Impact of COVID-19 Pandemic on Pathology Residency Program: An Experience from India
Arti KHATRI1, Somshankar CHOWDHURY1, Dipti SIDAM2, Sonali MALIK3, Toshali PANDEY4, Sumanashree MALLAPPA5
1Department of Pathology, Chacha Nehru Bal Chikitsalaya, DELHI, INDIA
2ESI Medical College, HARYANA, INDIA
3Gajra Raja Medical College, GWALIOR, INDIA
4Maulana Azad Medical College, DELHI, INDIA
5Kodagu Institute of Medical Sciences, KARNATKA, INDIA
Keywords: Coronavirus, COVID-19, Pandemic, Pathology, Learning, Residency
To study the impact of the COVID-19 pandemic on pathology residents through a questionnaire-based survey.
Material and Method: We designed a Google survey questionnaire with 20-questions and distributed it to the pathology residents across India
via e-mail and WhatsApp. All the responses collected were analysed using appropriate statistical methods.
Results: We received a total of 81 responses. The majority (n=55, 68.8%) of the residents were aged 26-30 years with a male-female ratio of 1:2.2.
Residents reported a significant decrease in classes as compared to pre-covid times. However, most institutions (90%) shifted to the virtual
method for various teaching sessions. About 94.7% of the residents felt a fall in the quality of training due to Covid. A significant number of
junior residents (76.92%) reported an inability to complete the target thesis enrolment. The residents saw a substantial decrease in the number
of peripheral smears, bone marrow, cytology, and histopathology cases compared to pre-Covid times (p value <0.001 for all). An overwhelming
83.8% of the pathology residents were posted for COVID-19 duties. About 48.8% turned Covid positive. About 77.5% (n=62) of residents felt
that the necessary training period would be extended.
Conclusion: The COVID-19 pandemic has immensely affected the training and teaching of pathology residents in India. Similarly, this pandemic
must have affected pathology residents all across the globe. Therefore, institutions can consider offering an extended period of up to one year,
depending upon residentsí requests.
The coronavirus disease 2019 (COVID-19) pandemic
has devastating effects on worldwide healthcare systems.
Drastic measures had to be taken by various institutes
universally to control its spread and impact. However, as
the focus shifted primarily on the COVID-19 patient care
and containment of the infection, the physical presence
of students and staff was cut short in Pathology and
other departments. These include cancellation of elective
procedures, reduction in the volume of acute care surgery
following surgical professional societies guidelines, and
cancellation of lectures and offline conferences (1,2).
Education and training of the pathology residents while
dealing with COVID-19 was a challenge in many institutions
(3). Most institutions continued medical education (CME)
programs and educational seminars by adhering to the
strict social distancing recommendations. Some meetings
have been postponed or held virtually, limiting their scope
and outreach. In-person academic activities, including
face-to-face teaching and simulation laboratories, have been interrupted. Many institutions resorted to innovative
learning methods, digital pathology, teleconferencing,
zoom meets, and online didactics to maintain the learning
The pathology residents are affected by various factors like
new learning modes, less on-site skills, and working away
from the department. In addition, the emotional stress and
breakdown on the news of illness and death of friends and
family have caused challenges for many pathology training
programs across the countries. It results in the disruption
of existing training models for the residents. However, how
much the teaching and training of pathology residents have
been affected in India is unknown.
So far, only a very few studies have been done in India regarding
the effect of this pandemic on residency programs.
Till now, no such research has been published in the field of
pathology. Therefore, in this study, we aimed to study the
impact of the COVID-19 pandemic on pathology residentsí
training programs in India.
We designed a Google survey questionnaire with 20
questions to assess the different aspects of pathology
teaching and learning. This study was conducted in
compliance with the principles of the Declaration of
Helsinki. The instituteís ethical committee approved
the study protocol. The consent was obtained from the
participants by attaching the consent form with the Google
survey. The questionnaire covered various areas like
haematopathology, cytopathology, and histopathology.
We distributed it to both junior and senior residents of
pathology all over India via WhatsApp (Meta, USA) and
e-mail. Postgraduates or junior residents are students who
have completed their graduation and have enrolled in a
two- or three-year pathology residency programme to earn
a postgraduate degree or a diploma respectively in the field
of pathology. The senior residents are those who recently
completed their pathology residency of two to three years.
In India, senior residency is a personal decision that one
can apply for one to three years. After completing the junior
residency, one can also work as a consultant pathologist in
any hospital or laboratory. The senior residents were also
chosen for this study because they have experienced both
pre-COVID and COVID-19 eras.
We sent the questionnaire by e-mail and WhatsApp to
the junior and senior residents of different institutes in
India in the first week of July 2021. A time duration of 10
days was given to residents to fill up the survey.
We collected the response data in Excel sheets.
Calculation of Sample Size: The sample size was calculated
using Cochranís formula.
N= z 2 p q/e 2.
p = the (estimated) proportion of the population with the
attribute in question.
q = 1 - p.
e = the desired level of precision (i.e., the margin of error),
Using the sample size of 4500 (derived from the National
Medical Commission website, considering 1195 MD
pathology seats every year, and one year of senior residency
on an average. Senior residency is not compulsory in India,
and not all opt for it after completing the post-graduation
At a 90% confidence interval and margin of error of 9%, the
population size is 82.
We did the statistical analysis using the Statistical Product
and Service Solutions (SPSS) Statistics for Windows,
Version 25.0 (Armonk, NY: IBM Corp). We used the
Wilcoxon signed-rank test to analyse the differences
between the pre-COVID-19 and COVID-19 responses. A
p-value of less than 0.05 was taken as significant.
The questionnaire with responses is provided in Table I
We received 81 responses from 22 institutions across 15
cities in India. One respondent refused to give consent,
so we analysed 80 responses. The majority (n=55, 68.8%)
of the respondents were females. Out of the respondents,
48.8 % (n=39) were junior residents and 51.2% (n=41) were
senior residents. Most of the hospitals were functioning as
COVID centres (56.3%), followed by partial COVID ( 40%)
and non-COVID (3.7%) centres during the COVID-19
pandemic (Figure 1
The residents reported a significant decrease in the
clinicopathological case discussion (tumour board and
clinicopathological meets) during the COVID-19 pandemic
There was a significant decrease in classes during the
COVID-19 pandemic (p value<0.001) (Figure 2). In
addition, the majority (n=72, 90%) of the residents reported
that their institutions have shifted to a virtual teaching
medium. However, only 55% (n=44) of the students found
the online mode helpful.
Click Here to Zoom
|Figure 2: Number of classes
attended per month in pre-
COVID and post-COVID
Regarding thesis/ research work, only (n=9, 23.08%)
residents could target thesis enrolment, while most (n=30,
76.92%) of the junior residents could not target thesis
enrolment. Out of these junior residents who reported a
deficit, 53.33% (n=16) and 23.33% (n=7) described a 20-
50% and 50-75% deficit in the target number of cases
required for their thesis completion, respectively.
There is a significant reduction in the number of cases seen
by the residents in various areas of a pathology residency.
In addition, there is a substantial reduction in the
clinicopathological classes, number of peripheral smears,
bone marrow smears, and biopsy/resection specimens examined by the residents compared to pre-covid times.
Also, there is a significant reduction in the FNACs done and
analysed. Approximately 95% (n=76) of the residents felt a
fall in the quality of training due to the Covid pandemic.
About 72.5% (n=58) of the residents suffered from various
psychological issues like anxiety, depression, burn-out,
fatigue, etc., while 27.5% (n=22) showed no psychological
problems during this pandemic (Figure 3).
An overwhelming 83.8% of the pathology residents were
posted in Covid duties, and about 48.8% turned Covid
positive (Figure 4).
About 77.5% (n=62) of residents felt that the training
period needed to be extended by respective departments to
acquire adequate experience in pathology. Out of the total
residents who wanted an extension, approximately 12.9%
(n=8), 50% (n=31), 29% (n=18), and 8.1% (n=5) of the
residents thought that an extension of three months, three
to six months, six months to one year, and more than one
year was required to gain proper exposure for training in
Pathology is a subject that can be mastered only by adequately
grasping core concepts (2). To become a pathologist
in India, one requires two to three years of vigorous
training (junior residency) to achieve a Diploma and Degree
in pathology. To achieve further experience in pathology
training, a postgraduate degree holder can opt for a Senior
residency program of up to three years in India. During
residency, a pathology resident acquires skills like tissue
processing, microscopic analysis, laboratory management,
immunohistochemistry, haematopathology, cytopathology,
transfusion medicine, etc. In the face of the ongoing
COVID-19 pandemic, as the medical needs increase, so
does the laboratory workload of the pathology department.
Pathology residents worldwide have experienced various
challenges in their training because of the pandemic.
Few articles reported the changes in the workflow in their
institution amidst the Covid-19 pandemic. In their paper,
Lieberman et al. (1) reported a significant disruption of
daily medical student learning activities with the focus
shifting to optimal patient care in their institution. They
rapidly implemented substantial changes to medical
education in clinical pathology to cope with it. They used
distance learning platforms like teleconferencing, which
is universally available to staff and students. Institutions
also started with Covid -19 and distance learning classes
to help the residents with the new platforms. They even
had feedback scoring systems implemented at the end.
Similarly, in their article on pathology residents, Cieri et
al. (3) stated that to adhere to social distancing norms, the
physical presence of staff and students in the pathology
department was cut down. They reorganised the work
logistics by introducing smart working, digital pathology,
and checkpoint activities. Digital pathology was used for
training across various disciplines of pathology. They
converted glass slides into high-resolution data. Though
they initially found it difficult to adjust to it away from the
microscope, they later found it a much better alternative.
They suggested the comprehensive implementation of
digital pathology soon.
Furthermore, we found in this study that to manage the
unprecedented need for an additional medical workforce,
many residents from various specialties, including
pathology personnel (around 84%), have been redeployed
to cater to COVID-19 patients and wards, which causes
significant stress to the resident doctors. These findings
are similar to the study done by Romero et al. (4), and
they reported that in the later part, as the Covid medical
needs increased, first and second-year postgraduates were
redeployed to work like interns and medical students. In
contrast, third and fourth-year students were retained to
handle pathology department workloads.
Romero et al. (4) also reported that educating pathology
residents while maintaining COVID-19 norms was
challenging. Resident rotations were rearranged with
limited residents working on-site on rotation and others
previewing the slides from residentsí rooms with a clear
separation between residents working on-site and others.
The transfusion medicine offered on-call phone assistance
only. Daily check-in webinars and assignments were
offered. Program directors periodically assessed residents
for learning milestones. Leaving the laboratory to work for
direct clinical care was stressful for many residents. Distance
learning digital methods were introduced, and residents
reported them helpful but also reported distractions during
didactics. So, these methods though effective did not exactly
replicate the pre-pandemic teaching and learning process.
In the light of these articles and the new hurdles faced
by pathology residents, we highlighted the impact of the
COVID-19 pandemic on pathology residents of India
through a questionnaire-based survey.
Use of smart methods, digital pathology, and virtual
conferencing for teaching pathology
Virtual sessions have been adopted in various nations as a
part of residency programs to compensate for the learning
loss due to the pandemic. According to research by Hassell et al. (5), the constraints faced by pathology due to a pandemic
necessitated modification to virtual means to avoid
jeopardising teaching and training. This was an entirely
new experience for the students, who had little or no access
to hands-on instruction and relied entirely on a digital environment
and virtual approaches to learn. For many, the
abrupt move from traditional on-site and hands-on procedures
to nearly virtual settings owing to a pandemic response
has been unnerving. For example, a Pathology resident
had to carry out case reviews, an essential component
of training that shifted either entirely or partly to a virtual
environment. The sudden switch to virtual teaching utilising
digital technologies was laden with difficulties and an
immediate perception that the teaching efficacy and quality
had suffered (2,5).
There is a shift from hands-on learning to virtual mode.
Although these options appeared effective, they still did
not match the pre-pandemic offline teaching. However,
some compensation has been offered to students by
adopting virtual classes in various pathology departments.
In India, as suggested by the current study, the majority
of the pathology departments (90%) shifted to the online
teaching mode. However, digital pathology in India is
still developing, and not all are flexible in using the new
Redeployment of the residents to work in direct
Many of them were redeployed to the wards to treat
Covid patients due to a shortage of clinicians. During this
period, pathology residents have ably shared the burden of
COVID-19 duties as around 83.8% of them have worked in
Covid wards. Due to significant portions of time devoted
to Covid patients and significantly less working time in
various areas of pathology, academic teaching and research
activities have suffered a lot. An article by Romero et al. (4)
confirms the same.
Covid-19 infection-related problems
Many residents have spent considerable time away
from their training due to post-exposure self-isolation
and hospital admissions while performing their frontline
duties (6). In the current study, nearly 49% of the
residents became Covid positive, and about 9% required
hospitalisation for Covid-related complications.
Not to be underestimated are the emotional and psychological
effects of the pandemic. In addition to the constant
stress of acquiring skills and providing care, the pressure to keep oneself healthy and prevent the virusís community
spread by not becoming a vector has been psychologically
crippling for many doctors (6). About 75% of the residents
faced various psychological issues in the current study. An
article by Romero et al. (4) also talks about the emotional
stress of keeping oneself safe and the news of losing near
and dear ones, which crippled their residents.
Although virtual sessions are not entirely compensated
for the offline class loss in pathology, virtual training is
still beneficial in compensating for some losses, as shown
by current study results. However, at the same time, some
specialities like surgical branches bear the most burnt as
virtual learning is highly restricted, as evidenced by the
fact that during the COVID-19 epidemic, the majority of
residents reported not receiving any educational sessions
from the university or surgery department staff during
Covid-19 pandemic (7).
Hence from this study, we found out that pathology training
in India has suffered during the COVID-19 pandemic.
Also, residents in the different pathology subspecialties
saw a significant caseload reduction compared to pre-
Covid times. Similar to this study, Hassell et al. reported
that most professors and program directors believed that
the transition had affected the quality (59% and 62%,
respectively) and efficacy (66%) of teaching pathology.
Similarly, residents shared this opinion regarding the
adverse impact on quality (59%) and effectiveness (64%) of
learning pathology (5).
Most of the residents are stressed and concerned about the
quality of their training. Therefore, most felt their training
period should be extended to compensate for the lost time.
It thus has become necessary to balance the social distancing
norms needed to slow the disease spread while ensuring
that trainee doctorsí educational and clinical needs are
minimally affected. Similarly, doctors in their training period
today shall soon manage laboratories or do the reporting
independently concerning the pathology training (2).
Based on the findings, we recommend that the institutes
consider offering an extension of up to one year to the
pathology residents all across India. Furthermore, as per
the study by Azimi Khatibani et al. (2), investment in
virtual telepathology infrastructure and training all the staff
and residents to use the same is a need of the hour.
The limitation of this study is that not all the residents have
responded to the survey, but we still have a large enough
sample to represent a pan-India scenario. The strength of
this study is that all the aspects of pathology residency, research, and academics have been included. We have also
incorporated the residentsí feelings about their training
and provided a possible solution.
The COVID-19 pandemic has adversely affected the
pathology residents all across India. Similarly, this
pandemic must have affected pathology residents all across
the globe. However, the exact impact is still unknown.
It is difficult to predict how long this pandemic will last,
and the pathology fellows and residents need to continue
their learning and training. Whatever loss has happened
to them due to the COVID -19 pandemic so far has to be
compensated by the institutions by giving them the option
of extension of their training period to offset this significant
loss by the residents. We hope our results help better the
residency training programs, understand the pandemicís
influence, and modify pathology teaching program
durations accordingly to provide more effective training.
Conflict of Interest
We did not receive payment or services from a third party
(government, commercial, private foundation, etc.) for any aspect of
the submitted work. We have no financial relationship with any third
party(government, commercial, private foundation, etc.).
There are no relationships/conditions/circumstances related to this
work that present a potential conflict of interest.
Concept: AK, SuM, Design: AK, SC, SuM, DS, Data collection or
processing: AK, SC, SoM, DS, SuM, TP, Analysis or Interpretation:
SuM, TP, AK, DS, Literature search: SoM, AK, SuM, SC, Writing:
AK, SuM, SoM, Approval: AK, SC, DS, SoM, TP, SuM.
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