Perceived gaps in preparation for pathology residency and opportunities for improvement

Abstract

The transition from medical school to residency is both a transformative and a challenging process. International literature suggests that there are known or perceived gaps in preparation for residency training in many areas of medicine. However, in the current published literature, there is no discussion of perceived gaps existing in pathology residency preparation. This study surveyed both pathology residency program directors and first-year pathology residents about the knowledge of pathology and basic medical skills residents received in medical school, perceptions about readiness for pathology residency, and perceived gaps in preparation for pathology residency that could be addressed. This survey found that program directors perceived that residents were more prepared for pathology residency than the residents felt themselves to be. Pathology program directors and residents both perceived that knowledge of normal histology was a weakness. Program directors were significantly more likely than residents to report that weaknesses in the preparation for pathology residency included challenges common to the majority of newly graduated physicians including in gathering pertinent clinical history from the medical record, struggles in identifying system failures, and contributing to a culture of safety, as well as specific challenges for pathology including limitations in basic microscope use. Suggested efforts toward improving preparation for pathology residency could be accomplished through undergraduate and graduate medical education approaches, as well as with increased support from pathology professional organizations.

Introduction

Transition from medical school to residency is an intense and transformative process that presents significant personal and professional challenges. In recent years, medical schools have made changes in their curriculum to attempt to bridge the gap between theoretical knowledge and practical, hands-on clinical experience and to include resilience and wellness training. However, reduced hands-on experiences in areas such as histology, gaps in medical knowledge with decreased pathobiology,¹ and limited exposure to certain specialties and clinical care have raised concerns about the readiness of medical students for residency.

These issues seem to be multidisciplinary and international. A review of the English-language literature suggests that for many medical specialties in different countries, there is a gap in residency preparation. A survey of newly trained doctors from the UK in 2000/2001 reported that only 36.3% of them felt prepared for their first year of clinical practice.² More recent studies from US surgical and obstetrics and gynecology residency programs showed similar findings: inadequate exposure to resident responsibilities in the fourth year of medical school led to recent graduates feeling unprepared or only moderately prepared for practice. Causes of this unprepared feeling were related to less hands-on experience and learning skills that are less patient oriented and more healthcare system oriented (electronic medical record).3, 4, 5

Following the 2000/2001 UK survey, changes were implemented in UK medical schools. The lecture-based medical curriculum with distinct clinical and pre-clinical parts and little integration between different sections was replaced by problem-based learning. The new curriculum emphasized integrating science teaching with clinical exposure. This led to an improvement in medical school graduates’ perception of readiness for residency, with 50.3% in 2003 and 58.5% in 2005 feeling that the medical school experience prepared them well for clinical practice.⁶

Recently, the Coalition for Physician Accountability’s Undergraduate Medical Education-Graduate Medical Education Review Committee recommended specialty-specific, just-in-time training to all incoming first-year residents to enhance resident preparation regardless of the medical school experience.⁷ Medical school reforms including increased mentorships, residency preparation courses at the end of the fourth year of medical school, and transition to residency or mini bootcamp preparation courses (weeks to months long) may help improve the perception of preparedness.8, 9, 10, 11

Limited exposure to pathology during a condensed medical school curriculum may be linked to the decreased understanding of what the pathologist’s duties entail.^12,13 The lack of understanding of pathologist’s duties can create the perception that medical students are poorly prepared to use pathology services in clinical practice or to choose pathology as a career. This, in turn, raises the issue of preparedness for pathology residency. In the current published literature, there is no discussion of perceived gaps in pathology residency preparation. To further explore this issue, the Graduate Medical Education Committee of the College of American Pathologists (CAP) conducted a study to query pathology residency program directors (PDs) and first-year pathology residents. The objectives of this study were to 1. Evaluate the state of preparation of pathology residents following implementation of an integrated curriculum in most medical schools. 2. Evaluate if there were differences based on US vs non-US training in medical school. 3. Establish if PDs and residents had different perceptions regarding readiness for residency. 4. Identify perceived gaps in preparation that may be addressed via enhanced residency orientation and/or medical school curriculum changes. Identifying these gaps will help assist medical schools to comply with the Liasion Committee on Medical Education standard 7, namely, to ensure that the medical school curricula adequately prepare medical students for any residency program.¹⁴

Materials and methods

An 11-question survey was developed to query the perception of pathology residency PDs regarding the current first-year residents’ preparation for the transition to pathology residency. This survey included questions on core medical duties and understanding of normal histology and common diseases, as well as whether a residency orientation was provided. A 25-question survey was developed for the first-year residents that included parallel questions to the PD survey. In addition, residents were asked about their medical school curriculum and other experiences prior to residency training. Some activities referenced in the survey are routinely performed by all resident physicians, while others are performed only by pathology residents. Activities chosen for the survey assess tasks/activities that would be expected of residents within the first 6 months of training. Basic demographic data was collected from both sets of survey respondents. Both surveys are available as Supplemental Material 1. According to the policy defining activities that constitute research at the University of Vermont/University of Vermont Health Network, this work met criteria for a project that does not require IRB review.

Data was collected via anonymous online surveys administered through Research Electronic Data Capture (REDCap) from January 16 to February 12, 2024. The timing of the survey distribution was intentionally chosen to be 6 months into the academic year, consistent with the approach used in the Association of American Medical Colleges Resident Readiness Survey pilot.¹⁵

Contact information for PDs was obtained from the Accreditation Council for Graduate Medical Education list of programs by specialty.¹⁶ PDs received an email inviting their program to participate in the study and requesting assistance in forwarding the resident survey to their current first-year residents. PDs then received a separate email with a link to access the PD survey. A screening question on each survey ensured respondents belonged to the intended group (PD or first-year resident). PDs received weekly emails (3 in total) to remind them to complete the PD survey and ask for their assistance in reminding first-year residents to complete the resident survey.

Because the data are anonymous, PD and resident responses cannot be linked and the institutions they represent are not identifiable. Respondents could skip any question; therefore, the number of respondents to a given question was the denominator used to determine percentages. Independent sample t-tests, one-way analysis of variance, and chi-squared tests were used to compare results between groups of respondents. Statistical analyses were conducted using SPSS Statistics for Windows v25.0 (IBM Corp, Armonk, New York).

Results

A total of 142 PDs were invited to participate and 46 responded, which corresponds to a 32% response rate. Seventy-eight first-year residents responded to the survey. A response rate cannot be computed because the number of first-year residents who received the survey is not known. However, 78 responses represent 13% of the pathology positions filled in the 2023 Main Residency Match.¹⁷ All responses received were included in our results and data analysis. Respondent demographics are presented in Table 1.

Table 1.

Respondent demographics.

Program directors	N (%)
Residency program size (N = 45)
8 or fewer residents	4 (9%)
9 to 16 residents	21 (47%)
17 to 24 residents	12 (27%)
25 or more residents	8 (18%)
Residents
Residency program size (N = 68)
8 or fewer residents	20 (29%)
9 to 16 residents	28 (41%)
17 to 24 residents	15 (22%)
25 or more residents	5 (7%)
Residency training track (N = 68)
AP only	3 (4%)
CP Only	1 (1%)
AP/CP	64 (94%)
AP/NP	0 (0%)
Medical school type (N = 71)
US allopathic	20 (28%)
US osteopathic	19 (27%)
Non-US medical school	32 (45%)

AP, Anatomic Pathology; CP, Clinical Pathology; AP/CP, anatomic and clinical pathology; AP/NP, anatomic pathology/neuropathology.

Overall preparation for residency

Perceptions of preparation for residency were rated on a 5-point scale ranging from Not at All Prepared (1) to Very Well Prepared (5). There was a significant difference in the degree of overall preparation for the first year of residency training as perceived by residents and PDs (M = 3.06 vs 3.63, respectively; t (122) = −3.005, P = 0.003). With respect to preparation for specific activities (see Fig. 1), only three activities showed a significant difference in perception between first-year residents and PDs: “gather pertinent clinical history from the medical record” (M = 4.37 and 4.02, respectively; t (116) = 2.361, P = 0.02), “basic use of a microscope” (M = 3.67 and 3.22 respectively; t (116) = 2.157, P = 0.03), and “identify system failures and contribute to a culture of safety and improvement” (M = 3.37 and 2.80 respectively; t (116) = 3.004, P = 0.003). It is also worth noting that perceived preparation to perform gross dissection was rated the lowest, while perceived preparation to gather pertinent clinical history and to collaborate as a member of an interprofessional team was rated the highest by both first-year residents and PDs.

Fig. 1.

Program director and resident ratings of preparation for specific activities. Five-point scale corresponding to (1) Not at All Prepared, (2) Slightly Prepared, (3) Somewhat Prepared, (4) Mostly Prepared, and (5) Very Well Prepared. ∗P < 0.05; means were compared via independent samples t-tests.

There was no significant difference in overall preparation ratings provided by first-year residents who attended US vs non-US medical schools; however, there were significant differences in perceived preparation for some activities (see Fig. 2). There was no significant difference in perceptions of overall preparation or preparation for specific activities based on medical school type (MD, DO, and non-US).

Fig. 2.

Significant differences in preparation between US and non-US medical school graduates. Five-point scale corresponding to (1) Not at All Prepared, (2) Slightly Prepared, (3) Somewhat Prepared, (4) Mostly Prepared, and (5) Very Well Prepared. All differences shown are significant at P < 0.05; means were compared via independent samples t-tests.

Fifty percent of PDs perceived the level or preparation for the current first-year residents as “about the same” as the entering first-year residents from 5 years ago. Despite this, two themes were identified within the free-text comments from PDs which included: prior pathology experience enhances preparation (7 comments) and observed knowledge gaps were perceived to result from reduced exposure/training in histology and pathology (7 comments).

Histology training

Perceived understanding of normal histology was rated on a 5-point scale ranging from poor (1) to excellent (5). First-year residents and PDs provided comparable ratings (M = 3.11 and 3.13, respectively), and there were no differences in the mean ratings based on medical school histology training format (stand-alone course [N = 36] vs integrated [N = 36]). First-year residents from non-US medical schools rated their perceived understanding of normal histology (N = 32, M = 3.44) significantly higher than those from US medical schools (N = 39, = 2.79), t (69) = −2.670, P = 0.009. First-year residents from non-US medical schools were also more likely to indicate their previous normal histology training as a stand-alone course (72% vs 33% of US graduates, χ² (1) = 10.446, P = 0.001). There is also a significant relationship between the approach to normal histology training and having attended a US vs non-US medical school (χ² (3) = 21.265, P < 0.001; see Fig. 3).

Fig. 3.

Approach to normal histology training.

Anatomy training

Most first-year residents (66%) reported that their anatomy training in medical school was in a stand-alone-course format. Similarly, most first-year residents (62%) reported that their anatomy training in medical school used both digital images and cadaver dissection. There was no significant difference in the format of anatomy training for first-year residents (stand-alone course vs system-based integrated experience) based on medical school location (US vs non-US). There was also no significant difference in the approach to anatomy training (i.e., digital images, cadaver, and combination) based on medical school location.

Basic microscopy

Most first-year residents (66%) reported that they were not taught basic microscopy in medical school. Interestingly, first-year residents from non-US medical schools were significantly more likely to have been taught basic microscopy (53% vs 21% of US medical graduates; χ² (1) = 8.052, P = 0.005). Furthermore, first-year residents from US allopathic medical schools were more likely to have been taught basic microscopy (30%) than first-year residents from US osteopathic medical schools (11%; χ² (2) = 9.681, P < 0.008).

Pathology experience

Perceived understanding of the pathology of common diseases was rated on a 5-point scale ranging from poor (1) to excellent (5). We use the term pathology of common diseases to include pathophysiology, gross and microscopic findings, and laboratory findings of common diseases such as colon cancer or inflammatory bowel diseases. This term can be inclusive of all those aspects or just some of those aspects. First-year residents and PDs provided similar ratings (M = 3.24 vs M = 3.13) with most respondents in both groups rating this as “fair.” Perceived understanding of the pathology of common diseases was also similarly rated when comparing first-year residents from US vs non-US medical schools (M = 3.03 vs 3.50); however, significant differences were observed based on medical school type (MD, DO, non-US; F (2, 66) = 4.616, P = 0.013). Graduates of US osteopathic medical schools rated their perceived understanding of the pathology of common diseases (N=19, M=2.68) significantly lower than did either US allopathic medical school graduates (N = 20, M = 3.35) or non-US medical school graduates (N = 30, M = 3.50).

None of the first-year residents reported completing a post-sophomore fellowship in pathology. However, 29% of residents reported being exposed to pathology during a required clerkship. The most common clerkship that provided exposure to pathology was general surgery (6), with exposure to pathology from internal medicine, obstetrics, and hematology each mentioned 2 times.

There was a wide variability of exposure to different areas of pathology during medical school among first-year residents and variability of exposure depending on whether the resident had attended an allopathic, osteopathic, or non-US medical school (see Fig. 4). For example, most residents had exposure to general pathology, followed by surgical pathology and microbiology, while the least amount of exposure was to informatics. General pathology indicates exposure to any pathology during the clerkship or post-clerkship period. The survey indicates that most medical students did have general pathology experience, mostly in non-US medical schools, and the least pathology experience in osteopathic medical schools. Interestingly, 15% of allopathic medical students had exposure to autopsy, while 28% of osteopathic medical students had exposure to autopsy and 53% of non-US medical students had exposure to autopsy. Differences in exposure were also seen in hematology and microbiology where US allopathic and osteopathic medical students had similar exposures (45% and 44% for hematology and 45% and 50% for microbiology), while non-US medical students had very limited exposure in these areas (17% for hematology and 3% for microbiology).

Fig. 4.

Percent of respondents with medical school exposure (required or elective) to general pathology or a pathology subspecialty area. The most common rotations completed were General Surgical Pathology, while the least common was informatics in osteopathic students.

Recommendations by survey respondents

Recommendations by both first-year residents and PDs to enhance preparation for residency fell into three main categories: enhancing medical school curriculum (40% of PDs and 49% of residents), hands-on/interactive learning experiences during medical school (12% of PDs and 32% of residents), and residency orientation/bootcamp experiences (28% of PDs and 8% of first-year residents).

Discussion

The differences and similarities between the perceptions of PDs and first-year residents provide insights into how efforts toward the transition to pathology residency could be structured. For example, there was a significant difference between PDs’ and first-year residents’ perception of overall preparedness for pathology residency. Program directors perceived that first-year residents were more prepared than the residents felt themselves to be. This could reflect the commonly discussed “imposter syndrome”¹⁸ where trainees may be more apt to doubt their own skills and successes than their PDs. Thus, at the beginning of residency training, PDs may want to reassure first-year residents that their baseline knowledge may be more substantive than they realize it to be.

Similarly, the PDs’ and first-year residents’ perceptions on preparation for specific pathology-related activities can help inform areas of focus in the first few months of pathology residency. Program directors and first-year residents agreed that identifying normal histologic tissue types and structures was a perceived weakness and that PDs would be wise to provide a curriculum that systematically reviews normal histology with their newest trainees. Program directors were significantly more likely than first-year residents to report that the basic use of the microscope was a perceived weakness. As microscope usage is no longer included in many medical school curricula, new pathology residents may not be as cognizant of their microscopy deficits as their PDs. As such, microscopy skills could also be a focus early in pathology residency training. Lastly, PDs and first-year residents agreed that perceived understanding of the pathology of common diseases was “fair,” “good,” or “excellent” in the majority of new pathology trainees. Based on this, the pathology of common diseases might not need to be an area of emphasis in the early months of pathology resident training. Alternatively, it could be strengthened in the undergraduate medical education (UME) curriculum as understanding the pathobiology of common diseases is important for residents of all specialties.¹

Possible systematic efforts toward improving the perception of resident preparation for their career in pathology could be accomplished through both UME and graduate medical education (GME) approaches. Undergraduate medical education efforts could include the incorporation of online resources such as the ABPath Histology Primer¹⁹ into medical school curricula or pathology resident bootcamps (either in UME or in GME) as a review of foundational histology of the organ systems. Resources like ABPath Histology Primer would strengthen histology knowledge for all undergraduate medical trainees, both for those pursuing a career in pathology and those not. Undergraduate medical education leadership could also consider welcoming a pathologist into their curriculum committee to ensure that pathology content is adequately represented throughout the curriculum. If first-year residents matriculating into pathology residencies are insecure in their pathology knowledge base, one can assume that first-year residents matriculating into other specialties are equally, if not more, uncertain about their understanding of pathology. Future research could further explore how first-year residents matriculating into non-pathology residencies perceive their understanding of pathology compared to those residents entering pathology since these latter residents have likely completed electives in pathology which the non-pathology residents have not. As pathology is germane to most areas of medical practice, strengthening UME pathology education could serve to improve UME for students pursuing training in any specialty. The importance of strengthening pathobiology in the UME curriculum for all medical students has been recently discussed in an article about the importance of pathobiology which was published in the New England Journal of Medicine.¹ Another possible resource could be the Pathology Competencies in Medical Education and Educational Cases: Update 2023²⁰ which contains pathology learning objectives felt to be important to all medical students, not just those medical students interested in pathology. These learning objectives are divided into three competencies including Disease Mechanisms and Processes, Organ System Pathology, Diagnostic Pathology and Therapeutic Pathology. Undergraduate medical education programs can use these learning objectives as guides to ensure that the foundational concepts felt to be important for all medical students are adequately covered. A foundational knowledge of pathology is essential for understanding for all physicians, in particular for graduating medical students diagnosing and treating disease, as evidenced by 45–55% of the questions on the step 1 United States Medical Licensing Examination are dedicated to pathology.²¹ In addition, 49% of residents commented that strengthening the UME curriculum would have enhanced their preparation for residency.

Graduate medical education efforts could include structured orientation or first-year resident activities that will (re)introduce topics that pathology trainees should understand or those that they perceive as weaknesses, like those described in the discussion previously. The use of resident onboarding or “bootcamp” experiences to address gaps in preparation for pathology residency has been successfully implemented in some programs,22, 23, 24 and this can serve as a model for GME efforts. Tailoring these introductory programs to meet the needs of pathology’s newest trainees and their perceptions is important for their future success.

Beyond UME and GME efforts, pathology professional organizations could also play a role in preparing residents for pathology residency. Instead of each residency program designing their own introductory educational activities for first-year residents, pathology organizations could explore creating a standardized curriculum that addresses common educational gaps, perceived or real, in matriculating pathology residents. This would serve to ease the burden on each of the residency programs of onboarding new pathology residents. It would also serve to introduce these same residents to professional organizations that will assuredly play a role in their pathology career. One resource already existing is the Program Directors’ Toolbox²⁵ administered by the CAP and the Association for Academic Pathology (formerly the Association of Pathology Chairs). This toolbox provides PDs and faculty with on-demand access to educational content, administrative tools, and other resources to share knowledge and innovative practices across institutions. Harnessing the content already existing in the Program Directors’ Toolbox could be integral to preparing first-year residents for a career in pathology.

As with any survey, there are strengths and limitations to be considered with this study. One notable strength is that the survey captured the perceptions of both PDs and first-year residents early in the residency year. This survey also focused on pathology residents mid-way in their first year of training, which should result in less recall bias than in surveys engaging with more mature pathology residents. Another unique aspect of this current survey is the breakdown of pathology first-year resident respondents by the location of their undergraduate medical training (US vs international medical graduates) and by the type of medical degree earned (MD vs DO). A limitation of the survey includes the inability to link PDs’ responses to those of their first-year pathology residents. This would have yielded additional perspectives to have considered, within individual residency programs, whether the PD and their first-year residents had similar or different responses to survey questions. Additionally, while the survey response was fairly robust, this survey was limited to first-year pathology residents, and thus, the absolute number of respondents was modest. A higher number of responders would have allowed for more definitive conclusions as well as if we had more longitudinal data of perceptions of preparation for residency. This could be a starting point for evaluating preparation over time in relation to the changing curriculum. Another limitation is that we cannot link types of teaching of histology, for example, with perception of preparation; thus, we cannot make definitive conclusions of the optimal preparation modality or timing of that preparation.

In conclusion, this survey of both pathology residency PDs and first-year pathology residents provides insights into how trainees perceive their preparation for pathology residency. Tasks that are essential for pathology residents (e.g., histology and microscopy) were evaluated; tasks important for residents of any specialty (e.g., gathering a pertinent clinical history and identifying system failures) were also evaluated in this survey. This underscores the importance of foundational training for all medical students to optimize the transition to residency. The early months of residency training are truly formative. Specific efforts should be made to introduce first-year pathology residents to their chosen field in a supportive manner and to establish a foundation for knowledge growth, skills training, and competence achievement. This survey informs the community of what those specific efforts might be and how medical schools, residency programs, and the field of pathology at large might work to contribute to such efforts. It also opens the door to perhaps the need for more rigorous evaluation of knowledge and skills at the beginning resident level so that we have more robust and long-term data that can inform programs and UME institutions of needed changes for specific curricular content, such as histology, for optimal preparation for residency.

Funding

Funding and support for the College of American Pathologists Graduate Medical Education Committee is provided by the College of American Pathologists in the form of educational staff support (authors KJ and AL), travel reimbursement for committee members (authors BKR, JKK, SB, JMC, MB, SC, HG, CBM, BP, KLW, and BB), and funding for publication.

Declaration of competing interest

The authors declare that there are no competing interests.

Supplementary data

The following is the Supplementary data to this article: