HISTOPATHOLOGY TRAINING AND FELLOWSHIP IN PAKISTAN-HOW TO MAKE IT MORE EFFECTIVE TO SIMULTANEOUSLY PREPARE FOR FELLOWSHIP OF ROYAL COLLEGE OF PATHOLOGISTS (FRCPath)

Histopathology Training for Fellowship in Pakistan

Abstract

Editorial

 Histopathology is considered the mostdefinite science which has a vital role not only in diagnosis but also in management of diseases specially cancer management, predicting prognosis as well as in surveillance of patients1. This specialty is being practiced in different parts of the country with variable quality assurance and standards. There are about 29 centres accredited by College of Physicians & Surgeons Pakistan (CPSP) all over the country, where fellowship training is being conducted in histopathology2.

 Since 2011, Royal College of Pathologists London has established an examination centre at Armed Forces Institute of Pathology (AFIP) Rawalpindi (Pakistan) for conducting Part 1 examination for Fellowship of Royal College of Pathologists (FRCPath)3. This has provided an opportunity for our local candidates to get Fellowship of Royal College of Pathologists (FRCPath) in addition to Fellowship of College of Physians& Surgeons Pakistan (FCPS). After passing FRCPath examination, our candidates can apply for the job of consultant in United Kingdom (UK) through article 14 after fulfilling the requirements4. To achieve this objective, efforts are required to be made on three levels including improvement in training system and more focused approach at the trainer and trainee levels.  The main drawback in our training system is extreme degree of variability in training standards in different training centres. Few centres are providing excellent training to the candidates, while few centres provide just ordinary training. To improve the training system, the first factor to be addressed and measures required to be taken are primarily related to equate the standards of training at different centres. In United Kingdom (UK), fellowship training is done under a Deanery based system. In this system, the candidates get rotational training in different regional centres which are known for different systemic pathology. This regular rotation in different centres provides equal opportunities to all candidates for training and exposure to all types of clinical and diagnostic material. In this regard, CPSP can play the role of Deanery and arrange rotation of trainees in different centres of the same province for specific period of time. If a province does not has good training centres, the candidates c n be sent to better centres in other provinces.  In all the training centres, the specimen dealing including gross examination, dissection, block selection and histopathological reporting should be according to standard guidelines. Guidelines issued by Royal College of Pathologists which are revised on regular basis can be followed. This will be extremely helpful for the candidates sitting in Royal College of Pathologists fellowship examination as many of questions are asked from the college guidelines including tissue pathways and datasets. There is a greater need that the candidates during their training period must be made aware and get expertise in ancillary studies including special stains, immunohistochemistry, flow cytometery, cytogenetics, molecular pathology techniques including Fluorescent in Situ Hybridization (FISH), Polymerase Chain Reaction (PCR) and Electron microscopy etc.  Autopsy training is an integral part of FCPS and FRCPath training programme and curriculum. The trainees must be made well versant with autopsy techniques and post mortem histopathology examination. Most of the centres in Pakistan conducting FCPS training in histopathology are not performing autopsies, so most of our candidates are not familiar with autopsy techniques and post mortem histopathology. Although since 2011, the Royal College of Pathologists London has given option for the candidates sitting in fellowship examination to opt for autopsy and gynaecological cytology free examination, however a significant number of autopsy related questions are asked in theory paper of FRCPath Part 1 examination. With this pattern of training, our candidates can sit and will have a fair chance of passing FRCPath Part 1 examination during their 3rd or 4th year of training and Part 2 examination after completing FCPS training.  There is a need to modify the examination system and marking pattern of FCPS Part 2 examination and to equate it with FRCPath Part 2 examination. Presently, in FCPS Part 2 examination all 5 long cases are immunohistochemistry (IHC) cases. These long cases should include one medical renal biopsy case with special stains, immunofluorescence/immunoperodidase and Electron Microscopic (EM) pictures, if required. Similarly there should be one medical liver biopsy case with special stains/immunohistochemistry. Rest of the 3 cases can be IHC cases. Frozen section examination should be made an interactive session with examiners as it happens in FRCPath examination instead of writing just benign or malignant on answer sheets as practiced in FCPS examination, presently. This will reflect the response of candidate to the given scenario, which is also the actual situation in practical life. In gross examination, images of 4 specimens can be given to each candidate asking them for gross examination, description and block  election followed by an interactive session with examiners later on. Presently in FCPS examination, one gross specimen is provided to the candidate for dissection and block selection, which is not sufficient to check the breadth of knowledge. Objective Structures Pathological Examinations (OSPEs) should also be included in FCPS examination as they are an integral part of FRCPath examination. One management related and one Royal College of Pathologists tissue pathway/dataset related OSPE should be included in FCPS Part 2 examination.  Time for each short surgical pathology case in FCPS examination should be increased from 7 minutes to 10 minutes as is the allocated time for each short surgical pathology in FRCPath examination. Similarly, time for each long case should be 20 minutes as given in FRCPath examination.  As far as marking system in FCPS examination is concerned, a close marking system should be adopted in FCPS examination as followed by Royal College of Pathologists in FRCPath examination. There should be no admissibility for passing the examination with more than 3 serious or erroneous errors. In surgical pathology short cases, the importance of further work up and clinicopathological comments (CPC) about management, behavior, prognosis and other aspects of disease should be given extra marks (Browne Points) as given in FRCPath examination.   The trainers should have full knowledge of curriculum, guidelines and training schedules of FCPS and FRCPath. They should conduct training according to the guidelines issued by the college. In this regard it will be very useful that CPSP makes arrangements to conduct workshops by the Fellows of Royal College of Pathologists from the country and abroad, highlighting the training schedule and examination pattern of Royal College of Pathologists, making the trainers well versant with both the systems. The trainers must participate in External Quality Assurance (EQA) schemes on regular basis which should be mandatory for them. Supervisors should regularly be monitored for getting the required Continuing Professional Development (CPD)/Continuing Medical Education (CME) points during each year. In case of not getting required CPD/CME points in the year, their supervisorshipmay be suspended temporarily or permanently.  As far as the trainees are concerned, histopathology training is very demanding and the candidate should know this fact before starting their training. They should have an aptitude for this specialty and this should be assessed by their supervisors while starting their training. They should be kept on a probation period for initial 6 months of training and if found unsuitable for this specialty, may be advised to change it. The trainees should also have a clear idea of curricula and guidelines of CPSP and RCPath which must be focused and followed. This will help them to have more chances of passing both fellowship examinations.

 Reference

 1. Gillet IR, Johnson NW, Curtis MA, Griffths GS, Stemme GE, Carmann RJ, et al. Role of histopathology in diagnosis and prognosis of periodontal diseases. J Clin Periodontol. 1990; 17 (10): 673-84.

2. College of Physicians and Surgeons Pakistan. Accredited Institutions for FCPS Part-2 Histopathology Training; 2012. 3. Royal College of Pathologists. Regulation and examination guidelines 2012. 4. Revolutionizing specialist training for specialist registers in histopathology in UK. RCPath Bulletin 2004; 125:25-6.   Brig Tariq Sarfraz MBBS, MCPS, FCPS, ARCPath Associate Royal College of Pathologists, London Consultant Histopathologist Head of Pathology Department Combined Military Hospital Kharian (Pakistan) E mail: tskhan_65@yahoo.com