Material and method: A search was performed through PubMed, Google Scholar, Semantic Scholar, and Ulakbim search engines for the Science Citation Index, Science Citation Index Expanded, Emerging Sources Citation Index, Directory of Open Access Journals, Scopus, PubMed as well as TR Dizin indexed articles. The findings are categorized into two periods as 2010 January - 2020 April (pre-COVID-19 pandemic) and May 2020 - 2023 June. A total of 24 reviews/editorials/letters to the editor and 63 research articles in the pre-pandemic period and 11 reviews/ editorials/ letters to the editor and 35 research articles between 2020 May and 2023 June are included in the analysis.
Results: Currently, medical education generally depends on core education programs with defined learning objectives and outcomes. Moreover, problem-based, case-based, and team-based interactive learning are being used along with traditional didactic courses. Additionally, digital/ web-based/remote education methods have gained prominence after the COVID-19 pandemic. The virtual or augmented reality and 3D drawing applications are offered as a solution for the autopsy and macroscopy courses. A scarce number of publications are found on measuring and evaluating the effectiveness of learning.
Conclusion: Artificial intelligence in pathology education is a topic that looks likely to become important in the near future. National and international comprehensive standardization is a necessity. A joint effort and collective intelligence are needed to achieve the desired goals in undergraduate pathology education.
Since the 1950s, new approaches have been developed to train the doctors of the future by creating core education programs with defined learning objectives and outcomes. Traditional lectures where each discipline was explained in detail have been replaced by integrated education, which includes clustered courses organized around systems (3,4). Methods such as problem-based, case-based, and teambased learning have started to take place in the educational life. Today, efforts are being made to move to interactive education models where students are more active and access information through research. New educational methods are combined with the old, didactic style of education to create up-to-date curricula. It is believed that with this system, it will be possible to train the doctors of the modern age (4-6).
What do we Expect from Medical Students in Pathology
Courses?
In the new medical school curriculum, the question of
`How much pathology should be taught to medical students?` is a topic of discussion. According to the current
approach, the competencies that medical students should
gain in pathology courses are as follows: they should learn
the causes, basic mechanisms, and processes (etiopathogenesis)
of diseases, integrate disease mechanisms into organ
system pathologies, and be able to adapt this knowledge to
the clinic for diagnosis and treatment. While preparing the
curriculum, it is necessary to determine the learning objectives
and optional sub-objectives for each competency as
well as to measure and evaluate the level of learning, integration,
and use of knowledge (4,7). In addition, it is aimed
that the graduates know and understand the role of the
pathologist, the importance of histopathology in patient
diagnosis, the examinations that will be required according
to clinical conditions, the limits of histopathology and
cytopathology, and the method of sending biopsy or cytology
samples to the pathology laboratory (8) (Table I).
Table I: Main objectives of pathology education at medical schools.
The pathology curriculum has to be classified as need-toknow, want-to-know and good-to-know and, it should be integrated with clinical sciences. Furthermore, problembased learning, case-based learning, and other interactive teaching methods should be implemented along with didactic lectures. Finally, evaluation methods should be arranged to give less emphasis on morphology and more weight on clinical interpretations (1-7).
OBJECTIVES, METHODS and SAMPLE
CHARACTERISTICS
The contribution of pathology curricula and educational
methods in medical schools to the training of contemporary
doctors in our country, as well as worldwide, is a subject
of debate. In this review, publications related to pathology
education in medical schools were examined by searching
through PubMed, Google Scholar, Semantic Scholar, and
Ulakbim search engines between 2010 January and 2023
June. The keywords, `undergraduate medical pathology
education` for articles in English and `mezuniyet öncesi tıp
patoloji eğitimi` for the ones in Turkish were used during the literature search. Publications indexed in Science Citation
Index (SCI), Science Citation Index Expanded (SCIE),
Emerging Sources Citation Index (ESCI), Directory of
Open Access Journals (DOAJ), Scopus, PubMed, as well as
TR Dizin (National Citation Index) were included in the
study, while publications not indexed in these databases
were excluded. The `PRISMA 2020 – Systematic Review
Checklist` was utilized at every stage of the study.
During the literature search, the impact of the COVID-19 pandemic, which affected the entire world since the beginning of 2020, was also observed in the field of pathology education. Therefore, in this study, it was considered to analyze the publications before April 2020, separately. The search findings were categorized into two periods as 2010 January - 2020 April and 2020 May - 2023 June. During the period from 2010 to 2020 April, a total of 24 reviews/editorials/ letter to the editor and 63 research articles were eligible for the analysis (n=87). From 2020 May to 2023 June, 11 reviews/editorials/ letter to the editor and 35 research articles were included in the analysis (n=46). The distribution of publications according to the scientific scope of the journals is shown in Figure 1.
Figure 1: Distribution of publications between 2010-2023 June (n=133).
As shown in Figure 1, 63 (72.4%) of the publications were research articles, and 33 (37.9%) of all publications were in SCI/SCI-E journals in the first 10-year period. Although the second period covered only a 3.5-year timeframe, it is noteworthy that there was a considerable increase in publications compared to the first period (52.8% of the first 10-year period). This finding reflects an increased interest in pathology education in medical schools during the pandemic era. Especially, the experiences and various recommendations are shared on the use of methods such as distance learning and digital pathology.
From 2010 to 2023 June, 66 different international journals, 19 of which (28.78%) were primarily focused on medical education, were published on the subject. The top 5 journals according to the frequency of the relevant publications were Arch Pathol Lab Med (SCI, 16 publications), Anat Sci Educ (SCI, 10 publications), Acad Pathol (ESCI, 9 publications), Human Pathol (SCI, 8 publications), and BMC Medical Education (SCIE, 8 publications). The top five countries publishing in this field were the United States of America (USA) (42 publications, 31.5%), India and the United Kingdom (10, 7.5%), Australia (7, 5.2%), and Turkey and Malaysia (6, 4.5%). Moreover, research was conducted in a total of 30 different countries from all continents, and 8 studies (6.0%) had a multinational setting. The distribution of the relevant publications according to the countries during the period between 2010 and 2023 June is shown in Figure 2.
OPINIONS and EXPERIENCES REGARDING
THE METHODS USED IN UNDERGRADUATE
PATHOLOGY EDUCATION
Views and Experiences in International Publications
2010-2020 April
In the late 1980s, medical schools started to move towards
system-based education. In this new curriculum, pathology,
in conjunction with other basic and clinical disciplines,
became part of the horizontal integrated education system.
Accordingly, between 2010 and 2020 April, publications,
especially reviews, emphasized the importance and benefits
of the integrated system. During this period, another key
topic was the recommendation for those responsible for
education to be `facilitators` rather than `educators`; it was
suggested that didactic lectures given by educators should
be replaced by modern teaching methods that encourage
students to learn on their own, such as flipped classrooms,
problem/case-based learning, working in small groups, and
peer teaching (1,5,6,8,9).
It is worth noting that in the period between 2010-2020 April, which reflects the period before the COVID-19 pandemic, articles on the use of digital microscopy in undergraduate medical education began to appear, albeit in small numbers. Ten articles published before 2020 compared digital microscopy and conventional light microscopy. In all of these studies, the benefits of pathology practices accompanied by digital pathology were emphasized (10-13).
During this period, articles about digital/web-based learning and distance education began to appear sporadically (6,11, 14-18). Herbert et al. in 2017 and Onan et al. in 2019 discussed the blending of online and face-to-face education (blended learning) in their studies and described its benefits (6,19). In addition, new methods related to digital/webbased learning began to be developed and introduced. For example, research was published on using animations in distance education (15), digital game-based learning (16), enhancing learning with patient simulation software (17), and learning through online app platforms (14).
Various articles pointed out that autopsy education, which was popular in previous generations, was gradually decreasing, making it difficult for students to see macroscopic pathology and understand clinical-pathological correlations. Pathology museums, which were popular and widespread in the past, were disappearing worldwide, and there was a dramatic decrease in the number of autopsies (1). During the period between 2010 and 2020 April, six articles emphasized the importance of learning through autopsy, cadaver, and macroscopic specimens (20,21). However, the publications acknowledged the fact that access to autopsies or macroscopic specimens was becoming increasingly difficult. Fortunately, there are researchers seeking for solutions. For example, Nautiyal et al. suggested that macroscopic pathology education could be digital-based. The authors mentioned that digital-based images and videos could be used instead of surgical specimens fixed in formalin because there was no distortion caused by fixative, and specimens were better understood (11). Another solution was proposed by Mogali et al. who developed and presented high-quality macroscopic specimens marked with Quick Response (QR) codes (22). Another research group proposed the use of 3D-printed autopsy or macroscopic specimens (23).
In this period, some studies have been conducted to increase learning and analytical thinking. In some of these studies, students were made to prepare multiple-choice questions (24-26) or crossword puzzles (27) and it is reported that students` analytical thinking skills improved, contributing to their learning.
Although measuring and evaluating the effectiveness of learning is a fundamental element of education, there are few publications on this topic. In the period from 2010 to 2020 April, six publications (6.89%) related to measurement and evaluation in pathology education in medical schools were identified (27-32). Patil and colleagues discussed the importance of balancing the distribution of topics and questions in exam preparation and the `blueprint` study they conducted for this purpose (30). The studies by Goneppanavar et al. and Htwe et al., shared experiences with objective structured practical examinations (OSPE) (27,28,31). Ho and colleagues discussed the benefits of their testing method using concept maps (32). In another study, it was mentioned that the practical examination in pathology microscopy and macroscopy, when conducted as a PowerPoint slide show on a computer, was more objective and structured compared to traditional desk-based exams, and saved time (31). Hu and colleagues questioned the relation between undergraduate and postgraduate exam success. In their study, students with high pathology performance in the pre-graduation period achieved higher scores in post-graduation exams such as United States Medical Licensing Examination (USMLE) and National Board of Medical Examiners (NBME) (29). Distribution of the articles according to the topics is shown in Figure 3.
2020 May - 2023 June
There has been a significant change in the content of publications
from 2020 May to June 2023, which also includes
the period of COVID-19 pandemic restrictions. Among the
published articles, 11 were in the form of reviews/editorials/
letter to editorial, discussing the benefits and challenges
of using distance learning and digital pathology for educational
purposes, which gained in importance during the
pandemic (8, 33-37). Hassell and Afzal suggested encouraging
and possibly mandating students in medical schools
to use virtual pathology resources. It was mentioned that
students taking elective virtual pathology internships
would better understand the role of the pathologist in the
healthcare team and the expectations from the pathology
laboratory, and thus the number of doctors choosing
pathology as their specialization could increase (33). Views
on the pros and cons of virtual learning in pathology are
summarized in Table II.
Table II: Positive and negative aspects of virtual learning in pathology.
Although the majority of research articles (n=18, 39.1%) came from the USA, articles have been published from 21 countries worldwide, including Turkey. In sixteen studies (34.78%), experiences related to distance education, digitally- based education, and digital microscopy have been shared (38-48). During this period, an increasing number of online education platforms have become available. In an article on this topic, it is explained that online platforms such as PathPresenter and PathElective can provide free, high-quality, organized pathology education to students. Besides, digital platforms like `Discovering Pathology` and `Slice` that gamify pathology education are mentioned (34).
After 2020, significant knowledge and experience were gained in the field of distance education. Furthermore, it became possible to compare experiences between distance and face-to-face education. Hernandez et al. reported success in student assessment and student satisfaction in remote pathology education during the pandemic, but emphasized that a hybrid education model might be more effective and beneficial (48). Tanaka and Ramachandran examined the benefits of remote education on both pathology residents and medical students, concluding that remote education was beneficial for students but emphasized that face-to-face education should not be abandoned for resident training (46). When students` evaluations of distance education were considered, studies by Xu in China and Belezini in Greece found that medical students preferred traditional face-to-face education and believed that distance education should support it (47-49). In a study by Mastour in Iran, a study performed under a strict level of exam security, it was reported that significantly higher success rates were achieved in measurement and evaluation assessments compared to face-to-face education at the end of remote education (41).
In the post-2020 period, experiences with more interactive learning methods replacing didactic education have continued to be shared. Hassell and colleagues found it beneficial for educators to conduct small group work during pathology practical training, using annotated digital slides. They stated that integrated digital pathology case materials could be interactively used and incorporated into the education with flipped classroom, group work, and game formats, following a system-based curriculum (34,36). In twelve studies (26%), the contribution of modern methods such as integrated education and case-based/team-based/flipped classroom methods to learning has been examined (47,49-52). Studies evaluating case-based and team-based education in remote education during COVID-19, which included clinical information, laboratory tests, additional tests such as cytogenetics or flow cytometry, digital slides, radiological images, and macroscopic images, have reported positive results from both students and educators (34-38).
The studies comparing the effectiveness of digital pathology compared to light microscopy in pathology education in medical schools in the pre-COVID-19 period were replaced with reports on the use of telepathology in education during the pandemic (38,39). In all these publications, it was reported that digital pathology could be easily and successfully used in compulsory or elective pathology courses if the technical problems could be overcome (38,39). In a study conducted in Turkey, positive experiences with the use of telepathology in undergraduate pathology education during the COVID-19 period were reported (38). In this article, it was explained that the case-based learning experience was integrated into the distance education platform, in which the cases with clinical, radiological, and morphological features uploaded to the Virasoft Pathoclass system were presented and discussed by students in pathology practice courses during the pandemic. Student survey confirmed that various contemporary educational methods such as telepathology, case-based and team-based learning, and peer education were successfully used together during the practice courses (38).
In this period, there are four articles addressing the benefits of macroscopy and autopsy practices. In one of the studies emphasizing the importance of autopsy, students stated in questionnaires and open-ended questions that autopsy increased anatomical knowledge, observational skills, and clinical-pathological correlations (53). Another study suggested that autopsy not only helps students understand the pathophysiological mechanisms in disease processes but also enhances their experience in coping with the feeling of death (54). Suggestions have been made that this need can be met with virtual reality and augmented reality technologies. Augmented reality technology (Google Glass, Alphabet Inc. and Microsoft HoloLens, Microsoft Inc.) has been experimented within autopsy education, and it is promising although currently at an experimental level (34). Digitally enriched virtual autopsy cases on websites and similar digital platforms can fill the gap in autopsy education, and many such digital platforms can provide resources for both medical students and pathology assistants (34). According to Wan and colleagues, the Interactive Digital Pathology Pool they created using two- and three-dimensional high-resolution anatomical pathology images improved students` success. They suggested that this pool could be enriched in the future by adding augmented reality and holographic images (55). Sutton-Butler and colleagues examined the effectiveness of the traditional method of examining macroscopic specimens in jars, a jar-based macroscopic specimen examination method, in an education study. In their study, 90% of students were satisfied with this education method, and 92% wanted this method to be used more frequently (56). Researchers suggested that returning to this traditional method could be beneficial for education, not only in anatomy and pathology but also in subjects such as ethics and organ donation (56).
In recent years, there has been an increasing number of articles in the literature about methods that make learning less monotonous and more enjoyable (57, 58). In a study conducted in Egypt, the contributions of the Kahoot! game (57) and educational games played with flashcards, as mentioned in Schukow`s letter to the editor (59), were some examples of game-based learning. The use of social media platforms in education has also been studied, and Hamnvag and colleagues have highlighted the contributions of Twitter to learning (57-59).
Regarding measurement and evaluation methods in pathology, only one publication has been found in the literature for the period 2020 May to 2023 June. In this particular study, it was suggested to combine different types and weights of questions rather than a single type in order to evaluate the performance of the students in the most accurate way (48).
In our country and in the global literature, the number of studies examining the impact of pathology education provided in the preclinical years of a medical school on the clinical education years or in professional life is inadequate. Indeed, this knowledge will contribute to the rearrangement of the curriculum and teaching methods, and one of the few examples is the study by Hu et al. showing that success in medical school pathology courses correlated with post-graduation exam success (29). In our country, two studies have been conducted in this field. In the first one, a questionnaire-based survey was conducted with 5th-year medical students to inquire about the benefits of the pathology education they received during the preclinical period on their clinical years. Students considered case-based learning and macroscopy training as the most effective methods and suggested that they should be emphasized. It was reported that didactic lessons were more useful when combined with different methods such as case-based learning, assignments/projects, presentation, and microscopy studies (51). In the second study, a survey was conducted in a heterogeneous group of doctors from different specialties or general practitioners who graduated after 2000, with an objective to explore which method of undergraduate pathology education was most beneficial for their active professional lives. They stated that a functional and clinically integrated pathology curriculum and diversified modern learning methods provided the most significant benefit (50). These findings support approaches that have been increasingly emphasized since 2010, such as integrated curricula, case-based learning, the benefits of macroscopy, and the use of diversified modern educational techniques.
Although the number of publications on artificial intelligence (AI) applications in pathology have been increasing in recent years, publications focusing on the use of artificial intelligence in pathology education are limited. In a small number of recent reviews that describe the use of AI in pathology, possible options for its use in the education of medical students and pathology residents have been briefly mentioned (60-62). Models to assist residents in learning glomerulopathies (63) and cytopathologic materials (64) have been developed and tested. Evidently, AI algorithms that can help in areas such as assessment and evaluation, and curriculum development are needed in addition to supporting learning.
Opinions and Experiences Published in Turkey
According to 2022 data, there are 118 medical schools and
143 programs in Turkey, with 97 of these schools being
state-owned and 46 affiliated with private universities (65).
A comprehensive study was published by Gençer and Dere
in 2019, which is the most extensive study conducted in
this field in Turkey and includes an analysis of the education
programs of 41 state universities that provides medical
education in Turkish and that use an integrated education
system. According to this study, pathology courses begin
in the second year in 58.2% (n=24) of medical schools,
while they are offered in both the second and third years
in 39%. In only one program (2.5%), pathology courses
are included in the curriculum of the first year of medical
school (66). In 7.3% of schools (n=3)), there is no pathology
practice course. When all the schools included in the
study are examined, the average theoretical course hours
for pathology is 125.39 ± 28.11, and the average practical
course hours is 26.21 ± 15.89. This study demonstrated
that there is no standardization in the implementation,
measurement, and evaluation of pathology education in
our country. The authors drew attention to the significant
differences in pathology education between schools in Turkey
and emphasized the need for a standardized pathology
education curriculum (66). A comprehensive analysis covering
all state and private universities in Turkey to understand
the general situation is currently not available.
In a study conducted regarding active physicians who graduated from medical schools in Turkey after 2000, 75% of the physicians (n=80) stated that pathology education was very useful or quite useful for their current professional lives, and 45% (n=48) found the education they received to be very adequate or quite adequate. The physicians considered the utility of the information (n=89, 83.2%), teaching methods (n=78, 72.9%), and the characteristics of the educator (n=75, 70.1%) to be important. They recommended case discussions (n=79, 72.9%), macroscopy (n=65, 60.7%), microscopy studies (n=62, 57.9%), problem-based learning (PBL) (n=61, 57.0%), and observation in the hospital laboratory (n=51, 47.6%) as major components of pathology education (51).
Sağol et al. shared their experiences with digital microscopy application in 2nd and 3rd-year medical students and reported that students easily adapted to the method, could review virtual slides from home, and had the opportunity to collaborate and participate interactively in classes (12). In a study conducted by Onan et al. before the COVID-19 pandemic with 3rd-grade students, an electronic education module and digital microscopy slides were added to traditional education. Students who used this blended teaching method in pathology education had higher success rates than those who did not. The authors reported that both students and educators were satisfied with the application (6). During the COVID-19 pandemic, telepathology began to be used in education in Turkey, as in the rest of the world, and it was applied by integrating it with case-based and team-based education (38, 67) (Table III).
Table III: Publications on pathology education in medical schools in Turkey.
CONCLUSION: QUESTIONS TO BE ANSWERED,
SUGGESTIONS and WISHES
Notably, the publications in the last 10 years before the
COVID-19 pandemic were focused on the weight of
pathology within integrated education in medical schools
and the transition from didactic education to active learning methods such as case /problem /team-based learning,
flipped classrooms, and peer education was obvious.
Additionally, digitalization started to find its place in educational
methods. While these topics continued to be of
interest after the COVID-19 pandemic, publications related
to digital/web-based/remote education methods gained
prominence. Various electronic learning platforms, some
of them free and open to everyone, have been developed.
The use of various digital games and social media platforms
to facilitate and make learning enjoyable has become more
widespread. However, experts continued to emphasize the
importance of autopsies and macroscopy, recommending
the use of virtual or augmented reality and 3D drawing
applications to meet this need. It is worth noting that
there are very few publications related to assessment and
evaluation in pathology education in medical schools. It is
an indisputable necessity to complete education by evaluating it with the most appropriate methods. Considering the
use of artificial intelligence in pathology education is also a
topic that needs consideration.
In Turkey, there is a need for comprehensive analyses that evaluate the infrastructure, curriculum, educational success, the number/quality of educators, and similar issues in undergraduate pathology education, covering all medical schools. Efforts should be made towards standardization in the implementation, measurement, and evaluation of pathology education. The following questions are awaiting answers: What should be the place and weight of pathology education in medical schools? What should be done to achieve learning objectives? How should learning outcomes be measured and evaluated? How can standardization be ensured and monitored? In a globalizing world, it should be kept in mind that not only national but also international and comprehensive standardization is necessary. In conclusion, it is believed that a joint effort is needed to achieve the desired goals in pathology education, and the answers to these questions can be found only with a collective intelligence.
Conflict of Interest
The authors declare no conflict of interest.
Authorship Contributions
Concept: SS, NE, Design: SS, NE, Data collection or processing: SS,
Analysis or Interpretation: SS, NE, Literature search: SS, Writing: SS,
NE, Approval: SS, NE.
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