Abstract

Objective. In Italy, shortage of pathologists is a problem that affects the quality of the National Health System (NHS). The cause of the shortage of pathologists in Italy must be sought in the lack of interests in the pathologist career by Medical Course Students (MCS) and in drop out of Post-Graduate Medical Schools (PGMS). We investigated reasons of both through two surveys.
Methods. We developed and proposed on Facebook two surveys, one to MCSs attending last years of study and one to Pathology School Residents (PSRs). Survey for MCSs consisted of 10 questions centered on their perception about pathologist activity; survey for PSRs consisted of 8 questions and investigated the most and least appreciated aspects of Italian PGMS.
Results. We obtained 500 responses from the MCSs and 51 responses from the PSRs. Our results show that lack of interest of MCS may be due to their incomplete knowledge of the pathologist’s activities. On the other hand, PSR answers show that some teaching aspects should be improved.
Conclusions. Our surveys showed that lack of interest of MCS in the pathology career depends on poor knowledge about the real clinical significance of pathology and PSRs believe that Italian PGMS do not meet their interest. One solution could be a renewal of teaching both in the pathology courses for MCS and in PGMS.

Introduction

Surgical pathology has dramatically changed in the last decades. Indeed, the development of new technologies has led to the development of new fields such as advanced molecular pathology, digital pathology, automatization, and traceability systems, destined to develop further in the coming years ¹.

In particular, the role of the Pathology Unit in molecular characterization of cancer and digital analysis of neoplastic tissue morphology and biomarkers have provided a new position for the pathologists in the management of the oncologic patients. Thus, alongside the classical activities in Pathology Units, such as autopsies, cytopathology and histology, new branches have been developing, with a potentially increasingly wide application in the next future. The introduction of new complex technologies for the characterization of biomaterials from oncologic patients is leading to an exponential increase of the workload of Pathology Units, often responsible for inconvenient delays for diagnosis and treatment, that has caught the attention of world media (Fig. 1). However, the development of this new starring role for surgical pathologists in the clinical management of the patients, does not correspond to an increasing attractiveness of the branch for Medical Course Students (MCS) and young medical doctors. Indeed, despite the growing demands for pathologists, there has not been an adequate increase in number of Italian trained pathologists in the last years, and the effectiveness of Pathological Units is undermined by the chronic shortage of pathologists.

The reasons for the lack of pathologists are principally the low number of Medical Course Students (MCS) which consider Pathology as a possible future career and the drop out of Post-Graduate Medical Schools (PGMS). Thus, it could be crucial to understand the lack of interest for pathology and reasons for dissatisfaction of pathology residents to ensure enough pathologists to the NHS.

The aim of this study was to investigate these two aspects, based on two different surveys aimed to get a picture of the opinion that both MCS and Pathology School residents (PSR) have on this discipline.

METHODS

We developed two surveys, one dedicated to MCS attending the 4th, 5th, and 6th years of Medicine and one to PSR. Both surveys were proposed on the social network Facebook. In particular, they were published on Facebook Medicine students’ groups pages from several Italian Universities - even unofficial groups - and on groups for students who had interest in PGMS.

Survey for MCS consisted of 10 multiple choice questions, providing specific information for students (attending year, region, taking surgical pathology exam), their interests about Pathology and their knowledge and perception about the discipline and the role of the pathologists (Fig. 2).

Survey for PSR consisted of 8 multiple choice questions; in addition to personal information, such as origin and year of specialization, the compilers were asked to give an opinion on the most appreciated and the least appreciated aspects in their training (Fig. 3).

In addition, in both surveys, relatively to the “opinion of the participants”, it was possible to choose more than one answer.

Both surveys were anonymous, they were available for a period of seven months from 25/5/2020 to 25/12/2020.

Results

MCS SURVEY

Overall, we obtained 500 answers to the MCS survey, 52.6% of participants were female (263 of 500) and 47.4% of participants were male (237 of 500).

340 out of 500 (68%) of MCS attended the 6th year of study or were recent graduates; 78 of 500 (15.6%) attended the fifth year of study and 82 of 500 (16.4) attended the fourth year of study.

The greatest participation was obtained by students from Campania who constituted 47.8% of the sample (239 of 500), 8% of the interviewees were from Puglia (40 of 500), 6.2% from Lazio and Piemonte (31 of 500), 5.6% from Sicilia (28 of 500). The respondents from other Italian regions were less than 5%.

76.8% of respondents had already passed pathology exam (384 of 500) while 23.2% had not yet passed it (116 of 500).

70.2% of students (351 of 500) absolutely did not consider PPMS among PGMSs of interest. 40 of 500 (8%) students considered it as a fallback solution, as an alternative to their PGMS of interest. 76 of 500 (15.2%) considered it among their choices and 33 of 500 (6.6%) considered it as the first choice.

44.4% (222 of 500) of students declared to be interested in the possibility of deepening their knowledge of the discipline.

A significant percentage of students recognized the diagnostic role of the pathologist in morphological (376 of 500, 75.6% answers), molecular diagnosis (323 of 500, 75.2% answers) and post-mortem examination (333 of 500, 66.6% answers). 303 of 500 (63.4%) students recognized the role of the pathologist in the precision medicine. Few students knew the pathologist’s clinical role, considering them as members of the multidisciplinary oncologic teams (22 of 500-4.4%) or recognizing them the competence to perform fine needle aspiration cytology (FNAC) (5 of 500-1%).

99.8% of respondents (499 of 500) recognized the importance of new technologies in pathology.

The most important new technologies indicated by MCS were immunohistochemistry (399 of 500 answers, 79.8%) and molecular biology devices (385 of 500 answers, 77%), followed by the possibility of image analysis by software (206 of 500 answers, 41.2%) and 15.8% of the interviewees (79 of 500) recognized importance of telepathology.

Results from the MCS survey are summarized in Figures 4-6.

PSR SURVEY

The survey dedicated to PSR received 51 responses, 51% of participants were female (26 of 500) and 49% of participants were male (25 of 500).

The geographic distribution, in this case, was much more fragmented with 19.6% (10 of 51) residents in Lombardia, 11.8% (6 of 51) in Lazio, while residents from other Italian regions were less than 10%.

Regarding the attended PPMS year, the interviews were distributed as follows: 12 for 1st year (23.5%); 12 for 2nd year (23. 5%); 10 for 3rd year (19.6%) and 17 for 4th year (33.4%). Approximately, 13.7% of the interviewed (7 of 51) attended PPMS as a fallback solution and 3.9% (2 of 51) still intend to attempt the test for the admission to another PGMS, 42% (24 of 51) considered PPMS as their first choice and 42% (24 of 51) considered it among their schools of interest.

Considering the evaluation of PPMS, 11.6% (6 of 51) expressed an insufficient score, 17.6% (9 of 51) rated as sufficient, 43.1% (22 of 51) rated as good, and 27.5% (14 of 51) gave an excellent rating.

The most common requests to improve their skills were theoretical training (52.9% - 27 of 51), participation in outpatient activities as cytology ambulatory (39.2% - 20 of 51) and possibility to access funding for scientific activity (39.2% - 20 of 51).

On the other hand, the aspects satisfying the trainees were gross room activities (62,8% - 32 of 51), microscopic activities in all their aspects (histological - 80.2% 40 of 51, cytological - 48% 24 of 51 and intraoperative - 52.9% 27 of 51) and possibility to perform autopsies (41.2% - 21 of 51). Other listed aspects (Fig. 6) have obtained the appreciation of less than 15 residents. Another criticism highlighted by residents was related to provision of Personal Protection Equipment (PPE) and safety measures in the workplace required by 35.2% (18 of 51) of the interviewees.

Regard to proposals relating to new technologies, residents focused their attention on teaching; instead, the use of multimedia monographic courses and multimedia teaching were the proposals chosen respectively by 72.5% (37 of 51) and 68.6% (35 of 51) of the residents. The development of research projects in collaboration with other universities was also a proposal chosen by most of the residents (68.6% - 35 of 51) for the future of PPMS.

Results from the PSR survey are summarized in Figure 7 and Figure 8.

Discussion

Better knowledge about molecular features of several neoplasms, the development of targeted therapies based on histological or molecular selection of patients, and the development of new digital technologies of diagnostics has exponentially increased the workload of the Pathology units in recent years. However, the increase in workload was not accompanied by an adequate increase in the number of the trained pathologists. The shortage of the pathologists is a relevant issue for the quality of Health Systems all over the world, as it affects several countries, as described in some recent studies ^2,3. Markl et al. ² reported a low number of pathologists in Europe, being the ratio between pathologists and inhabitants about 1/30,000 while such ratio for other specialists (such as gastroenterologists or surgeons) was up to 12 times higher.

In the US, from 2007 to 2017 workforce of the pathologists had declined approximately from 2.03% to 1.43% of all physicians ³, whereas in China there are only 20,000 licensed pathologists for a population of 1.4 billion.

In Italy, the shortage of pathologists is a serious problem with potential effect on the quality of the national health system (NHS). According to Italian National Pathologist Society (Società Italiana di Anatomia Patologica e Citologia - SIAPEC), each pathologist must provide about 2,500 diagnoses per year to meet the requirements of health units, resulting in an increasing need for pathologists ⁴.

The shortage of pathologists may be mainly due to the lack of interest of MCSs in the pathology professional course and drop out of PPMSs. Regarding lack of interest in the pathology professional course, several survey all over the world showed that Pathology is perceived as unattractive by the students, mainly due to the way the discipline is presented them in the Pathology Course ⁵.

Indeed, students do not appreciate the Pathology Course for excessive amount of materials to study ⁶, or for antiquated methodology of learning ⁷. Furthermore, MCSs expressed their dissatisfaction for Pathology course based only on lectures without clinical correlations ⁸ and for the lack of deep knowledge about the practical work of pathologists ⁹. Regarding drops out of Pathology PGMS, it partially depends on the access method to PGMS: in 2013, the Italian Ministry of University and Research replaced the local-university management of PGMS with a national engagement to promote meritocracy and transparency in the access process ¹⁰. Subsequently, from 2017, a unique admission test regulated access to all PGMSs ¹¹.

The new admission test has ensured greater transparency on the means for the access to PGMS; on the other hand, this system does not allow young doctors to compete specifically for the preferred school and ensures that participants with a low score, after the test, opt for a PGMS often with poor interest for them, that they will try to drop out in the subsequent years. These problems affect specialization courses with greater workload or legal risks (for example General Surgery, Anesthesia, and Intensive Care), specialization courses with a poor clinical role (Pathology and Clinical Biochemistry) or specialization with lower job opportunities (Community Medicine and Primary Care).

PPMS appears to be one of the most affected by the problem of dropouts. More specifically, in the 2016-2018 period, 25 of 160 (15.6%) young doctors attending PPMS tried the admission test again to enter a different PGMS; 15 (9.4%) succeeded in dropping out PPMS for another PGMS or for General Medicine Course ¹². Thus, given the high number of drop out of PPMS, probably there are other modifiable factors that condition this abandonment.

With our study, we tried to identify reasons of possible lack of interest of Italian MCS about pathology and possible modifiable factors that may be facilitate PPMS’s drop out, and if it was possible to deduce solutions to this problem.

MCS SURVEY

The survey for MCSs essentially confirmed that Italian students perceive the same critical aspects of pathology course identified by students of the other countries. Indeed, even if most MCSs were in the full decision-making phase for their future (attended the sixth year or already graduated), about 78% did not consider PPMS in their interest.

Indifference to Pathology studies could partially be explained by students’ lack of the knowledge of the clinical role of the pathologist. Indeed, although 76.8% of students had already passed the pathology exam, only 63.4% recognize the pathologists role in precision medicine, falling to 24% on the knowledge of the pathologist’s clinical skills (for example execution of FNAC or participation to the decisional process of the multidisciplinary oncologic groups). This lack about knowledge on the discipline is confirmed by the answers about new technologies, as MCSs reported technologies such as immunohistochemistry and molecular biology, already widely used in pathology laboratories for decades, and did not consider telepathology and image analysis, the real new frontiers of pathology. Probably, the importance of these technologies was not sufficiently underlined during their pathology course.

Therefore, the survey showed that MCSs have a poor knowledge of the pathologist’s role, mainly in the direct involvement in the care of patients; this poor knowledge translates into a lack of interest in the profession of the pathologist, and not greatly considered as a future job opportunity.

PSR SURVEY

The poor interest of MCSs in pathology is also present in PSRs. Indeed, 13.7% of PSRs attended PPMS as a fallback solution, while only 42% considered PPMS as their first choice. Survey for PSRs identified several motives of dissatisfaction. The answers provided by the residents in the survey showed that the main request from the PSR is frontal teaching (52.9%). This data indicates that trainees do not consider individual study and practical activity enough to acquire adequate competence. Indeed, considering the technological proposals, the greatest success was obtained by those focused on teaching (multimedia teaching or interactive monographic courses). Thus, while many of the interviewees attended the last years of PPMS, 17.6% still consider PPMS as a fallback solution and about 3.9% intend to try the admission test for other PGMSs again. Other aspects the residents noted to improve were the possibility to actively participate to cytology activities and in multidisciplinary groups. In addition, they seem very interested to be involved in research projects.

Conclusions

Our results indicated some aspects mainly linked to the lack of Italian trained pathologists. In fact, if MCSs do not know the real clinical importance of pathology, on the other hand most of PSRs believe that PPMS should improve their skills to enter work as trained specialists.

The solution emerging from this survey included a renewal of teaching to highlight the important role change of the pathologist, increasingly involved in the clinical-care process. More innovative and interactive teaching modules should be introduced to capture the interest of the students and emphasize the clinical-therapeutic aspects of surgical pathology. PSRs should be introduced in a clear and structured learning path able to lead them at a level of consciousness harmonized with the skills required of trained pathologists by the requirements of the modern healthcare system.

ACKNOWLEDGEMENTS

The authors would like to thank students and residents who participated in the surveys.

CONFLICTS OF INTEREST

The authors declare that they have no competing interests.

FUNDING

No funding to declare

AUTHORS’ CONTRIBUTIONS

GDA contributed to concept design, data analysis, manuscript editing and preparation; SL and EC contributed to data analysis and literature search; RF contributed to concept design and manuscript review; AR contributed to definition of intellectual content and manuscript review.

ETHICAL CONSIDERATION

The research was conducted ethically, with all study procedures being performed in accordance with the requirements of the World Medical Association’s Declaration of Helsinki.

Informed consent was obtained from each participant for study participation and data publication.

Figures and tables

Figure 1.Shortage of pathologists all over the world have caught the attention of world media.

Figure 2.Survey for MCS.

Figure 3.Survey for PSR.

Figure 4.Survey for MCS - Features of participants.

Figure 5.Survey for MCS - Participants ‘interest for surgical pathology.

Figure 6.Survey for MCS - Participants’ knowledge about surgical pathology.

Figure 7.Survey for PSR - Features of participants.

Figure 8.Survey for PSR - Opinion of Participants.

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