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The Teaching of Organ Pathology in European Undergraduate Programs in Medicine, II
Path. Res. Pract. 190,636-640 (1994)
Pathology in Europe
The Teaching of Organ Pathology in European Undergraduate Programs in Medicine, III
o.
H. Iversen
University of Oslo, Institute of Pathology, Rikshospitalet, Oslo, Norway
History
At the IX European Congress of Pathology in Hamburg in 1982 the European Society of Pathology set up a working group on the undergraduate teaching of pathology in Europe. New ideas and teaching methods were discussed, and some of the main problems facing pathology teachers were taken up. The group formulated a set of educational objectives for teaching pathology, outlined the subject contents and number of teaching hours necessary to achieve these objectives, and discussed at what point during the medical course the teaching should take place. These proposals were published as a article in Path Res Pract 178, 518-519,1984. At the X European Congress in Athens in 1985, we considered the teaching of general pathology in European undergraduate education programs in medicine. Subject contents, time, place, teaching methods and the construction of a syllabus guide for general pathology were discussed and defined in detail. The results of this discussion were published in Path Res Pract 181, 365-369, 1986. In two symposia in Porto in 1989 we concentrated on the teaching of organ pathology as a separate subject, apart from general pathology. We discussed teaching methods and the length of time that should be allotted to specific organs. The organs and systems that were discussed in detail were the heart and blood vessels, the respiratory system, the bone marrow, the blood and lymphoreticular tissues, the alimentary tract and pancreas, the liver and biliary tract, and the kidneys and urinary tract. We had planned a fourth symposium to deal with the remaining parts of organ pathology at the XIII Congress in Ljubljana in 1991, into which Professor Dusan Ferluga and his colleagues put a great deal of work. Unfortunately, the congress had to be cancelled. At the XIV Congress in Innsbruck in 1993 we completed our discussion on organ pathology, and our suggestions and conclusion are given below. In addition, we suggested a forthcoming symposium on examination forms to be held in Copenhagen in 1995, as part of the XV Congress.
1 Teaching symposium at the XIV European Congress of Pathology, Innsbruck, September 9th 1993. Participants: O. H. Iversen, Norway, N. Jonsson, Sweden, C. J. Kirkpatrick, Germany, K. Lapis, Hungary, C. F. Lindboe, Norway, K. W. Schmid, Germany, W. F. Whimster, Great Britain.
0344-0338/94/0190-0636$3.50/0
© 1994 by Gustav Fischer Verlag, Stuttgart
Organ Pathology in Undergraduate Education . 637
Introduction (0. H. Iversen) Iversen pointed out that quality control is just as essential for undergraduate teaching as it is at the postgraduate level. Furthermore, with the increasing cooperation between the peoples of Europe, both formally and in practice, it seems logical to coordinate the training of physicians throughout Europe. He emphasized that the proposed curriculum was a minimum core curriculum, and that it ought to be expanded at those universities which are able and willing to assign more hours to pathology. At many universities neuropathology, dermatopathology, ENT and eye pathology, orthopaedic pathology, and others are taught as part of the clinical curriculum, albeit often by clinicians ratherthan pathologists. Nevertheless, this leaves more time for the study of the pathology of the large organ systems. The Endocrine System (K. W. Schmid) Professor Schmid suggested that the endocrine system should be treated as a whole, consisting as it does of a highly integrated set of glands and a widely distributed set of cells whose primary function is the control of homeostasis. He suggested the following program: 1) Introductory lecture, with a review of the physiological and biochemical principles of hormones, their regulation and actions, and the pathophysiological mechanisms. 2) General survey of the above principles as they apply to the major diseases of the endocrine glands, including hyperfunction, hypofunction, benign and malignant tumours, etc. 3) The organ pathology of the endocrine organs (pituitary, pineal gland, adrenals, thyroid gland, parathyroid glands, endocrine pancreas, diffuse endocrine systems), including anatomical abnormalities, inflammation, secretory malfunctions, tumours. 4) Special emphasis on practical histology, showing the application and interpretation of changes in hormones and neuroendocrine markers located by immunochemical methods. Student participation and activity should be encouraged as much as possible and preferably discussions and problem-solving exercises should be included. A final test, preferably consisting of a written and an oral examination might be introduced. The Nervous System and the Muscles (C. F. Lindboe) Professor Lindboe stressed that 4 hours was far too short for the formal teaching of neuropathology (see General Discussion). He suggested, however, that if only 4 hours were available, the student ought to spend almost all the time in attending macroscopical and microscopical cours.es, because they are the most efficient methods of learning neuropathology.
He suggested that the following subjects should be taught in this way: 1 + 2) Demonstration of unfixed, fixed or plasti-
nated specimens
Contusions, lacerations, brain oedema, herniation, extra- and intracerebral haematomas, ruptured saccular aneurysms, infarctions of different ages and locations, purulent meningitis, brain abscess, encephalitis, multiple sclerosis, atrophy, malformations, periventricular leukomalacia, tumours (gliomas, meningiomas, metastases).
3 + 4) Histological sessions, with discussion of the
most relevant diseases
Infarcts (recent and old), ischaemic nerve cell damage (recent and old), meningitis, encephalitis, Alzheimer's disease, multiple sclerosis, gliomas (low and high grade), meningiomas, skeletal muscle pathology (enervation, dystrophy, myositis), and a discussion of special staining methods in neuropathology (Bodian, Luxol, GFAP, NFP). The Male Reproductive System (K. Lapis) Professor Lapis suggested that only one of the hours should be devoted to lecturing, while the remaining three should be utilized for practical teaching at the autopsy table and for the study of histological preparations in small group tutorials. 1) A lecture on the embryonic development of the male genital tract and postnatal development of the testis, physiological steps of spermatogenesis and the regulation of prostatic growth. Some emphasis should be on male infertility, testicular tumours, nodular prostatic hyperplasia and its complications, and prostatic cancer. 2-4) Three hours' practical teaching in which the following subjects should be covered: for the penis: congenital anomalies, phimosis, inflammations, condyloma acuminatum, verrucous carcinoma, carcinoma in situ and carcinoma; for the testis <~d epididymis: atrophy, acute, specific and chronic orchitis and a brief review of cryptorchidism. Autoimmune diseases, gonorrhoea, mumps, tuberculosis, syphilis and torsio testis. Of the testicular tumours, germ cell tumours of the sex cord and gonadal stroma, and testicular lymphoma and adenomatoid tumours. For the prostate, acute and chronic prostatitis, nodular hyperplasia, and carcinoma. The Female Reproductive Tract, Including the Breast J. Kirkpatrick)
(c.
Professor Kirkpatrick suggested the following outline for 6 hours of teaching: 1) The first lecture should be used as an introduction to the female reproductive tract, beginning with describing the general cyclical changes which occur
638 . O. H. Iversen
2)
3)
4)
5)
6)
in the internal genitalia, and emphasizing the close interaction between the ovary and endometrium. A brief review of the diagnostic techniques used in pathology for these organs provides an opportunity to discuss, using examples, the advantages and limitations of cytology and curettage. The last half of dle lecture should deal with the pathology of pelvic inflammatory diseases and endometriosis. Tape slide sessions and poster demonstrations could be used as supplements. The second lecture should be about the pathology of the endometrium and the myometrium. The following topics should be treated: endometritis, endometrial hyperplasia of cystic glandular type, of adenomatous type with varying degrees of atypia, and endometrial neoplasia with particular emphasis on adenocarcinoma. Adenomyosis and myometrial neoplasia with leiomyoma and (rare) leiomyosarcoma can then be discussed. The use of real case histories are an effective method here and many of the pathological lesions could be treated under the clinical heading of menorrhagia or post-menopausal bleeding. The third lecture should deal with lesions of the uterine cervix: cervicitis, ectopia and squamous metaplasia, hyperplasia, and neoplasia, including cervical intra epithelial neoplasia (CIN), micro-invasive carcinoma and invasive carcinoma. This subject lends itself easily to a formal lecture accompanied by case histories and tape slide sessions. The fourth lecture should concentrate on lesions of the vulva, vagina and ovaries. Vulvar pathology encompasses inflammation, "dystrophies", intraepithelial and invasive carcinomas and other lesions, including condylomata acuminata. Vaginal pathology should cover inflammation and neoplasms. Concerning the ovary, a variety of cysts should be mentioned, and ovarian neoplasms of epithelial type, benign, borderline and malignant, germ cell tumours, sex cord stromal tumours and miscellaneous tumours, including metastases. The lecture should be accompanied by tape slide sessions, posters and histological slide demonstrations. The fifth lecture should deal with infertility and pregnancy. Endocrinological disturbances associated with infertility are best dealt with by a clinician, while genital tract malformations could be treated by a morphologist. On the topic of pregnancy the following items are suggested: ectopic pregnancy, placental lesions, the pathology of preeclampsia and eclampsia, disseminated intravascular coagulation, and trophoblastic lesions such as hydatidiform moles and choriocarcinoma. Tape slide sessions would be a good ideal here, in addition to teaching in small groups. The lectures on the pathology of the breast should start with a description of the breast's anatomy, and the micro-anatomy of the terminal duct lobular unit. The most i~portant diseases can be conveniently classified as non-neoplastic diseases (inflam-
mation and fibrocystic disease) and neoplasia. In this context the lecture should cover atypical hyperplasia, carcinoma in situ, duct carcinoma in situ with its different forms, lobular carcinoma in situ, and finally invasive carcinoma of ductal or lobular forms. Features such as connective tissue reactions, microcalcification, correlation with mammography, mucin-producing carcinomas and medullary carcinoma should be mentioned. Paget's disease of the nipple should also be described. Diagnostic methods are important: cytology, needle biopsy, frozen section diagnosis, and hormone receptor determination. A more clinically oriented presentation could include a discussion of the pathology of a lump in the breast. The Skin, Bones and Joints (N. Jonsson) In many medical schools the pathology of these organs are not taught as part of the pathology course, but rather in connection with clinical courses in dermatology and in bone and joint diseases. If the clinicians are willing to call in a pathologist to supplement the clinical teaching, this would leave more teaching time for some of the major topics in pathology, as mentioned above. In dermatopathology the first two subjects should concern biopsy techniques for the skin, some recapitulation of skin histology and architecture, and a review of the general reaction patterns of the different tissues in the skin. Inflammatory reactions and mechanisms of blister formation should be emphasized. Examples of some dermatoses should be given. The third theme should be devoted to non-melanocytic tumours and tumour-like lesions, and the fourth to melanocytic lesions, naevi, dysplastic naevus syndrome, and melanomas, treating the macroscopical appearance, histology and relation to UV radiation. If an extra hour is available, it could be devoted to training in microscope work. The students should be given an opportunity to learn to take punch biopsies during the clinical course in addition to the formal teaching. For othopaedic pathology, important subjects should be the cell types in soft tissues and their reaction patterns, with survey of soft tissue tumours and tumourlike conditions, mentioning osteoporosis, osteomalacia, inflammatory conditions and a few instructive bone diseases, for instance osteitis fibrosa cystica, and Paget's disease. One lecture should be devoted to tumours and tumour-like conditions of the bone, mentioning the principles of diagnosis and emphasizing osteogenic sarcoma and other bone tumours, both primary and metastatic. Finally, macroscopic demonstration of surgical specimens and some of microscopic training would be a great advantage. Students ought to have the opportunity to take part in clinicopathological conferences in connection with the clinical training.
Organ Pathology in Undergraduate Education' 639
Eye, Ear, Nose and Throat Pathology (W. F. Whimster) These organs are also frequently dealt with in connection with clinical courses only. This is a very good solution; and again it would release more hours for pathology. The core curriculum in ENT pathology should cover the ear with otitis externa and media (mastoiditis, brain abscess), congenital and acquired cholesteatoma, some malformations of the inner ear, and some tumours of the external ear, middle ear and acoustic neuromas. Otosclerosis and ototoxicity and presbyacusis could be mentioned. In the nose, the sinuses and the nasopharynx, adenoids and tonsils, infections, polyps, angiofibromas and nasopharyngeal carcinoma and lymphoma should be mentioned. In the larynx and hypopharynx, acute and chronic inflammations, polyps, and tumours should be mentioned, and for the salivary glands and neck, infections and tumours, especially pleomorphic adenoma, Warthin's tumour, carotid body tumour, and Sjogren's syndrome. One should also mention cysts, including thyreoglossal duct cyst and branchial cysts. Eye pathology should cover geographical and epidemic blinding diseases by viruses and chlamydia, trachoma, diet and vitamin deficiency, onchocercosis, diabetes and sickle cell disease, glaucoma, with open and closed angel glaucoma, the effects of ageing, and an exaggerated healing response. Retinopathies due to ischaemia must be mentioned, and neovascularization, diabetic eye disease, the retinopathy of prematurity. Corneal diseases are important, latency of herpes virus and corneal dystrophies. Tumours, including extra- and intra-bulbar tumours, must be discussed. Retinoblastoma should be mentioned, with the role played by its interesting retinoblastoma gene, and ocular melanomas. Finally, the effect of systemic diseases like hypertension, diabetes, ageing and autoimmunity of the eye should be touched upon. If there is time, congenital abnormalities of the eye and orbita might be touched upon. General Discussion and Summing Up The symposium was well attended, with about 50 participants. There was general agreement on the importance of presenting a core curriculum, particularly in view of the latest developments in the teaching of medicine. Demands for more time to be devoted to subjects like preventive medicine, psychology and doctor patient relations and to practical training in venepuncture, use of the stethoscope, etc., are encroaching on the time available for pathology and other theoretical subjects. Pathologists need to make the point very clearly that a knowledge of the main principle of pathology is a basic requirement for good medical practice. While no
one would dispute the importance of learning about the psychological aspects of medicine and patient contact, not to mention practical training, it must be borne in mind that the natural place for these subjects is in connection with hospital work and clinical practice. An ability to diagnose disease correctly is an essential prerequisite for good doctor-patient relations. All the participants agreed that pathology is under threat, and that the situation calls for the attitude of the British general whose dispatch from the front line read as follows: "Situation hopeless. Surrounded on all sides by the enemy. Attacking at dawn tomorrow." However, it was pointed out that the best method of attack was to cultivate friendly relations with clinicians and to encourage a spirit of cooperation among the entire body of undergraduate teachers. Some of the participants raised the question of quality control with respect to examination, and the chairman was asked to contact the organizing committee for the next pathology congress in Copenhagen to arrange for a symposium on examinations to be held. Among the subjects to be discussed here will be examination methods: the advantages and disadvantages of essays, multiple choice tests, practical examinations, e.g. in microscopy and macroscopical descriptions, and oral examinations. The value of examinations as a teaching method should also be discussed .. The chairman suggested that as a culmination of this set of sessions on teaching, a brochure should be published setting out our suggestions for the teaching of undergraduate pathology. Funds might be obtained from the European Society of Pathologists, and perhaps from advertising. The brochure could be distributed, perhaps for a small charge, to all the departments of pathology in Europe. It would contain the agreed core curriculum for the whole field of general and organ pathology, and suggestions for teaching methods and forms of examination. The suggestion received general support. Finally, a discussion arose as to whether the publication of a minimum core curriculum would rebound on pathology departments that already have a generous allowance of teaching hours. The curriculum is based on a minimum of 80 teaching hours, around 20 for general pathology and 60 for organ pathology. Dr. Whimster mentioned the very large variations in teaching hours between the various universities in the UK and Ireland, ranging from 59 hours at King's College, London, to 342 hours at the University of Teaching hours" alloted to core curriculum for pathology in Europe Obligatory Optional General pathology
17-19
Organ pathology
63
20-26
83-89
Total pathology
80-82
25-33
105-115
"One hour
= 45
5-7
Sum
minutes lecturing time
22-26
640 . O. H. Iversen
Dundee. He suggested that the brochure should emphasize strongly that the recommended curriculum represented an absolute minimum. There was general agreement that medicine would benefit from an increase in the number of hours devoted to pathology teaching. It was also stressed that new teaching methods will also affect pathology. Problem-oriented teaching in small groups will increase the teaching load of university pathologists, and integrated teaching, i.e. teaching all aspects of a subject or of a particular patient to-
gether, will break down the traditional divisions, which usually reduces the importance of and the time allotted to pathology. A further difficulty is the tendency to reduce formal teaching by 30 percent for undergraduates and to postpone the rest to postgraduate education. This cuts down on the time available for undergraduate pathology, and many of the participants felt that this would have undesirable consequences which would soon be regretted.
Received February 12, 1994 . Accepted March 5, 1994 O. H. Iversen, Institute of Pathology, University of Oslo, Rikshospitalet, 0027-0sI0, Norway
Pathology in Europe
The Teaching of Organ Pathology in European Undergraduate Programs in Medicine, III
o.
H. Iversen
University of Oslo, Institute of Pathology, Rikshospitalet, Oslo, Norway
History
At the IX European Congress of Pathology in Hamburg in 1982 the European Society of Pathology set up a working group on the undergraduate teaching of pathology in Europe. New ideas and teaching methods were discussed, and some of the main problems facing pathology teachers were taken up. The group formulated a set of educational objectives for teaching pathology, outlined the subject contents and number of teaching hours necessary to achieve these objectives, and discussed at what point during the medical course the teaching should take place. These proposals were published as a article in Path Res Pract 178, 518-519,1984. At the X European Congress in Athens in 1985, we considered the teaching of general pathology in European undergraduate education programs in medicine. Subject contents, time, place, teaching methods and the construction of a syllabus guide for general pathology were discussed and defined in detail. The results of this discussion were published in Path Res Pract 181, 365-369, 1986. In two symposia in Porto in 1989 we concentrated on the teaching of organ pathology as a separate subject, apart from general pathology. We discussed teaching methods and the length of time that should be allotted to specific organs. The organs and systems that were discussed in detail were the heart and blood vessels, the respiratory system, the bone marrow, the blood and lymphoreticular tissues, the alimentary tract and pancreas, the liver and biliary tract, and the kidneys and urinary tract. We had planned a fourth symposium to deal with the remaining parts of organ pathology at the XIII Congress in Ljubljana in 1991, into which Professor Dusan Ferluga and his colleagues put a great deal of work. Unfortunately, the congress had to be cancelled. At the XIV Congress in Innsbruck in 1993 we completed our discussion on organ pathology, and our suggestions and conclusion are given below. In addition, we suggested a forthcoming symposium on examination forms to be held in Copenhagen in 1995, as part of the XV Congress.
1 Teaching symposium at the XIV European Congress of Pathology, Innsbruck, September 9th 1993. Participants: O. H. Iversen, Norway, N. Jonsson, Sweden, C. J. Kirkpatrick, Germany, K. Lapis, Hungary, C. F. Lindboe, Norway, K. W. Schmid, Germany, W. F. Whimster, Great Britain.
0344-0338/94/0190-0636$3.50/0
© 1994 by Gustav Fischer Verlag, Stuttgart
Organ Pathology in Undergraduate Education . 637
Introduction (0. H. Iversen) Iversen pointed out that quality control is just as essential for undergraduate teaching as it is at the postgraduate level. Furthermore, with the increasing cooperation between the peoples of Europe, both formally and in practice, it seems logical to coordinate the training of physicians throughout Europe. He emphasized that the proposed curriculum was a minimum core curriculum, and that it ought to be expanded at those universities which are able and willing to assign more hours to pathology. At many universities neuropathology, dermatopathology, ENT and eye pathology, orthopaedic pathology, and others are taught as part of the clinical curriculum, albeit often by clinicians ratherthan pathologists. Nevertheless, this leaves more time for the study of the pathology of the large organ systems. The Endocrine System (K. W. Schmid) Professor Schmid suggested that the endocrine system should be treated as a whole, consisting as it does of a highly integrated set of glands and a widely distributed set of cells whose primary function is the control of homeostasis. He suggested the following program: 1) Introductory lecture, with a review of the physiological and biochemical principles of hormones, their regulation and actions, and the pathophysiological mechanisms. 2) General survey of the above principles as they apply to the major diseases of the endocrine glands, including hyperfunction, hypofunction, benign and malignant tumours, etc. 3) The organ pathology of the endocrine organs (pituitary, pineal gland, adrenals, thyroid gland, parathyroid glands, endocrine pancreas, diffuse endocrine systems), including anatomical abnormalities, inflammation, secretory malfunctions, tumours. 4) Special emphasis on practical histology, showing the application and interpretation of changes in hormones and neuroendocrine markers located by immunochemical methods. Student participation and activity should be encouraged as much as possible and preferably discussions and problem-solving exercises should be included. A final test, preferably consisting of a written and an oral examination might be introduced. The Nervous System and the Muscles (C. F. Lindboe) Professor Lindboe stressed that 4 hours was far too short for the formal teaching of neuropathology (see General Discussion). He suggested, however, that if only 4 hours were available, the student ought to spend almost all the time in attending macroscopical and microscopical cours.es, because they are the most efficient methods of learning neuropathology.
He suggested that the following subjects should be taught in this way: 1 + 2) Demonstration of unfixed, fixed or plasti-
nated specimens
Contusions, lacerations, brain oedema, herniation, extra- and intracerebral haematomas, ruptured saccular aneurysms, infarctions of different ages and locations, purulent meningitis, brain abscess, encephalitis, multiple sclerosis, atrophy, malformations, periventricular leukomalacia, tumours (gliomas, meningiomas, metastases).
3 + 4) Histological sessions, with discussion of the
most relevant diseases
Infarcts (recent and old), ischaemic nerve cell damage (recent and old), meningitis, encephalitis, Alzheimer's disease, multiple sclerosis, gliomas (low and high grade), meningiomas, skeletal muscle pathology (enervation, dystrophy, myositis), and a discussion of special staining methods in neuropathology (Bodian, Luxol, GFAP, NFP). The Male Reproductive System (K. Lapis) Professor Lapis suggested that only one of the hours should be devoted to lecturing, while the remaining three should be utilized for practical teaching at the autopsy table and for the study of histological preparations in small group tutorials. 1) A lecture on the embryonic development of the male genital tract and postnatal development of the testis, physiological steps of spermatogenesis and the regulation of prostatic growth. Some emphasis should be on male infertility, testicular tumours, nodular prostatic hyperplasia and its complications, and prostatic cancer. 2-4) Three hours' practical teaching in which the following subjects should be covered: for the penis: congenital anomalies, phimosis, inflammations, condyloma acuminatum, verrucous carcinoma, carcinoma in situ and carcinoma; for the testis <~d epididymis: atrophy, acute, specific and chronic orchitis and a brief review of cryptorchidism. Autoimmune diseases, gonorrhoea, mumps, tuberculosis, syphilis and torsio testis. Of the testicular tumours, germ cell tumours of the sex cord and gonadal stroma, and testicular lymphoma and adenomatoid tumours. For the prostate, acute and chronic prostatitis, nodular hyperplasia, and carcinoma. The Female Reproductive Tract, Including the Breast J. Kirkpatrick)
(c.
Professor Kirkpatrick suggested the following outline for 6 hours of teaching: 1) The first lecture should be used as an introduction to the female reproductive tract, beginning with describing the general cyclical changes which occur
638 . O. H. Iversen
2)
3)
4)
5)
6)
in the internal genitalia, and emphasizing the close interaction between the ovary and endometrium. A brief review of the diagnostic techniques used in pathology for these organs provides an opportunity to discuss, using examples, the advantages and limitations of cytology and curettage. The last half of dle lecture should deal with the pathology of pelvic inflammatory diseases and endometriosis. Tape slide sessions and poster demonstrations could be used as supplements. The second lecture should be about the pathology of the endometrium and the myometrium. The following topics should be treated: endometritis, endometrial hyperplasia of cystic glandular type, of adenomatous type with varying degrees of atypia, and endometrial neoplasia with particular emphasis on adenocarcinoma. Adenomyosis and myometrial neoplasia with leiomyoma and (rare) leiomyosarcoma can then be discussed. The use of real case histories are an effective method here and many of the pathological lesions could be treated under the clinical heading of menorrhagia or post-menopausal bleeding. The third lecture should deal with lesions of the uterine cervix: cervicitis, ectopia and squamous metaplasia, hyperplasia, and neoplasia, including cervical intra epithelial neoplasia (CIN), micro-invasive carcinoma and invasive carcinoma. This subject lends itself easily to a formal lecture accompanied by case histories and tape slide sessions. The fourth lecture should concentrate on lesions of the vulva, vagina and ovaries. Vulvar pathology encompasses inflammation, "dystrophies", intraepithelial and invasive carcinomas and other lesions, including condylomata acuminata. Vaginal pathology should cover inflammation and neoplasms. Concerning the ovary, a variety of cysts should be mentioned, and ovarian neoplasms of epithelial type, benign, borderline and malignant, germ cell tumours, sex cord stromal tumours and miscellaneous tumours, including metastases. The lecture should be accompanied by tape slide sessions, posters and histological slide demonstrations. The fifth lecture should deal with infertility and pregnancy. Endocrinological disturbances associated with infertility are best dealt with by a clinician, while genital tract malformations could be treated by a morphologist. On the topic of pregnancy the following items are suggested: ectopic pregnancy, placental lesions, the pathology of preeclampsia and eclampsia, disseminated intravascular coagulation, and trophoblastic lesions such as hydatidiform moles and choriocarcinoma. Tape slide sessions would be a good ideal here, in addition to teaching in small groups. The lectures on the pathology of the breast should start with a description of the breast's anatomy, and the micro-anatomy of the terminal duct lobular unit. The most i~portant diseases can be conveniently classified as non-neoplastic diseases (inflam-
mation and fibrocystic disease) and neoplasia. In this context the lecture should cover atypical hyperplasia, carcinoma in situ, duct carcinoma in situ with its different forms, lobular carcinoma in situ, and finally invasive carcinoma of ductal or lobular forms. Features such as connective tissue reactions, microcalcification, correlation with mammography, mucin-producing carcinomas and medullary carcinoma should be mentioned. Paget's disease of the nipple should also be described. Diagnostic methods are important: cytology, needle biopsy, frozen section diagnosis, and hormone receptor determination. A more clinically oriented presentation could include a discussion of the pathology of a lump in the breast. The Skin, Bones and Joints (N. Jonsson) In many medical schools the pathology of these organs are not taught as part of the pathology course, but rather in connection with clinical courses in dermatology and in bone and joint diseases. If the clinicians are willing to call in a pathologist to supplement the clinical teaching, this would leave more teaching time for some of the major topics in pathology, as mentioned above. In dermatopathology the first two subjects should concern biopsy techniques for the skin, some recapitulation of skin histology and architecture, and a review of the general reaction patterns of the different tissues in the skin. Inflammatory reactions and mechanisms of blister formation should be emphasized. Examples of some dermatoses should be given. The third theme should be devoted to non-melanocytic tumours and tumour-like lesions, and the fourth to melanocytic lesions, naevi, dysplastic naevus syndrome, and melanomas, treating the macroscopical appearance, histology and relation to UV radiation. If an extra hour is available, it could be devoted to training in microscope work. The students should be given an opportunity to learn to take punch biopsies during the clinical course in addition to the formal teaching. For othopaedic pathology, important subjects should be the cell types in soft tissues and their reaction patterns, with survey of soft tissue tumours and tumourlike conditions, mentioning osteoporosis, osteomalacia, inflammatory conditions and a few instructive bone diseases, for instance osteitis fibrosa cystica, and Paget's disease. One lecture should be devoted to tumours and tumour-like conditions of the bone, mentioning the principles of diagnosis and emphasizing osteogenic sarcoma and other bone tumours, both primary and metastatic. Finally, macroscopic demonstration of surgical specimens and some of microscopic training would be a great advantage. Students ought to have the opportunity to take part in clinicopathological conferences in connection with the clinical training.
Organ Pathology in Undergraduate Education' 639
Eye, Ear, Nose and Throat Pathology (W. F. Whimster) These organs are also frequently dealt with in connection with clinical courses only. This is a very good solution; and again it would release more hours for pathology. The core curriculum in ENT pathology should cover the ear with otitis externa and media (mastoiditis, brain abscess), congenital and acquired cholesteatoma, some malformations of the inner ear, and some tumours of the external ear, middle ear and acoustic neuromas. Otosclerosis and ototoxicity and presbyacusis could be mentioned. In the nose, the sinuses and the nasopharynx, adenoids and tonsils, infections, polyps, angiofibromas and nasopharyngeal carcinoma and lymphoma should be mentioned. In the larynx and hypopharynx, acute and chronic inflammations, polyps, and tumours should be mentioned, and for the salivary glands and neck, infections and tumours, especially pleomorphic adenoma, Warthin's tumour, carotid body tumour, and Sjogren's syndrome. One should also mention cysts, including thyreoglossal duct cyst and branchial cysts. Eye pathology should cover geographical and epidemic blinding diseases by viruses and chlamydia, trachoma, diet and vitamin deficiency, onchocercosis, diabetes and sickle cell disease, glaucoma, with open and closed angel glaucoma, the effects of ageing, and an exaggerated healing response. Retinopathies due to ischaemia must be mentioned, and neovascularization, diabetic eye disease, the retinopathy of prematurity. Corneal diseases are important, latency of herpes virus and corneal dystrophies. Tumours, including extra- and intra-bulbar tumours, must be discussed. Retinoblastoma should be mentioned, with the role played by its interesting retinoblastoma gene, and ocular melanomas. Finally, the effect of systemic diseases like hypertension, diabetes, ageing and autoimmunity of the eye should be touched upon. If there is time, congenital abnormalities of the eye and orbita might be touched upon. General Discussion and Summing Up The symposium was well attended, with about 50 participants. There was general agreement on the importance of presenting a core curriculum, particularly in view of the latest developments in the teaching of medicine. Demands for more time to be devoted to subjects like preventive medicine, psychology and doctor patient relations and to practical training in venepuncture, use of the stethoscope, etc., are encroaching on the time available for pathology and other theoretical subjects. Pathologists need to make the point very clearly that a knowledge of the main principle of pathology is a basic requirement for good medical practice. While no
one would dispute the importance of learning about the psychological aspects of medicine and patient contact, not to mention practical training, it must be borne in mind that the natural place for these subjects is in connection with hospital work and clinical practice. An ability to diagnose disease correctly is an essential prerequisite for good doctor-patient relations. All the participants agreed that pathology is under threat, and that the situation calls for the attitude of the British general whose dispatch from the front line read as follows: "Situation hopeless. Surrounded on all sides by the enemy. Attacking at dawn tomorrow." However, it was pointed out that the best method of attack was to cultivate friendly relations with clinicians and to encourage a spirit of cooperation among the entire body of undergraduate teachers. Some of the participants raised the question of quality control with respect to examination, and the chairman was asked to contact the organizing committee for the next pathology congress in Copenhagen to arrange for a symposium on examinations to be held. Among the subjects to be discussed here will be examination methods: the advantages and disadvantages of essays, multiple choice tests, practical examinations, e.g. in microscopy and macroscopical descriptions, and oral examinations. The value of examinations as a teaching method should also be discussed .. The chairman suggested that as a culmination of this set of sessions on teaching, a brochure should be published setting out our suggestions for the teaching of undergraduate pathology. Funds might be obtained from the European Society of Pathologists, and perhaps from advertising. The brochure could be distributed, perhaps for a small charge, to all the departments of pathology in Europe. It would contain the agreed core curriculum for the whole field of general and organ pathology, and suggestions for teaching methods and forms of examination. The suggestion received general support. Finally, a discussion arose as to whether the publication of a minimum core curriculum would rebound on pathology departments that already have a generous allowance of teaching hours. The curriculum is based on a minimum of 80 teaching hours, around 20 for general pathology and 60 for organ pathology. Dr. Whimster mentioned the very large variations in teaching hours between the various universities in the UK and Ireland, ranging from 59 hours at King's College, London, to 342 hours at the University of Teaching hours" alloted to core curriculum for pathology in Europe Obligatory Optional General pathology
17-19
Organ pathology
63
20-26
83-89
Total pathology
80-82
25-33
105-115
"One hour
= 45
5-7
Sum
minutes lecturing time
22-26
640 . O. H. Iversen
Dundee. He suggested that the brochure should emphasize strongly that the recommended curriculum represented an absolute minimum. There was general agreement that medicine would benefit from an increase in the number of hours devoted to pathology teaching. It was also stressed that new teaching methods will also affect pathology. Problem-oriented teaching in small groups will increase the teaching load of university pathologists, and integrated teaching, i.e. teaching all aspects of a subject or of a particular patient to-
gether, will break down the traditional divisions, which usually reduces the importance of and the time allotted to pathology. A further difficulty is the tendency to reduce formal teaching by 30 percent for undergraduates and to postpone the rest to postgraduate education. This cuts down on the time available for undergraduate pathology, and many of the participants felt that this would have undesirable consequences which would soon be regretted.
Received February 12, 1994 . Accepted March 5, 1994 O. H. Iversen, Institute of Pathology, University of Oslo, Rikshospitalet, 0027-0sI0, Norway