or anatomic and clinical pathology, with fellowship training in gynecologic pathology, is the course of training taken by those in active concentrated practice in this field. The advantages and disadvantages of the various training options in gynecologic pathology are discussed. The advantages of additional training and experience in cytopathology as well as the advantages of clinical experience in gynecology and obstetrics are discussed.     

Pathologists and laboratory medicine: personal experiences]

The author started his career as an anatomical pathologist and now works as an anatomical and clinical pathologist. Most Japanese anatomical pathologists are not well trained for laboratory medicine, but they are required to have a knowledge of laboratory medicine and are expected to become managers of laboratories in general hospitals. The reconstruction of the laboratory is necessary to include an anatomical pathology division and a new post-graduate education system should be established in which both anatomical and clinical pathologists should be cross-taught mutual fields.     

A study on task-analysis of clinical pathologists as medical consultants in Nihon University Hospital--a Japanese perspective by comparison with current status in the USA

To identify our role and the customers' satisfaction, the on-call consultation service records of the Department of Clinical Pathology, Nihon University School of Medicine, Itabashi Hospital (NUIH), were analyzed. Between 1995 and 1998, 1,789 consultation services were recorded, and approximately 40% were from physicians, and 50% were from medical technologists. During office hours, many physicians made contact with us at the office of clinical pathology, the clinical laboratory and other places in the hospital by various means. They asked us to interpret multidisciplinary laboratory data, and to provide the specific information that might affect clinical management. Medical technologists asked for clinical information of patients with extreme measured values and requested that we contact with physicians. In contrast, on weekends/holidays or after routine working hours, physicians sometimes requested non-automated laboratory tests such as peripheral blood smears/bone marrow smears or Gram stains. The major contents of our responses to medical technologists were concerned with blood banking and handling of instruments not to be operated in routine work. These results reconfirm that we are still required to have clinical competence for common laboratory procedures and to have the capability of interpretation of multidisciplinary laboratory data in the university hospital. Traditionally, most Japanese clinical pathologists have been focused their attention on bench work in research laboratories. However, the present study shows that the clinical pathologists need to bridge the real gap between laboratory technology and patient care. Our on-call service system can enhance the education of clinical pathologists, and improve not only laboratory quality assurance but also patient care. In addition, in response to a need for customer access to this service with a shortage of clinical pathologists, a more effective method would be to set up a proactive systemic approach in a more rigorous academic environment adopting advances in medical informatics.     

Postgraduate instruction and certification in the system of the continuing education of pathologists

The experience in changing pathology service, postgraduate training and attestation in the system of continuous education of pathologists is presented. The authors analysed different ways of pathologist training: specialization in subinternship, internship and clinical internship, short-term courses, at places of work and outpatient problem seminars, etc. The four-year program of pathologist training is suggested.     

Integrated expert systems and videodisc in surgical pathology: an overview

We present an overview of our 6-year experience in the design of expert systems for anatomic pathology. Our practical goal is to help practicing pathologists with learning, teaching, and the task of diagnosis by providing them with dynamic expert knowledge by means of a personal computer. This project could only be undertaken by first addressing a scientific goal: to characterize the problem-solving strategies that expert pathologists use in making a diagnosis and to state them in the logical terms of computer science. Our approach has been to build systems first for experimentation and then for use. The result of our work is an integrated computer-based approach that handles expert knowledge as formal relationships and morphologic images and that uses a number of logical strategies to provide multiple perspectives on diagnostic tasks. Configured as a pathologist's workstation, this approach can be expected to enhance the performance of trained general pathologists and pathologists in training. Lymph node pathology has been used as the prototype domain for this research, but care has been taken to seek a generalized authoring and inference structure that can be applied to other areas of pathology by changing the contents but not the structure itself. Excursions into various surgical pathology specialties suggest that the ways the system is constructed and exercised is fundamentally robust. Such computer-based expert systems can be expected to generate a new standard in the practice of pathology--based on the "gold standard" of classical morphology, but including the coordinated use of new methods from immunology and molecular biology in a multidisciplinary approach to diagnosis when these techniques are relevant. The benefits from this technology can be expected to be widespread with the evolution, refinement, and diffusion of these systems.     

Problems and opportunities in pathology manpower.

Speculations regarding the future of pathology manpower most often depend on whether the perspective taken is pessimistic or optimistic. In this article, I propose that the pessimist-optimist options are inadequate. To speculate responsibly about the future, our first task must be to understand clearly the present problems and opportunities. Problems facing pathology are numerous: (1) practitioners are retiring at an increasing rate, (2) inadequate numbers of newly trained pathologists are available to fill vacancies, (3) training program numbers continue to decline, (4) attrition of trainees is substantial, and (5) recruitment of new trainees encounters significant barriers. Despite these problems, significant opportunities to improve training program environments, decrease attrition, and increase recruitment are available. The future of pathology will depend on how we respond to the problems and opportunities that we currently face.