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Abstract
Pathology is the study of disease and is an important component in medical education. However, with medical curriculum reform, its role and contribution to medical courses is under potential threat. We surveyed the status of pathology in all six Irish medical schools. Information was received from five direct undergraduate and four graduate entry programmes. Pathology was recognisable as a core subject in all but one of the medical schools, was generally taught in years two or three, and the greatest contact hours were for histopathology (44–102 hours). Lectures were the most common teaching modality, and all used single best or extended matching answer multiple-choice questions as part of assessments. Currently, pathology is very visible in Irish medical education but needs to remain relevant with the move to theme and case-based teaching. There is heavy reliance on lectures and on non-academic/full-time hospital staff to deliver teaching, which may not be sustainable.
- pathology
- medical education
- staff
- integrated teaching
- lectures
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Background
Pathology is the study of disease and incorporates a wide diversity of disciplines including histopathology, haematology, chemical pathology, microbiology, immunology and related specialties. However, pathology is also a clinical discipline as well as a science.1
Over the last 20 years or more, there have been significant changes in medical education, including a shift from discipline-identifiable courses to a style of teaching that either focusses on themes or systems with both case-based and problem-based learning. In a survey of 83 US medical schools in 2000, integration of various subjects and disciplines was present in 51% of schools, and lectures were the most common mode of teaching.2 There was also a move to have a greater emphasis on case studies and clinical pathological correlations as learning modalities.3 However, there has been a concern that with greater integration and multidisciplinary teaching, the importance of pathology, and its visibility, in healthcare education is becoming lost.
Some Irish medical schools have moved away from the Flexnerian model of medical education where there is a preclinical and clinical curriculum style format or division. These schools have increasingly favoured more integration of clinical and non-clinical content with an emphasis on systems, case-based teaching and clinical skills when designing their curricula. However, some still have a curriculum with a basic science focus followed by a more clinical emphasis. Certain disciplines including pathology are generally still recognisable as in the USA, in contrast to the UK, where theme-based medical education has blurred the distinctions between subjects and disciplines.
As many Irish medical schools are reviewing their curricula, we set out to survey the current profile of pathology in Irish medical schools and specifically how it is delivered, who delivers the teaching and how it is assessed/examined to inform future approaches to ensuring pathology remains relevant in medical education.
Methods
A pro-forma questionnaire was developed to gather the relevant information. We especially wished to collect information and some details on the number of students, in both direct undergraduate entry (ie, usually but not always students coming straight from secondary school) and graduate entry (students with a pre-existing university degree which is a prerequisite for admission) programmes, when or in what year pathology was taught during the medical course, and over how many semesters. We attempted to collect the number of contact hours for the various disciplines of pathology, for example, histopathology, and how pathology is assessed. We also sought information on who delivers the teaching; academic medical staff (ie, recognised and salaried hours paid by the university to medically qualified doctors); non-academic medical staff (ie, full-time hospital-employed staff), and non-medical academic staff (eg, science graduates).
The questionnaire was piloted initially to ascertain that it was clear and understandable as to what was being sought, included as a supplementary file. It was then forwarded to those involved in overseeing, developing or delivering that part of the curriculum in Irish medical schools where pathology was taught during 2018.
Results
Information and some details were provided by the six medical schools in Ireland, including from all five direct undergraduate entry programmes (DUEPs) and all four graduate entry medicine programmes (GEMPs). Three of the six had both DUEPs and GEMPs. In general, the number of students was lower in a GEMP, that is, 70–140 per year compared with a DUEP, that is, 130–350 students per year (table 1). Pathology was a recognisable subject or topic in all but one of the medical schools and was included in an integrated teaching format (ie, taught with other disciplines/subjects such as Medicine) in all but one. There was some variation in when pathology was taught but years 2 and 3 of the medical course were the most common years.
General details about pathology teaching in Irish medical schools
The number of whole-time-equivalent medical academic staff involved in pathology teaching varied from 0.62 to 16 and the number of non-medical academic staff from 1 to 17 (table 2). Overall the number of academic staff per 100 medical students ranged from 1.2 to 9.2. However, a high proportion of teaching was delivered by non-academic medical staff, that is, full-time consultants in many of the medical schools, with 60% of the teaching being delivered by such staff in one of the medical schools.
Teaching of pathology by medical and non-medical staff
The greatest number of contact hours was for histopathology in both DUEPs and GEMPs, ranging from 44 to 102 (table 3). Contact hours for microbiology ranged from 8 to 76 but those for haematology, chemical pathology and immunology, were much lower and in some courses were less than 10 hours over the whole course. However, some aspects of these disciplines may be covered elsewhere such as during the teaching of Medicine. Lectures were the most common method of delivery with over 100 lecture hours in total dedicated to pathology teaching in three medical courses. These were followed by practicals/demonstrations, case-based activities and tutorials.
Contact hours for the various disciplines and teaching modalities in the teaching of pathology in Irish medical schools
All six medical schools use the single best answer-type multiple choice questions (MCQs) as well as extended matching-type MCQs (table 4). The long essay-type question was used in two DUEPs and one GEMPs. Data interpretation of diagnostic test results was used as a method of assessment in four DUEPs and two of the GEMPs.
Methods of assessment of pathology teaching in Irish medical schools
Discussion
We believe that the results from this brief survey are a reasonable reflection of the teaching of pathology in Ireland now. Pathology remains visible in most medical courses but with a great reliance on lectures as the main teaching modality. Also, much teaching is dependent on non-academic medical staff and this may in part explain the heavy use of lectures. However, a positive aspect of this is that much of the teaching is therefore delivered by practising pathologists who have insight into the clinical relevance. They may also serve as role models to inspire students whose recruitment is vital for the future of pathology.
Limitations to the survey include not having any details on course outcomes or the medical graduate profile, the absence of data on the views of students and others, and we did not provide precise definitions of some categories of teaching delivery such as tutorials and case-based teaching, as the former may include or be based on case material. Nor did we clearly specify some terms such as ‘pathology as an identifiable subject’. We also do not have reasons for the variation in some of the parameters such as the number of academic staff/100 students, the proportion of teaching delivered by non-academic medical staff and the teaching contact times between pathology disciplines and between medical schools. However, these may be partly explained by the fact that the medical schools vary in how old they are, have evolved independently and vary in their funding models.
A recent literature review of teaching and learning in pathology emphasised the value of pathology but found considerable variation and changes occurring.4 In UK medical schools, pathology is generally taught in two blocks and there is a strongly held belief that pathology is a bridge between basic sciences and clinical medicine. However, there is an increasing trend for aspects of pathology to be taught by non-pathologists such as in genetics and infectious diseases.4 Recent changes in medical education in the UK have generally been more rapid than in Ireland and the USA, with five new medical schools about to increase medical school places by 25% with the partial phasing out of GEMPs.5
In a review of pathology education in the USA in 2013 and 2014, 82 of 98 medical schools offered courses in laboratory medicine or pathology but the assessment of the students’ competency in laboratory medicine only occurred in eight schools.6 However, laboratory medicine also incorporates the appropriate use of the laboratory and the interpretation of tests and is not necessarily just about understanding the basis behind human disease. Students are aware of the need to acquire competence in pathology-related subjects as over two-thirds of the Step 1 US Medical Licensing Examination (USMLE) consists of questions in histopathology, microbiology, immunology and genetics.7
Smith and colleagues have proposed a curriculum for educating medical students in laboratory medicine, which covers the various disciplines of pathology as well as molecular diagnostics.8 However, there is still some controversy as to how best to assess learning outcomes in the USA and whether this should be tied in with USMLE results.8 9
The perceptions and views of medical students on how curricula prepare them for medical practice are of relevance. Over 15 years ago, a survey from the University of Manchester, UK found that in general students felt better prepared after an integrated course rather than the traditional preclinical and clinical course, with clearly identified subjects or disciplines.10 In Germany, a survey of 1018 German medical students found general satisfaction with a lecture-based curriculum but interestingly, many supported the incorporation of microscopy, seminars and podcasts in to teaching programmes.11
With increasing pressure on clinical practice and research assessment exercises in universities in many countries, medical education as a priority often gets squeezed. In a survey of 833 clinical teachers in a German medical school, participants believed that the most important indicator of high-quality teaching was student learning outcomes that were sustainable, but they were hampered by the absence of protected preparation time during working hours and the lack of recognition for teaching.12 There were also issues regarding the involvement and the facilitating of time and resources for non-academics.
Pathology in Irish medical schools continues to have a relatively high profile compared with medical schools elsewhere, where it has often disappeared as an identifiable topic, which is apparently the case in the UK. This profile is perhaps also reflected in the numbers applying for higher specialist training posts in Ireland in recent years where the total number of applicants for all disciplines has varied from 17 to 41 with 11 to 26 being appointed each year (Ciara Buckley, RCPI, personal communication). However, the visibility of pathology, may be under threat as greater integration and theme-based medical education, may mean reduced pathology content, less visibility and possibly difficulties in recruitment. As courses become more vertically integrated with more clinical exposure and experience in the early years of medical school sometimes at the expense of pathology, there is a case for including more pathology in the later years when its relevance may be clearer.
There is a heavy reliance on lectures as a form of teaching delivery for pathology in Ireland with less opportunity for problem-based learning and smaller group teaching sessions. There is also great dependency on non-academic medical staff, which may not be sustainable with the move towards smaller-group teaching and pressures on service delivery from hospitals. Further work arising from this survey might include exploring the views of medical students and non-pathology teaching staff on the teaching of pathology, the reasons for the variation in some of the parameters, for example, staffing levels, and the monitoring of USMLE results as changes in the curricula occur. Finally, Irish pathologists need to retain the strengths of the current system including the relatively high visibility of pathology with the capacity to attract sufficient and high calibre applicants for training, but they also need to adapt to changes in medical education. However, this needs to be facilitated by universities and medical educators.
Supplemental material
Acknowledgments
We acknowledge and thank colleagues in helping us to confirm the data included in this survey.
Footnotes
Handling editor Tahir S Pillay.
Contributors HH drafted the questionnaire with NS and with DL, GC, LB, RWW and MT provided the data. HH drafted the manuscript which was reviewed and amended by all the authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.