Adaptations of Pathology Residencies During COVID-19

Pathology is the medical discipline that provides essential diagnostic information to patients and clinicians. In United States (US), to become a pathologist, a candidate must satisfactorily complete education in an accredited medical school and a minimum of three years in an approved pathology residency. Most pathology residents choose to study both clinical and anatomical pathology (CP and AP) which adds an additional training year.

The University of Missouri-Kansas City School of Medicine (UMKC) combined anatomic and clinical pathology program is a four-year program having a total of eight residents. Unless specified differently, references are to this program. The anatomic division includes tissue evaluation via daily in-person slide reviews on a double-headed microscope, in-house autopsy service, pediatric pathology at nearby Children’s Mercy Hospital, outside forensic autopsies at the Jackson County medical examiner’s office. Cytology is taught by participating in ultrasound-guided fine needle procedures. In the clinical division residents engage in group resident-attending discussions, laboratory rounds, and off-site rotation at the Community Blood Center. Residents rotate in cytogenetics and pediatric pathology at Children’s Mercy Hospital and hematopathology and microbiology at St. Luke’s hospital, both in Kansas City.

On March 11, 2020, the World Health Organization declared COVID-19 a pandemic, and hospitals started postponing elective surgeries and implemented social distancing. Pathology departments around the country adopted innovative methods to provide a high level of service to their physicians and patients while still delivering quality medical education. Alternatives were sought to adapt hands-on, collaborative learning during the pandemic. Training programs faced common and disparate challenges. Collectively these adaptations worked well during the pandemic and some will be incorporated into post-pandemic education.

Many pathology programs implemented distant slide review via whole scan imaging scanner,^{1, 2} or via telephone/email,³ while other programs used plexiform barriers on multiheaded microscopes.⁴Virtual teaching was used in some pathology residency programs.^1–3,5–9 Others used a hybrid model, alternating between on-site and remote anatomic training.¹⁰ Large surveys of teaching institutions were conducted; the majority of the responders agreed on the negative impact of COVID on the teaching/learning process.^{3, 4} The full impact of the pandemic on some programs is indeterminate.^{1, 5} There were some positive aspects of the pandemic, including higher resident involvement in research, increased interaction with laboratory managers and CP teaching faculty,⁸ and improvement of skills in using digital pathology.¹⁰ Our pathology program adopted distant learning modalities through various formats and platforms to avoid pandemic-related educational deficiencies.

Survey of Pathology Residency COVID Adaptations

This study reports the adaptations of pathology teaching programs during the COVID pandemic and the strategies used to overcome them. We surveyed our current pathology residents and reviewed the literature on strategies other programs used and assessed effectiveness.

Methods

We have summarized measures taken to minimize virus transmission by the UMKC hospitals and pathology department. We reviewed the literature using PubMed and Google Scholar. We conducted a survey among our pathology residents to assess the impact of the COVID pandemic on their training, social lives, and mental health. We used a questionnaire with open-ended questions, all residents completed the survey within two weeks (Figure 1).

Figure 1.

UMKC Pathology Intradepartmental Questionnaire

Findings

COVID globally overwhelmed healthcare systems including pathology teaching programs and clinical services.¹¹ We present the results of our research in these categories: A) measures taken by hospitals and pathology department; B) an intradepartmental survey; and C) a review of literature.

COVID Adaptations

New measures implemented at UMKC hospitals included mandatory use of personal protective equipment (PPE), cancellation of elective surgical procedures, restriction of patient visitors, mandatory COVID tests on all patients, screening of employees for COVID symptoms or exposure, and mandatory leave for ill employees.

In the UMKC pathology department, outside rotations e.g., blood bank and forensic pathology, were cancelled and residency interviews were conducted virtually.

We temporarily switched to on-the-phone slide reviews instead of traditional one-on-one sessions. All in-person activities like daily didactics and tumor conferences were conducted via online Zoom meetings. Organizations such as the College of American Pathologists and the United States and Canadian Academy of Pathology offered resident lectures for home use.^{12, 13} Our program provided learning materials to residents such as downloadable lectures and question banks.

Due to lack of full room ventilation, our institution quickly began a policy of hospital autopsies only on patients with a known negative COVID status.

Intradepartmental Survey Results

We conducted the intradepartmental survey via questionnaire in summer 2022. Most of our residents reported negative impacts on their personal and professional lives (Figure 2).

Figure 2.

Results of UMKC Pathology Intradepartmental Survey

Review of Literature

Other pathology residency programs took different measures to manage education and patient care during the pandemic. These measures included whole slide imaging (WSI) via scanners for personal learning, slide conferences, and didactic learning sessions,¹ Others used a combination of in-person teaching with plexiglass barriers at a multiheaded scope and remote teaching using a camera attachment, enabling remote learning and real time feedback to the lecturers.⁵

A majority of 261 pathology trainees, program directors, and faculty reported that an increase use of digital pathology had adversely affected the quality and effectiveness of their teaching.³

At the Ohio State University Wexner Medical Center (OSUWMC) in Columbus, Ohio, the digital slide workflow was already in place when the pandemic happened, and their transition to pure digital sign-out was easy and smooth. The residents were exposed to the same number of cases as pre-pandemic.² A national survey on Spanish pathology residents reported a reduction in workload and learning activities as a negative impact on their training.⁴ The University of Toronto pathology program adopted similar methods and started a citywide weekly “Virtual Gross Round,” “Virtual Autopsy Round,” and an online resident in-house exam. Their survey with 20 participants reported a negative impact on their education. They concluded that virtual learning is as effective as in-person learning, but skill and attitude are best acquired through in-person teaching.⁶

Another study in a dermatopathology training program found some benefits to virtual teaching such as quantitative increase in online lectures, flexibility in time and place, and a larger pool of presenters. Other benefits were spending more time with family, more self-study time, and being away stressors in the conventional resident’s life. Negatives responses toward virtual education included reduced visual prompts, fewer audience responses, reduced non-verbal communication, social isolation, and limitations in elective rotations.⁷

The Department of Pathology at Houston Methodist Hospital redeployed the trainees from the AP service into various laboratories and CP services allowing them to work with the managers and CP faculty. They also provided trainees with some unique opportunities such as participation in the development and continuous quality improvement of COVID testing. They reported that virtual meeting tools have become crucial for communication, educational activities, and potentially improved research.⁸

In a study at Aga Khan University Hospital in Pakistan, all academic sessions like slide seminars and journal clubs were conducted virtually via Microsoft Teams during the pandemic. They held monthly resident exams through Google Docs. They reported an overall positive experience, and concluded the pandemic was an opportunity for new paths for residency education and discarding some traditional old methods.⁹

At the University of Texas MD Anderson Cancer Center, Houston, they transitioned to a hybrid on-site and remote anatomic training, in which fellows alternated weekly between working remotely and working on-site. A survey conducted among the fellows concluded the hybrid method was effective in maximizing learning opportunities while maintaining the safety of staff and community.¹⁰

Brown University found that the involvement and responsiveness of the audience were affected by the transition to remote teaching due to imperfect internet connectivity, audio problems, interruptions due to unintended activation of computer “sleep mode,” poor sound quality, and limited viewing due to small screen size, and a plethora of incidental distractions.¹⁴

The overall pros and cons of the different measures taken for pandemic-related education are summarized in (Figure 3) and other effects on life aspects in (Figure 4).

Figure 3.

Pros and Cons of Modifications in Residency Training Education during the COVID Pandemic Regarding Online Video/Virtual Microscopy Conferences

Figure 4.

Pros and Cons of the Social, Financial, and Pandemic-Related Changes

Conclusion

Most UMKC pathology residents reported a negative impact of the COVID on residency training and their personal life. The new virtual learning modalities were partially effective and reduced the pandemic impact. COVID adaptations allowed residents to find personal and professional growth and new ways of self-education. Our clinical and learning environment adapted to the new modalities which are efficient and effective. Virtual activities will remain. COVID adaptations and experiences were similar among a survey of other medical teaching institutions. The full impact of the COVID-19 pandemic on residency training and patient care will not be fully understood for many years.