Obstacles to Educating Pathologists and Retaining Them in Their Country of Origin

Pathology diagnostic services have made significant progress in recent years. The tests are not only specific but also more sensitive. The use of techniques such as immunohistochemistry has led to new insights into the cellular origins of tumors and provides information relevant to both diagnosis and optimal treatment. Consequently, pathologists, at least in most developed countries, are expected to meet stringent training, management and quality-assurance standards.

Unfortunately, most developing countries are unable to take advantage of the progress made because of their severe limitations in human resources, leading, in the case of pathology, to too few laboratories — many of which are understaffed. A trained pathologist requires at least nine years of undergraduate and postgraduate education. If the training is of poor quality, or well-trained pathologists do not practice in their countries of origin, this could (and does) have a major negative impact on cancer control and the many other areas of health where pathological plays an important role in diagnosis.

The obstacles to the effective training of such a specialized body of physicians in countries with limited resources are numerous and have diverse and complex causes. The most important of these are addressed in this article.

Shortage of Institutions and Staff

The indicators relating to the availability of health system resources show significant shortages in the number of physicians, laboratory workers and funding in developing countries (Table I). Yet these are the essential prerequisites for the establishment of a credible pathology service. Pathologists working in these countries are therefore very few. Tanzania has some 16 pathologists for a population of approximately 40 million; Ghana had only six trained pathologists in 2006 while Laos had just one. Even in relatively more developed countries like Pakistan or India, the number of pathologists per capita is a small fraction of that in, for example, the United Kingdom. The shortage of pathologists creates a vicious cycle; not only are institutions understaffed, but the quality of the services is substandard. In some training institutions (e.g., university affiliated), a pathologist might have to handle more than 10,000 biopsies a year. This enormous work load will inevitably affect his or her other duties, such as teaching or research.

Country	Physicians per 10,000 population	Lab Health Workers per 10,000 population	Per Capita Expenditure on Health (US $)
Australia	25	4	3181
UK	23	3	3064
USA	26	23	6350
India	6	<1	36
Nigeria	3	<1	27
Pakistan	8	<1	15
(who health statistics 2008)
Table 1. Health systems resources availability.

Professional institutions such as colleges of pathologists do not exist in most developing countries, such that pathology training, such as it is, is organized by non-pathologists. Even if small, academic bodies of pathologists are better able to plan and supervise training for pathologists.

Opportunities for continuing education and further specialization are limited. The institutions that grant a diploma in pathology or certify an individual as having met the requirements for practice do not generally require participation in continuing education programs for continued certification. Pathologists, therefore, rarely remain up-to-date with respect to the progress being made in their field. As a result they are unable to take advantage of new diagnostic tools, even when these are financially feasible, leading to loss of credibility and frustration.

The availability of professional journals and access to teaching materials is generally poor. Although the advent of the Internet has improved the situation somewhat, the type of high speed access required is not always available and may be costly. Moreover, there is a well-recognized gap in the availability of information on the Internet and its utilization.

Nature of Pathology Training

The training provided in many institutions is generally similar to that given in more developed countries. This not only makes such institutions appear more “modern” but is also attractive for those who wish to enroll in the institution – often because after successful completion of their training they are more likely to find opportunities abroad. This means that the prevalent diseases and conditions in the country are generally underemphasized. As a result, those who stay in their own country find themselves bewildered and unable to cope with on-the-ground realities.

Autopsies are an essential requirement for training a pathologist yet medical autopsies are rarely performed. This deprives the trainees of a very valuable means for learning and confirmation of the diagnoses they made in the course of the patient’s disease – in some ways, this is similar to the loss of patients to follow-up after treatment.

Unattractive and Hierarchal Service Structure

The structure of pathology services is generally unattractive and financial remuneration is a fraction of what a trained pathologist could command in an affluent country. A qualified pathologist in Pakistan would normally receive approximately $7,000 per annum. Although the cost of living is less, this still compares extremely poorly with the average earnings of a pathologist in USA, which on average is $223,000.

Frequently, newly trained pathologists working for the government are posted to a small hospital in an area distant from a major city, leading to professional and social isolation with poor chances of further advancement. There is little money even for routine services, let alone academic work or research, and access to the limited available funding is tightly controlled by the local bureaucracy. If an enterprising pathologist were to try and arrange his own resources, this could create major difficulties with his administrative superiors. This system has evolved over decades and in the absence of radical government reforms is likely to persist for the foreseeable future. Given political instability, such reform is highly unlikely to be a priority of governments. The lack of security in some rural regions also adds to the poor quality of life and provides an added deterrent to those who might otherwise rise to the challenge of providing improved pathology services in outlying areas.

Brain Drain

The reasons that persuade pathologists to leave their own countries are numerous and complex. The serious negative impact of the continuing exodus, however, is only too obvious in developing countries. Although fewer in terms of the absolute numbers of migrants, the poorest countries tend to be the worst affected, although as countries try to improve their educational programs, this is likely, for a time, to lead to pathologists being more readily able to acquire jobs in other countries. According to a report, in Zimbabwe in 2006, out of 145 senior registrars, only 36 were still working in Zimbabwe, and there were only 72 specialist consultants instead of the predicted 189. There were only two specialist pathologists out of the eight required even to staff the existing programs and a serious shortage of senior pathologists. A deficit in State Certified Medical Laboratory Technicians was estimated to be in the region of 89%, further impairing the ability of pathologists to practice efficiently.

Internal Brain Drain

Although not publicized as much, the desire of trained personnel to work in major urban centers leaves large areas in low- and middle-income countries without any pathology cover. This is despite of the fact that in many countries, the candidates for training from less developed regions of the country are granted incentives. Yet few choose to serve the regions from which they came after completing their training (a parallel to the international brain drain). In Tanzania for example, out of 16 or so pathologists, 13 serve in the capital city, Dar es Salaam. In Ghana, in 2006, all trained pathologists in the country were working in the capital city, Accra. As a consequence, the diagnosis of a malignancy in peripheral areas could take weeks or months.

What Needs To Be Done?

Humans have emigrated for times immemorial for reasons that were not dissimilar to those operating today. It will take decades, if not more, to change the situation. Improvements are predicated upon substantial changes in the material and cultural environment. This will take a great deal of time. However a number of steps can be proposed to stop the continuing slide and to materially improve the situation.

Establishing and Improving Indigenous Institutions

Although financial considerations are significant for emigrants, they are not the only reason that professionals wish to practice in other countries. The ability to improve and develop professionally is also a major reason. Some institutions in developing countries have provided a good academic environment with reasonable financial packages and have been successful in attracting qualified natives who migrated to return, while retaining more of those trained locally. All consultant pathologists working at Shaukat Khanum Memorial Hospital in Lahore, Pakistan, for example, have had additional training abroad, mostly in the USA and UK. A similar situation is seen at the Aga Khan University in Karachi.

A number of institutions in developed countries, such as the College of American Pathologists and the University of Calgary, have developed plans through which trained pathologists spend a variable period of time in these institutions. Such collaboration can help to improve available services – as long as trainees are not tempted to return to the high-income countries. A more sustainable program is one in which permanent facilities are established in developing countries in collaboration with local governments. During the 1960s, Indiana University helped establish a postgraduate program at the Basic Medical Sciences Institute in Karachi. More than a hundred pathologists have passed through this training program, and in turn, trained hundreds more, which has improved the quality of pathology throughout Pakistan.

Changes in Training

Thought should be given to training programs in pathology. It may be more useful, for example, to aim for shorter training courses covering all essential aspects of the major disciplines of pathology. This approach to emphasizing generalist training has several strengths. More pathologists can be trained and their deployment more flexible. Such pathologists will have more knowledge of the common conditions they will encounter, particularly in peripheral areas. After working in rural regions for some years, they will have developed valuable experience in pathology as a whole and some of them could receive more advanced training in the sub-specialty of their choosing. The same approach could be employed for technologists.

Training must be in tune with the conditions faced in everyday practice and the available resources. Training in the use of manual equipment (which tends to be more reliable and more readily maintained) and special emphasis on the prevalent diseases is important. In order to achieve this, it is essential for pathologists in developing countries to establish their own academic and professional institutions, such as Colleges of Pathologists, which should also be given more control over the national pathology curricula. Such institutions could also have a major role in accreditation and continuing education.

South-South Cooperation

There are a number of world-class institutions in developing countries (Fig. 1). There should be more cooperation among them in deciding upon curricula and the actual provision of training in-country. Such training is far less expensive, should be adapted to the local or regional needs, and is not as likely to lead to migration as training abroad. In this regard, INCTR has helped train health professionals from Afghanistan and Nigeria in India and Pakistan. Such efforts should be more extensive and better organized.

Telepathology

The digital revolution has transformed the way pathology is practiced all over the world, including in the developing countries. Telepathology, in which diagnoses are made in other countries to which pathology images of sections are transmitted, is already providing a service in the Solomon Islands, where there are no pathologists. Several software systems are available and openly accessible (i.e., at no cost). In Virtual Slides, the microscopic images seen from a microscope attached to a computer can be moved remotely from any computer connected to the Internet. In iPATH, libraries of images can be created for training purposes, and digital images uploaded to a password-protected website for consultation purposes. Many pathologists, including those recently retired from senior positions in high-income countries, would be willing to give some of their time to endeavors of this kind, which require no travel and minimal cost. Digital technology could knit far flung areas into a network and provide a better and reliable output. It will become an increasingly valuable component of continuing medical education and will be especially useful for countries like Afghanistan, Iraq and African countries, which are presently drastically underserved. In this context initiatives like Open Educational Resources Cancer Community (OERC) (http://teachingcommons.cdl.edu/oerc/) could be very useful.

It is vital for the provision of reliable pathology services in developing countries to have well-trained pathologists who remain in their own countries or return home to work. However, many obstacles will need to be overcome before this goal can be achieved. There are no shortcuts, but the solutions are clear: the establishment of more academic institutions producing more and better trained pathologists and the provision of better working environments.

Manzoor Ahmad
College of Pathologists
Rawalpindi, Pakistan