Pathology underpins all branches of medical practice. It provides the core of medicine and is key to understanding the mechanisms by which disease is produced and progresses. Medicine cannot be learnt, understood, and practised without sufficient undergraduate exposure to pathology. Undergraduates need a solid understanding of pathology to embrace major advances during their medical careers, regardless of their eventual speciality. Pathology itself should be a rewarding career which should attract the more able students. However, there are a number of factors which preclude this.

Students are influenced by role models, particularly those with a talent for teaching. In recent years student enthusiasm is unlikely to be kindled since there has been a considerable reduction in academic pathology posts. This was highlighted in 2006, but even since then, there has been a further reduction of 46%. [1,2] Some of the reasons for this are that pathology research scores insufficiently in the Research Assessment Framework, clinical lecturer posts have been removed since they fail to contribute to the assessment returns, and academic posts have been converted into clinical NHS roles, thereby easing workload pressures.

Curriculum pressures have made room for other specialities at the expense of pathology. The traditional pathology course now finds little place in the modern curriculum. There is little in the way of replacement. Integrated clinical and pathology teaching has had variable, often poor, outcome; but it seems curriculum changes have resulted in “the baby being thrown out with the bath water”. Pathologists must ensure that they remain involved in teaching undergraduates and also in examining regardless of what form the curriculum and future examination take. By 2020, there will be 1500 additional places for medical students in the UK, but the large numbers already present in some schools – particularly those having undergone mergers- must not result in even further diminution of pathology teaching. [3]

To address this issue, in 2014 the Royal College of Pathologists (RCPath) formulated a curriculum for medical students, but the college is unclear about its implementation. [4] The GMC now proposes that all UK medical students, as well as those from abroad who wish to practice in the UK, will have to pass a common Medical Licensing Assessment (MLA), although this should not preclude assessments from their own medical schools. MLA proposals are awaited, but must include assessments in pathology.

The diminution of pathology teaching has already had an impact. Consultants in post, particularly in District General Hospitals report that advice has to be provided with considerable frequency to junior doctors who do not have the necessary background in pathology and consequently lack confidence. This is compounded by there being little patient continuity and less oversight of junior doctors by their seniors, brought on by the European Working Directive.   

It is difficult to address some of these problems particularly as laboratory services are being outsourced for financial expediency. This gives students and trainees a poor recognition of what pathologists do. Joint ventures have been set up, but arrangements, with exceptions, make little allowance for the integrated approach of teaching and research, of particular importance in teaching hospitals. [5] Often the geographical and intellectual separation of service and academic activities precludes an interactive approach to the responsibilities of patient management and research. This is contrary to what should be provided by university hospitals and unlikely to encourage able students into pathology specialties. 

Pathology initiatives to encourage recruitment such as MB/PhD programmes, pathology summer schools and case conferences involving pathologists may be merely tinkering at the edges but there is little information on outcome.  

Financial constraints result in each medical specialty fighting its own corner, but this must not jeopardise the future of medical education and practice. Pathologists via their Royal College and their various societies, cannot do it alone, but perhaps pathologists themselves should have been more proactive in foreseeing threats and producing measures to emphasise the importance of their specialties. In the 1980s the Royal College of Surgeons would not recognise training posts unless there was a full range of Consultant and support services in pathology. [6] Alas, this is no longer the case. Perhaps other Royal Colleges could resuscitate this approach? Pathologists must ensure that organisations such as The Academy of Medical Royal Colleges, The Academy of Medical Sciences and the Medical Schools Council are aware of the current plight and are persistently pressurised to act. Ultimately, patients and the public will benefit.

Jangu Banatvala, Emeritus Professor of Virology, King’s College, London. 

References:

1. Wright, N.A., The Waxing and Waning of Academic Pathology: a Personal View.
Understanding Disease. A centenary celebration of the Pathological Society. Wiley, 2006. Editors, Peter A. Hall & Nicholas A Wright.

2. Fisher, D. Survey of Medical Clinical Academic Staffing Levels 2017: A report by The Medical Schools Council. 2017.

3. McAdams, A. Employment Adviser at The British Medical Association, June 2017

4. Pathology Undergraduate Curriculum, The Royal College of Pathologists, September 2014

5. The Bulletin of the Royal College of Pathologists, Number 179, July 2017

6. The Royal College of Surgeons, Manual of Basic Surgical Training, Appendix D, 1998