Perceived readiness for practice of current and former anatomic pathology residents in Tanzania

Abstract

One of the proposed primary barriers to high-quality pathology services in Sub-Saharan Africa has been the variability in pathology training. In this study, we evaluated the perceived readiness for practice of current and former anatomic pathology residents at Muhimbili University of Health and Allied Sciences in Tanzania. An online survey evaluating perceived readiness in the ability to perform core professional competencies in anatomic pathology was distributed to previous and current Muhimbili University of Health and Allied Sciences pathology residents. The survey had 30 of 45 (67%) respondents, which included current and former residents. More than 95% of participants either strongly agreed or agreed that the Muhimbili University of Health and Allied Sciences training program prepared them to perform grossing, surgical pathology report writing, fine-needle aspiration, and effective interdisciplinary consultation. Fewer participants were confident in activities related to laboratory management. The program's major strength was the exposure to a large number of cases, while weaknesses included a small number of faculty, insufficient mentorship, and limited infrastructure. Current and former trainees of the Muhimbili University of Health and Allied Sciences pathology residency program overall felt that their training prepared them for independent clinical practice. Additional training in laboratory management should be considered.

Introduction

One of the primary barriers to robust pathology services in Sub-Saharan Africa (SSA) has been the variability in the quality and structure of pathology training.¹ Training programs in anatomic pathology across the region differ widely in several aspects, including case load, curriculum design, methods of resident evaluation, and the availability of faculty with subspecialty expertise. For example, some training centers encounter a high volume of diagnostic cases, while others suffer from limited specimen throughput, which affects the breadth of resident exposure and hands-on experience.² To address these inconsistencies, the College of Pathologists of East, Central and Southern Africa was formed in 2010 and the development of a standardized curriculum was completed in 2018.³ However, the implementation of this curriculum varies across institutions, and gaps persist in areas such as the availability of subspecialty rotations. Furthermore, assessment strategies for residents are not uniform—ranging from logbooks and continuous assessments to final oral and practical exams. Compounding these issues is a shortage of faculty with specialized training, leading many programs to rely on general pathologists, which can limit resident exposure to disciplines like neuropathology or dermatopathology.^2,3

Muhimbili University of Health and Allied Sciences (MUHAS) in Dar es Salaam, Tanzania, is one of the country's premier academic institutions for training healthcare professionals. The MUHAS anatomic pathology residency was founded in 1988 and was the only program until the launch of Tanzania's second anatomic pathology residency program in 2020 at The Catholic University of Health and Allied Sciences—Bugando. Therefore, the vast majority of pathologists practicing in Tanzania, and many in the East African region, were trained at MUHAS. Competency-based medical education (CBME) has increasingly been adopted by medical training programs worldwide to prepare healthcare professionals to address local public health priority areas and is defined as “an outcomes-based approach to the design, implementation, assessment, and evaluation of medical education programs, using an organizing framework of competencies” by the International CBME Collaborators.^4,5 In 2008, MUHAS partnered with the University of California, San Francisco to change the curricula of all of its accredited training programs from knowledge-based to competency-based with the goal of ensuring that graduates are equipped with specific professional competencies to address the medical needs of the country's population.⁶ The Tanzania Commission for Universities (TCU) accredited the new curricula in September 2011, and faculty started implementation in October 2011.⁶

Entrustable professional activities (EPAs) were first proposed in 2005 and are “units of professional practice, defined as tasks or responsibilities, to be entrusted to the unsupervised execution by a trainee once he or she has attained sufficient specific competence.“⁷ Entrustable professional activities have been suggested as a more objective and concrete means for evaluating trainees by translating competencies into discreet and well-defined tasks required for a specialty's practice.⁴ In 2017, the College of American Pathologists (CAP) Graduate Medical Education (GME) Committee published a list of 19 EPAs, including 7 for anatomic pathology, 4 for clinical pathology, and 8 that apply to both anatomic and clinical pathology.⁴ Entrustable professional activities are flexible and can be adapted to the specific needs of individual programs, which is an important consideration when applying frameworks developed for high-resource settings to low-resource settings. In this study, we conducted a survey of current and former anatomic pathology residents of MUHAS to determine the attitudes on whether their training prepared them to carry out critical pathology EPAs independently and to identify any potential gaps. The survey was based on the EPAs recommended by the CAP GME Committee. Improving pathology residency is critical for several reasons, including enhancing diagnostic accuracy, ensuring adherence to quality assurance practices, as well as promoting research which can in turn improve patient care.

Materials and methods

Study setting

The study was conducted at MUHAS in Dar es Salaam, Tanzania, in 2022. The MUHAS anatomic pathology residency has had a range of 3–7 residents per year since 2013, 1–2 residents per year from 2009—2013, and 0–1 residents between 1988 and 2008. At the time of the survey, there was only one other pathology residency program in Tanzania at Bugando Medical Center, but it was only recently established and did not have any graduates yet. The MUHAS department of anatomic pathology has 6 faculty, which includes three full-time faculty, two adjunct faculty, and one faculty member on contract. None of the faculty members had formal subspecialty training. Muhimbili University of Health and Allied Sciences has trained 42 residents between 1988 and 2022.

The anatomic pathology residency is a three-year Masters of Medicine program composed of 6 semesters. The curriculum includes a range of courses in the basic sciences, epidemiology, biostatistics, systems-based pathology, laboratory techniques, and autopsy medicine across the 6 semesters. Courses in Epidemiology and Research Methodology, Biostatistics, Bioethics and Professionalism, and Molecular Biology are mandatory and are offered during the first and second semesters of Year 1. They are delivered through a blended learning approach comprising of lectures, faculty-led seminars, assignments, independent study, and practical workshops. Successful completion of these courses is a prerequisite for initiating the residency program's required dissertation research proposal. System-based pathology courses are taught throughout the 6 semesters using a combination of scheduled lectures or faculty-moderated seminars and practical skill sessions, as well as ad hoc teaching, including the review of pathology cases, fine-needle aspiration clinic, and autopsy. Basic and advanced histology and cytology methods are also covered through practical laboratory sessions.

Clinical rotations begin during the second semester at the Central Pathology Laboratory (CPL) at Muhimbili National Hospital (MNH), a national referral hospital and the teaching hospital affiliated with MUHAS. At the time of the survey, MNH receives more pathology specimens than any other institution in Tanzania, with approximately 12,000 surgical specimens and 6000 cytology specimens in a year. There are no duty hour restrictions for residents in Tanzania.

Trainees are rigorously evaluated and given feedback during their training. For structured coursework, trainees complete a logbook and continuous assessment examinations. Trainees are supervised during their clinical rotations and given ongoing verbal feedback throughout their residency. In addition to written and practical examinations, each assignment given to the resident is accompanied by a formative assessment. For example, there are specific checklists and scoring keys tailored to the type of activity—such as seminar or journal club presentations, routine surgical pathology case reporting, and autopsy performance. The average cumulative scores obtained from these assessments contribute to continuous assessment, which accounts for 50% of the final grade. The MUHAS postgraduate guidelines also include a progress report evaluation form which must be completed by end of each semester. Each resident will also meet with their supervisor for an informal review once per semester. At the end of each semester, the final grades are published on the Student Academic Registration Information System, an online platform that functions as a student portal.

The TCU also mandates that all postgraduate students submit a dissertation accompanied by a manuscript draft as a prerequisite for the master's degree. This requirement likely contributes to the observed interest in research among postgraduate students. The residents work with at least two supervisors who advise them throughout the study and receive a small amount of funds to subsidize completion of their study. Although funding to support research is limited, trainees are encouraged to submit abstracts to local, national, and international research meetings. However, few residents publish their dissertations in peer-reviewed journals. Several factors contribute to the low publication rate among both residents and practicing pathologists, including high publication fees and the lack of direct benefit for non-academic pathologists.^8,9

Study design

We not only designed a 23-question survey based on the EPAs recommended by the CAP GME Committee for anatomic pathology but also included targeted questions related to demographics and research. Attitudes on how well their training prepared them for particular EPAs as well as research were scored on a five-point Likert scale (1 = strongly disagree; 5 = strongly agree). Two open-ended questions regarding the strengths and weaknesses of the training program were also included.

All former and current trainees who had enrolled in the anatomic pathology residency program between 1988 and 2022 at MUHAS were invited to participate. Residents in their first semester were excluded because they do not begin their clinical rotations in anatomic pathology until their second semester.

The survey was distributed to former and current trainees via e-mail using an online survey platform (Google Forms, Mountain View, CA) in October 2022, and the survey link was active for approximately 6 weeks. The e-mail contained an informational statement explaining the purpose of the survey and that participation was voluntary and all responses were anonymous. All participants provided consent to participate. This project received a waiver from the institutional review board at Memorial Sloan Kettering Cancer Center because it was a component of a quality improvement initiative.

Results

Participant demographics and backgrounds

A total of 45 current and former trainees were invited to participate by e-mail. There were 30 of 45 (67%) individuals who responded to the online survey, of whom 37% (11/30) were women and 63% (19/30) were men (Table 1). Most of the participants were Tanzanian (80%, 24/30). The current primary positions of the respondents included non-academic staff pathologists at a public hospital (27%, 8/30), academic pathologists at a university (27%, 8/30), staff pathologists at a blended private/public hospital (10%, 10/30), one participant (3%, 1/30) who was both an academic pathologist at a private university and staff pathologist at the affiliated hospital, and current residents (10/30, 33%). Most graduates were primarily practicing in Tanzania (23/30, 77%), with others practicing in Rwanda (13%, 4/30), Botswana (3%, 1/30), Swaziland (3%, 1/30), and Namibia (3%, 1/30). Among those who had completed their training, most participants had graduated in the past 5 years (80%, 16/20); one respondent graduated more than 20 years prior (5%, 1/20). For current trainees, most participants reported that they were in their 5th semester (80%, 8/10), with one in the 3rd semester (10%, 1/10) and one who declined the respond (10%, 1/10). The vast majority indicated that their long-term career goal was to practice a mix of diagnostic pathology and research (23/30, 77%). Data on the participants’ are summarized in Table 1.

Table 1.

Characteristics and career aspirations of study current and former Anatomic Pathology trainees at Muhimbili University of Health and Allied Sciences.

Characteristic	Responses (n = 30)
Sex
Male	19 (63%)
Female	11 (37%)
Nationality
Tanzanian	24 (80%)
Rwanda	5 (17%)
Swaziland	1 (3%)
Current primary position
Resident	10 (33%)
Staff pathologist at public facility (non-academic)	8 (27%)
Academic pathologist at a university	8 (27%)
Staff pathologist at a blended public and private facility	3 (10%)
Academic at a private university and staff pathologist at affiliated hospital	1 (3%)
Staff pathologist at private facility	0 (0%)
Years since graduation
0–3	11 (37%)
3–5	5 (17%)
5–10	3 (10%)
>10	1 (3%)
Not applicable (current residents)	10 (33%)
Primary country of practice
Tanzania	23 (77%)
Rwanda	4 (13%)
Botswana	1 (3%)
Swaziland	1 (3%)
Namibia	1 (3%)
Long-term career plan and aspiration
Practice a mix of diagnostic pathology and research	24 (80%)
Practice pathology at a private practice	3 (10%)
Practice pathology at a public referral hospital	2 (7%)
Undecided	1 (3%)
Research only	0 (0%)

Attitudes of former and current trainees on the MUHAS anatomic pathology residency

The survey contained 14 questions based on the CAP GME EPAs for anatomic pathology. Entrustable professional activities on intraoperative consultations and frozen section interpretation, as well as rapid onsite evaluation for cytologic specimens were excluded since these are not a component of routine anatomic pathology practice in Tanzania. Graduates of the program were asked how well they felt that their residency training at MUHAS prepared them to carry out each EPA (Table 2). All graduates (20/20, 100%) felt that they were able to compose a complete diagnostic report for surgical pathology specimens, while 90% (18/20) felt that they were able to compose a diagnostic report for cytopathology specimens. For the ability to perform a medical autopsy, 85% (17/20) agreed or strongly agreed that their training was adequate. Fewer participants felt that their training prepared them for EPAs related to laboratory management. There were 16 of 20 (80%) individuals who felt that their training enabled them to optimize test utilization, while 85% (17/20) felt they acquired sufficient skills on how to analyze individual and laboratory practice to improve the quality of care and patient safety. Only 75% (15/20) of respondents stated that they would be able to evaluate and choose a new assay or instrument for the laboratory, 70% (14/20) would be able to implement the new assay or instrument, and 60% (12/30) would be able to serve as a laboratory inspector for an accrediting organization. In regards to conducting research, most participants (100%, 20/20) either agreed or strongly agreed that they would be able to independently write a proposal and complete a research project. When evaluating the responses of current trainees, the results were similar (Table 3).

Table 2.

Survey responses from graduates of the anatomic pathology residency program at Muhimbili University of Health and Allied Sciences.

Question prompt	No response	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
1. Gross specimen and submit relevant tissue sections	0 (0%)	0 (0%)	0 (0%)	1 (5%)	2 (10%)	17 (85%)
2. Compose a written diagnostic report for surgical pathology specimens	0 (0%)	0 (0%)	0 (0%)	0 (0%)	8 (40%)	12 (60%)
3. Compose a written diagnostic report for cytology specimens	1 (5%)	0 (0%)	1 (5%)	0 (0%)	10 (50%)	8 (40%)
4. Perform fine-needle aspiration biopsy	0 (0%)	0 (0%)	0 (0%)	0 (0%)	3 (15%)	17 (85%)
5. Perform a complete medical autopsy	0 (0%)	0 (0%)	0 (0%)	3 (15 %)	7 (35%)	10 (50%)
6. Evaluate and manage issues related to pre-analytical phase of testing	0 (0%)	0 (0%)	1 (5%)	1 (5 %)	11 (55%)	7 (35%)
7. Provide diagnostic opinions and clinical expertise in interdisciplinary settings	0 (0%)	0 (0%)	0 (0%)	0 (0%)	10 (50%)	10 (50%)
8. Provide timely and effective consultations in response to provider inquiries	0 (0%)	0 (0%)	1 (5%)	1 (5 %)	6 (30%)	12 (60%)
9. Apply test utilization data to best deploy institutional resources and provide better patient care	0 (0%)	0 (0%)	1 (5%)	3 (15 %)	7 (35%)	9 (45%)
10. Analyze individual and laboratory practice to improve quality of care and patient safety	0 (0%)	1 (5%)	1 (5%)	1 (5 %)	12 (60%)	5 (25%)
11. Evaluate and choose new assays, test systems, and instruments for pathology laboratory	0 (0%)	0 (0%)	2 (10%)	3 (15%)	9 (45%)	6 (30%)
12. Oversee implementation of new assays, test systems, and instruments	0 (0%)	0 (0%)	3 (15%)	3 (15%)	11 (55%)	3 (15%)
13. Serve as laboratory inspectors as part of the peer inspection process for accrediting organizations	1 (5%)	1 (5%)	1 (5%)	5 (25%)	7 (35%)	5 (25%)
14. Write a proposal and complete a research project	0 (0%)	0 (0%)	0 (0%)	0 (0%)	9 (45%)	11 (55%)

Table 3.

Survey responses from current trainees in the anatomic pathology residency program at Muhimbili University of Health and Allied Sciences.

Question prompt	No response	Strongly disagree	Disagree	Neutral	Agree	Strongly agree
1. Gross specimen and submit relevant tissue sections	0 (0%)	0 (0%)	0 (0%)	0 (0%)	5 (50%)	5 (50%)
2. Compose a written diagnostic report for surgical pathology specimens	0 (0%)	0 (0%)	0 (0%)	0 (0%)	7 (70%)	3 (30%)
3. Compose a written diagnostic report for cytology specimens	0 (0%)	1 (10%)	1 (10%)	1 (10%)	6 (60%)	1 (10%)
4. Perform fine-needle aspiration biopsy	0 (0%)	1 (10%)	0 (0%)	0 (0%)	5 (50%)	4 (40%)
5. Perform a complete medical autopsy	0 (0%)	1 (10%)	1 (10%)	2 (20%)	6 (60%)	0 (0%)
6. Evaluate and manage issues related to pre-analytical phase of testing	0 (0%)	0 (0%)	0 (0%)	0 (0%)	9 (90%)	1 (10%)
7. Provide diagnostic opinions and clinical expertise in interdisciplinary settings	0 (0%)	0 (0%)	0 (0%)	2 (20%)	6 (60%)	2 (20%)
8. Provide timely and effective consultations in response to provider inquiries	0 (0%)	0 (0%)	0 (0%)	0 (0%)	9 (90%)	1 (10%)
9. Apply test utilization data to best deploy institutional resources and provide better patient care	0 (0%)	0 (0%)	1 (10%)	1 (10%)	6 (60%)	2 (20%)
10. Analyze individual and laboratory practice to improve quality of care and patient safety	1 (10%)	1 (10%)	1 (10%)	1 (10%)	4 (40%)	2 (20%)
11. Evaluate and choose new assays, test systems, and instruments for pathology laboratory	0 (0%)	1 (10%)	2 (20%)	2 (20%)	4 (40%)	1 (10%)
12. Oversee implementation of new assays, test systems, and instruments	1 (10%)	1 (10%)	2 (20%)	2 (20%)	4 (40%)	0 (0%)
13. Serve as laboratory inspectors as part of the peer inspection process for accrediting organizations	0 (0%)	0 (0%)	1 (10%)	0 (0%)	6 (60%)	3 (30%)
14. Write a proposal and complete a research project	0 (0%)	0 (0%)	1 (10%)	0 (0%)	6 (60%)	3 (30 %)

Participants commented on the strengths and weaknesses of the program. The comments were similar for both current residents and graduates of the program and are summarized in Table 4. The primary strength noted by many participants was the exposure to a large number and wide breadth of cases. One respondent stated “Being at the national hospital, the … training program has access to extremely precious, abundant/large volume and constant inflow of diverse surgical pathology specimens.” Conversely, some felt that the high case volume hindered the ability of residents to learn. One participant stated that there was “too much workload for residents [and] therefore little time for studies,” while another stated that the residency consisted of “many hours of hospital work with less structured, academic value.”

Table 4.

Reported strengths and weakness of the MUHAS anatomic pathology residency program.

Themes	Subthemes
Strengths	•Exposure to a large number and wide breadth of cases •Trainees heavily involved in the clinical work
Weaknesses	•Lack of structured curriculum •Small number of faculty with limited subspecialty training •Limited active teaching and hands on instruction, including grossing and autopsy •High workload with prolonged working hours •Inadequate training tools, equipment, and environment •Limited research mentorship and research funding for resident projects

MUHAS: Muhimbili University of Health and Allied Sciences.

Areas for improvement that participants mentioned primarily focused on the low number of faculty available to support the training program and the need for better training tools and equipment. Many mentioned that the insufficient number of faculty led to a “lack of individual mentorship and active teaching with objective assessment of progress to … address any issues or trainee weaknesses” and that there was “inadequate/or lack of … subspecialty faculty.” Some also felt that there was “poor direct hands-on skills training” and that “not having enough lecturers to run the residency program leads to poor planning and disorganization.” One individual stated that “training equipment such as microscopes are not enough … currently we have only one regular microscope and recently two donated bihead microscopes.” Other respondents noted the “absence of [a] comprehensive pathology library,” including slide teaching sets, and a “lack of … Wi-Fi.” Because of the lack of institutional Wi-Fi, trainees pay out of pocket for personal internet plans so that they can access online educational materials. More than one participant stated that the morgue had “poor infrastructure” and that there were “concerns of biohazards in learning autopsy.” One individual observed that there was a “shorter duration on lab management and quality assurance skills acquisition” which “is usually during [the] final year when there is a lot to be accomplished,” suggesting that there was relatively less focus on lab management.

Discussion

This study explores the self-perceived readiness for practice of previous and current trainees in the MUHAS anatomic pathology residency program. The overall goal was to assess for potential areas of improvement in the training program based on the EPAs developed by the CAP GME.⁴ Entrustable professional activities break down a specialty's practice into well-defined tasks and responsibilities that all practitioners are expected to be able to carry out independently after completion of their training and provide a structured framework for not only assessing trainees but also evaluating programs.

Most respondents felt that by end of their pathology residency programs, they had acquired competency in a broad range of EPAs including grossing, generating complete reports for surgical pathology specimens, performing fine-needle aspiration biopsies, provide support for interdisciplinary conferences, and conducting research. In terms of diagnostic practice, the only major area of weakness that was noted was the ability to generate cytology reports. A similar observation was made in a study evaluating resident satisfaction of a program in Sudan, in which 73% were satisfied with their cytology skills compared to 86% who were satisfied with their surgical pathology skills.¹⁰ The finding that most respondents were confident in their research skills contrasts with a prior study of MUHAS oncology trainees who reported a lack of adequate training and mentorship in research as well as prior publications noting a comparatively low number of cancer research publications from East Africa.^8,9,11 However, similar to the study of MUHAS oncology trainees, our study corroborates the desire to incorporate research into their careers.

The survey showed that fewer participants felt that their training prepared them for EPAs related to laboratory management, including how to choose a new test or instrument, how to implement a new assay, and how to perform a laboratory accreditation inspection. This may be explained by the fact that the resident curriculum has few total seminar and lecture hours allocated to laboratory management and that most of the teaching sessions are conducted by external guest speakers and not faculty members who are not readily available. Moreover, while the clinical pathology laboratory at MNH's CPL has been accredited by the Southern African Development Community Accreditation Services in accordance with International Standard ISO 15189:2012 since 2014, the anatomic pathology laboratory is not accredited.¹² This difference in accreditation status is partly attributable to the prioritization and resources made available by the government and international funding agencies and donors to optimize testing for human immunodeficiency virus (HIV) and other communicable diseases and, therefore, the overall quality and infrastructure in the clinical laboratory. As a result, the anatomic pathology faculty themselves may not be familiar with critical quality management requirements needed for accreditation. Therefore, a dedicated effort to train faculty in quality management and develop a practical curriculum for residents is needed. This training and curriculum development can be facilitated by partnerships with other local or international accredited laboratories or through professional societies.

Respondents reported that the main strength of the residency program was the exposure to a large number and wide breadth of cases and that residents were integral parts of the clinical work at MNH. This strength is particularly important as MUHAS is a premier training hub and receives a range of students from East, Central, and South Africa for pathology residency. For example, an article describing pathology services in Nigeria noted that the surgical pathology specimen volume was insufficient to adequately train residents.¹³ Therefore, the comparatively high volume of cases at MNH CPL provides trainees with the opportunity to be exposed to a variety of disease entities and gain competence in pathology diagnosis. However, the higher workload was also perceived as a limiting factor for optimal learning and is an observation also noted in a study of pathology residents in Turkey.¹⁴ One weakness in the training program included the small number of faculty who also had limited subspecialty training. At the time of the survey, MUHAS had three fulltime faculty, none of whom had formal sub-specialty training. Residents also receive clinical training from MNH CPL, which has 8 pathologists. Two of those pathologists at MNH have formal subspecialty training—one in renal pathology and the other in dermatopathology. The low number of pathologists and lack of sub-specialization has been observed throughout SSA and is in part caused by a shortage of training programs.1, 2, 3 Because of the small number of pathologists and the heavy clinical and administrative workload, many participants reported limited access to individual mentorship, insufficient hands-on teaching for grossing and autopsy, as well as a feeling of disorganization for how the program was run. Strong mentorship is a critical component of supporting the growth and success of physicians. Mentorship can facilitate professional development and increase career satisfaction, particularly for those in academic medicine.15, 16, 17, 18, 19 Additional weaknesses are related to the limited infrastructure, including sufficient microscopes, reliable internet access, access to educational materials such as textbooks and academic journals, and facilities with robust biosafety, which have been described in other laboratories in SSA.^1,2,20,21 Suggestions to overcome some of these limitations include inter-institutional collaborations, virtual training courses, as well as harmonization of training programs across countries.^2,22, 23, 24 Inter-institutional partnerships can provide access to resources, such as experts in quality management or other topics, but may not be readily available locally. Virtual training courses can provide additional training in subspecialty topics, while establishing cross-regional curriculum and competency assessments can ensure that pathology residents all receive comparable and high-quality training.

Limitations for this study include the potential for selection bias. While MUHAS maintains an e-mail list of former and current trainees, some former trainees may not have received the invitation to participate. Moreover, some graduates may have had a greater interest in improving the pathology program at MUHAS and therefore were more likely to respond. For example, there were no respondents who primarily worked in a private laboratory. Moreover, the MUHAS pathology residency curriculum has evolved over time, with a major overhaul in 2011. However, most of the respondents were current trainees or graduates within the last 5 years, with only one trainee who attended the program prior to 2011. Therefore, the survey likely represents more recent experiences with the residency program. It is unclear why engagement by more remote alumni was so low. While current residents were invited to participate in the survey, they may not be aware of how well their program has prepared them either because they have not completed their training or because they have not been expected to practice entirely independently. However, the responses between current trainees and graduates were similar.

Conclusions

This study provides insights into the strengths and weaknesses of the anatomic pathology residency program at MUHAS. While graduates and current residents feel that the program prepares them to perform most EPAs independently and confidently, areas that need improvement include laboratory management, the number of faculty, availability of mentorship, the frequency of hands-on teaching, availability of microscopes, and access to up-to-date educational materials such as textbooks and journals. Overall, current and former trainees feel that their training at MUHAS prepares them for pathology practice.

Authors' contributions

DLN and EV conceptualized and designed the study. EV conducted the data collection. DLN and AHK analyzed the data and wrote the original draft of the manuscript. AHK, DLN, and EV reviewed and edited subsequent drafts of the manuscript. All authors read and approved the final manuscript.

Funding

This work was in part supported by the National Institutes of Health (NIH) Fogarty International Center and National Cancer Institute (NCI) (D43TW011598, AHK), NCI (K08CA263299, DLN), and Cancer Center Support Grant (P30CA008748, DLN).

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.