The Teaching of Pathology in Undergraduate Education Programs in Medicine in Europe

PATHOLOGY

RESEARCH AND PRACTICE

© Gustav Fischer Verlag

The Teaching of Pathology in Undergraduate Education Programs in Medicine in Europe O. H. Iversen Institute of Pathology, University of 0510,0027 Rikshospitalet, Oslo, Norway

Introduction At a council meeting of the European Society of Pathology in 1982, the members voted unanimously that a working group be set up to study the teaching of pathology in undergraduate education programs in medicine in Europe, and give reports at the various congresses of our society. Dr. Iversen of Oslo was made responsible for this. The working group consisted initially of the speakers at the 1982 congress symposium. Accordingly, 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. There was general agreement that one should try to establish a common core of knowledge in general and organ pathology for all European medical faculties, and that this might help teachers and faculties in planning their curricula and in realizing the plans. However, each country would have to adapt this plan to its own tradition, economy and circumstances. 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 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 medical education programs for undergraduates. 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). Pathol. Res. Pract. 193: 241-256 (1997)

Two symposia at the XII Congress in Porto in 1989 concentrated on the teaching of organ pathology as a separate subject (apart from general pathology). One 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, published in Path Res Pract 186: 542-548 (1990). At the XIV Congress in Innsbruck in 1993 we completed our discussion on organ pathology and discussed in detail the endocrine system, the nervous system and the muscles, the male reproductive system, the female reproductive system, the breast, the skin, bones and joints, the eye, and the ear, nose and throat. This was followed by a general discussion and summing up, in which we recommended that the whole course in pathology ought to take 105-115 hours, of which about 1/5 should be devoted to general pathology and 4/5 to organ pathology. The results were published in Path Res Pract 190: 636-640 (1994). At the XV Congress in Copenhagen in 1995 the teaching series was completed with a discussion on forms of examination. The results were published in Path Res Pract 192: 97-100 (1996).

Preface This study contains a somewhat shortened version of what was presented at the conferences, including the subjects Pedagogical Principles, General Pathology and Organ Pathology in European Undergraduate Education Programs in Medicine, and Quality Assurance-Discussion of the Validity and Reliability of Various Forms of 0344-0338/97/0193-0241 $5.00/0

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Examination. Specific names for the various items mentioned are not given. More details can be found in the five articles referred to above. This presentation is meant as a guideline and an inspiration to improve the teaching of pathology at the academic level. The speakers at the various sessions were: O. H. Iversen (Norway)I-5 W. F. Whimster (UK) 1,3-5 D. Ferluga (Yugoslavia)I-3 A. Anaya (Spain)! A. Cantaboni (Italy)l.2 G. Kloppel (Germany)l F. Bolek (Germany)l 1. Diebold (France)1 p. Prudhomme de Saint Maur (France)' V. Tsakraklides (Greece)2 F. Langmark (Norway)2 p. Anthony (UK)3 A. E. Becker (The Netherlands)3 H. Oliva (Spain)3 D. Serrao (Portugal)3 R. Trincao (Portugal)3 M. L. Matos Beja (Portugal)3 N. Jonsson (Sweden)4 C. J. Kirkpatrick (Germany)4.5 K. Lapis (Hungary)4.5 C. F. Lindboe (Norway)4 K. W. Schmid (Germany)4 R. S. Donner (USA)5 J. Tranum-Jensen (Denmark)5 1

Hamburg; 2Athens; 3Porto; 4Innsbruck; 5Copenhagen

I. Pedagogical Principles The pathology teacher may envisage his role in roughly one or two ways. He may try to stuff as many as possible of his favorite scientific details into the students, or may see himself as a spreader of grains of knowledge for the students themselves to pick up and digest. The latter type of teacher ought to be preferred. University education should not be thought of as filling a vessel, but as lighting a fire. The teacher of pathology must certainly be interested in the factual content of his teaching, but must also consider the way in which he conveys his information to the students. An ideal teacher is full of enthusiasm and knows his subjects so well that he can simplify without compromising scientific "truths." It appears to be important to teach the general principles of pathology in such a way as to give students a broad understanding of disease and to enable them to deduce tissue and organ changes from the basic principles of the inflammatory reaction, the immune mechanisms, the process of carcinogenesis, etc.

Undergraduate education in pathology must be designed to build on the knowledge of normal anatomy, physiology and biochemistry. In pathology the students learn the ways in which normal structure and function can and do go wrong in specific cells, tissues and organs. Many students unfortunately regard pathology as a hurdle to be quickly overcome and then forgotten instead of as the basis of rational medical practice. Rivalry between disciplines often results in a lack of balance in the time allotted to the different subjects in medicine, so that some subjects are covered in too much detail and others in too little. Although most students pass their examinations in pathology, the standards are often not very high and after graduation many students are surprised to discover how much more pathology is really needed in order to specialize. It is the duty of pathology teachers to improve this situation. The educational process is a combination of teaching and learning. Traditional pathology teaching has usually consisted of large groups of students with the teacher playing a dominant role in lectures and demonstrations. The disadvantage of this is that the student assumes a passive role. Modern educational trends are in favour of more active learning. Small discussion groups encourage the exchange of information between teacher and student, and between students. This may develop the student's ability to react to new situations and his creative ability. Pathology has often consisted of a boring presentation of morphological changes in a static way, and the students have therefore regarded it as a dull subject. Modern pathology teaching should show the relation between general pathology and the dynamic basic sciences, and between organ pathology and clinical disease. Slide seminars and clinico-pathological conferences should be incorporated. Lectures and individual study should be balanced by small group discussions. Using a variety of methods will make the pathology course more interesting and allow for the individual learning needs of the students. New technological developments, such as audiovisual aids, computer assisted instruction and interactive program courses, can make education more interesting. Formal evaluation and selfevaluation during the course may stimulate the students and provide necessary feedback information for both teacher and students. In most European countries pathology is taught between the basic sciences and the clinical subjects in the belief that it belongs to both. Some knowledge of general pathology and the main morphological alterations in tissues and organs is needed to understand disease, but detailed organ pathology is difficult to learn outside a clinical context. Some medical schools have completely broken up pathology into small units that are taught along with clinical medicine. This can break the continuity of the learning of pathology and minimize its importance as a discipline of its own. A good solution is to

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start with a course in general pathology, followed by a basic course in systemic pathology, and then add organ pathology in connection with the appropriate clinical discipline. Students should sit for the final examination in pathology when they have acquired enough clinical experience to see the importance of pathology for their daily work with patients. Undergraduate students tend to become so concerned about studying the symptomatology, diagnostics and therapy of diseases that they may not appreciate that each organic disease is associated with some derangement in the working of cells. In Milan the whole structure of the medical curriculum has been systematically assessed. Pathology has been given a unique position, starting with the students during the basic sciences years and carrying them through clinical medicine, stressing the continuity of the whole study of medicine with emphasis on how biochemical events are mirrored by cell-tissue-organ changes and how the latter can again explain the signs and symptoms of the disease in each particular patients. New research results and interesting medical cases should be brought into the teaching. To teach pathology successfully, pathology teachers and medical faculties need to keep questioning their methods of teaching. What are the factors that determine our attitude towards teaching and education? Memories of good teachers and how they taught can provide an ideal to live up to. Personal experiences in teaching can also be stimulating. Finally, there must be a permanent spirit of enthusiasm for teaching. The teacher at the academic level in pathology has often only reluctantly tried to tackle the problems of education in sciences, since the teaching is only a by-product of the scientific carreer and not the primary aim. But since progress in all the sciences depends largely on our ability to stimulate the activities of new students, we should also consider how much it would benefit us to inspire and inform future teachers in pathology about principles of education and new aspects of undergraduate education in pathology. It is an important task for the European Society of Pathology to try to work out such a program. Morphological and dynamic pathology has integrative functions between clinical medicine and the basic disciplines. The student must systematically learn to inspect and understand the phenomena observed - meaning not only learning to observe, but also to analyse as well as to synthesise. The presentation of morphological pathology should take these aims into account. The amount of clinical medicine and pathophysiology to be included in the teaching of pathology depends on a successful presentation of the connection between the disease and its underlying pathobiology. This varies from case to case, and depends largely on the ideas and personality of the teacher. The teacher of morphological

pathology should present the student with all the facts necessary to understand the correlation between the clinical picture and its morphological and functional background. This could be called synoptical presentation in morphological pathology. A very good method is interdisciplinary lectures given by a clinician, a pathologist and a pathophysiologist together. The teachers of pathology all over Europe probably teach in a fairly similar way because the patients mostly suffer from the same diseases. There was a great difference, however, in the time used to teaching. The time for pathology in East Germany (in 1982) was six times that allotted in France. DDR had more than 300 teaching hours in pathology, in Yugoslavia and Norway pathology had around 200 hours, but in France and the UK barely 50 hours, and may even have had less in some medical schools. These differences call for cooperative investigation between countries to discover whether they produce totally different types of doctors. However, before such a cooperation can be organized, many questions must be answered, such as: What do the students learn during the curriculum if they do not learn pathology? How can one convince clinicians that the time allotted to pathology is most often insufficient, and that cooperation and time-sharing will also benefit clinical teaching? Is not the teaching of pathology an art which is partly related to the national traditions of the various countries? Would it make things better or worse to try to even out the differences? If, nevertheless, we should agree upon the need for a platform for the teaching of pathology in Europe, the following points should be taken into account: 1) What should be the educational objectives of pathol-

ogy for undergraduate students? 2) What is the subject content necessary to achieve these objectives? 3) How much time do we need to achieve these objectives? 4) When should the teaching take place during the medical course? Dr. Yrjo ColIan from Finland emphasized that a physician's job largely consists of decision-making, and that general pathology ought to include the art of decision-making. Morphometry is a branch of general pathology that is especially suitable for teaching decision-making. It was stressed that not all groups should have exactly the same number of hours, each medical school has to choose what is most convenient according to the tradition there. The aim of the whole endeavour should then be to propose a common core curriculum in Europe for the teaching of general and organ pathology, which each of us can put before our medical faculties and say: This is in principle the way we want pathology to be taught in Europe in the coming years.

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Pedagogical Principles

The idea of teaching pathology is to convey from the teacher to the students a scientific attitude, a great amount of factual knowledge, and some practical training. Almost all studies on pedagogics have shown that even the most intelligent students learn only 10-20% of what is taught. Many learn less. The following methods of teaching are available for pathology: if;TI Books and atlases. This is the main source of information for the students. What the teacher can do is to inspire the students to read books, and advise them to the best books. The lecture format. The lecture approach has often been criticized. It is said to be impersonal, useless, boring and dehumanizing. But the lecture method has several advantages and can be made very effective in providing at least part of the education. It is probably the most effective and efficient method of transmitting a large amount of factual knowledge to a large group of students. The lecturer can precisely select and organize the content of the lecture. We should, therefore, in spite of new technological advances in teaching, still regard a well prepared and well delivered lecture as a very good method for transmitting information to rather large groups of students. EM Tutorials. Small group teaching can be a very good method of transferring information, but is time-consuming and a heavy burden for the teachers who have to repeat the same items many times. Still, good tutorials have a high value. The method of teaching in small tutorials is different from that of giving a lecture. The teacher's understanding, friendliness and positive body language become very important. The specific pedagogics must be learnt. !Jjj Audiovisual teaching systems can be presented as slides with spoken text, slides with books, video programs with spoken or printed texts, or as an interactive system. It is rather impersonal, but since pathology is easy to illustrate, it can be a very good and important method. Gv Problem solving. This is teaching which takes its inspiration from a single case, and is in many ways run as a clinicaUpathologicaUanatomical conference (CPC). From a particular patient case the students are inspired to find their ways to diagnosis and final assessment, based on biopsies and (often) autopsy results from the patient. Treatment strategies can be discussed. Practical teaching with macroscopical specimens, or at the autopsy table. This is a very good method, but it can only be done with relatively small groups of students.

Histology classes. The demonstration and study of selected histology slides is a very good way of exemplifying the pathological processes and training the student to understand the mechanisms of disease and the biopsy reports. The idea for the undergraduate teaching is not to produce a diagnostician, but to use the histological examples to illustrate disease processes. Classes of up to 50 students can be taught by one teacher, provided one has 50 microscopes and slide sets. IIA Elective teaching, in the way that one, or a group of few students write a small thesis on a subject of pathology, is usually the way the most interested and intelligent students select, when it is permitted. r~J Examination. The way the examination is conducted determines its pedagogical quality. Examinations may be organized in various ways (see Chapter 5). A I-hour oral examination with one question in general pathology, one in special pathology, a histological slide, and a macroscopical specimen, would be a good way of conducting examination. If students are permitted to listen to the others, then such an oral examination would also be an excellent pedagogical method.

There is always the conflict between practical training and theories. The teaching of any part of the undergraduate clinical curriculum involves two, at times conflicting, aims. One is to stimulate a spirit of inquiry, to instill an understanding of concepts and to endow the student with the means that are necessary for a lifetime of self-enlightment. This might properly be called education. Most of the courses, however, are necessarily taken up with the learning of skills, i.e. professional training. The teaching of organ pathology should be heavily oriented towards the clinical usefulness, indeed the essential role, of pathology: it must be shown to be "medical." It is a common experience that students at this early stage of the curriculum are anxious to be freed from the confines of theory and look forward to becoming doctors. The consequence of this is that it will be a mistake to run the whole pathology course during the preclinical period. General pathology only should be given at this stage. Integrated teaching of pathology with clinicians, each representing diseases of organs and systems in all their aspects together is attractive for teaching pathology, but it has its dangers, the most notable being a tendency to downgrading of the pathology component. However, many are warm proponents of problemoriented teaching in the organ pathology course. They feel that, apart from some introductory lectures, the students should be inspired to read good textbooks, and then the teaching could concentrate on specific cases, teaching the students to go forward as if they were diagnosticians. This is what they need to do in pathology in future practical work.

The Teaching of Pathology in Undergraduate Education Programs . 24S Some voices express fear that there are certainly not enough cases to get through all the pathology in this way, and therefore some important aspects of organ pathology would be left out from the teaching. At the examination, however, they would be questioned in all important fields of pathology, and hence most of the teaching should be aimed at inspiring the students through interesting, problem-oriented, case-centered teaching to read the whole book. The general opinion is that while problem-oriented teaching of this type is a very valuable component in teaching, a systematic series of lectures, tutorials or AV-systems is also necessary.

II. General Pathology in European Undergraduate Education Programs in Medicine Introduction

In pathology as a whole we study disease, abnormal cells, tissues and organs, and furthermore, the relationship between altered form and deranged function. Considering the enormous weight of present knowledge, it seems impossible to imbue students with all the details of special pathology, not to mention all the subspecialities. General pathology comprises the basic principles that can create awareness and further some basic understanding. Pathology can be symbolized by a tree. The roots are the basic sciences: chemistry, physics, anatomy, etc. General pathology is the main trunk, which contains the basic knowledge for the understanding of disease. Organ pathology represents the larger ramifications. The smaller branches, leaves, flowers, and seeds represent the clinical sciences. The trunk collects the saps from all the basic sciences, integrates them into a common stream of basic knowledge, gives them a new interpretation (i.e. pathology instead of physiology) and directs them into the main branches (organ pathology), and through these nourishes the leaves, flowers and seeds (clinical medicine). From this point of view, general pathology is in fact the most important part of pathology. With some clinical experience, some knowledge of organ pathology and anatomy, and a thorough knowledge of general pathology, almost all special cases can be deduced. General pathology comprises the mechanisms behind the lesions, morphological and functional descriptions and explanations of the effects of diseases on the various tissues and organs of the body, e.g. the principles of the inflammatory lesion, ageing, degeneration, carcinogenesis, etc. General pathology is taught at different stages in the medical curriculum at the various universities. Some-

times it is part of the premedical curriculum, sometimes it is taught at the beginning of the clinical curriculum. Ideally, there ought to be a short introductory course in general pathology either towards the end of the preclinical curriculum or at the beginning of the clinical one. Then, about 6 months before the final examination in pathology, and after the course in organ pathology, a more comprehensive course in general pathology ought to be given, since the students have then acquired a knowledge of organ pathology and some clinical experience. It will be a considerable task to convince the medical faculties of the necessity of such an ambitious plan. The group working with teaching problems in the European Society of Pathology wishes all university pathologists good luck in implementing a General Pathology Curriculum of this size and content at your medical school. The Sick Cell, Cell Injury, Cell Degeneration and Cell Death Students have to learn about the cellular changes that constitute organ and tissue changes. On the assumption that they have a sufficient knowledge of cellular structure and biology, they should be taught about inborn errors of metabolism and the consequent derangements of enzyme activity, substrate deficiency, and substrate competition. They should be introduced to morphological changes as signs of cell injury at both the ultrastructural and the light microscopical levels. They should learn functional cell pathology and the morphology of hydropic and fatty change. They must know about the reversibility and irreversibility of cell changes, the causes and signs of necrosis and autolysis, and how phagocytosis, apoptosis, and pinocytosis are important normal functions of cells. The type of cell injury that follows immune-mediated injury should also be taught. The Inflammatory Response One should start with a definition, followed by a discussion on the local and systemic signs and symptoms, a short historical survey, and then discuss the events in the acute inflammatory response: the time and strength sequences of vascular changes, exudation, diapedesis, phagocytosis. This should be followed by the chronic type of inflammation, the mononuclear cell response, the proliferation of endothelial cells and fibroblasts, and the granulomatous response. Changes in lymphatics and lymph nodes and in parenchymal cells should be mentioned. The major groups of chemical mediators and their mechanism of action must be touched on. The healing processes belong under inflammation: resolution, regeneration, repair, and fracture healing in

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bone. Scarring, keloid and liver cirrhosis should be included. Different types of inflammation should be classified according to their duration, morphologic type, causal agent, and the tissue or organ system affected. Specific and non-specific types of inflammation must be mentioned as well as local and general complications of inflammation.

General Immunopathology

dent needs training both in principles and in the observation of real examples. Atherosclerosis is a good basic example, including of course the principles of changes in the heart (i.e. hypertrophy, dilatation, myocardiopathy, valvular pathology) and in the circulation (i.e. congestion, oedema, bleeding and haemostasis, coagulation, thrombosis, emboli, infarcts, ischaemia, hypertension). Finally, changes in the lymphatic circulation must be dealt with.

General immunopathology should give an idea of the importance of immunology in human pathology, describe the immune mechanisms that may induce tissue injury and the types of tissue injury produced by immunological processes, relate the immune process to inflammation and to genetic factors, and describe briefly the principles of the diseases related to normal and altered immune reactivity. This means that the immunocompetent cells must be defined, the functional anatomy of the immune system described, and the five basic types of immune reactions involved in tissue injury elaborated. Primary and secondary immune deficiency syndromes, the relationship between infection and immunity, and tumour cell immunology ought to be mentioned together with transplantation problems.

The General Pathology of Ageing

Abnormal Accumulations

The General Pathology of Neoplasia

The topic of abnormal accumulations could be dealt with very pragmatically on the basis of its practical importance: when will a clinician have to consider a condition involving abnormal accumulations? The lectures should stress the importance of alertness to these changes. A classification may be added according to anatomical location, exogenous or endogenous types, inborn or acquired, and the type of substance accumulated. Dystrophic and metastatic calcification, amyloidosis, abnormal accumulation of melanin, hemosiderin, bilirubin, and uric acid should then be discussed. The mechanisms behind the alterations must be stressed. Examples showing the abnormal accumulations in the intercellular ground substance, and in the cells ought to be provided. Atherosclerosis is a very important example of abnormal accumulation of fat and calcium in vessel walls.

The best way to start is with the definition of a tumour, neoplasia, cancer, carcinoma, sarcoma, teratoma and hamartoma. The differences between a benign and a malignant tumour must be stressed. The macroscopical and microscopical aspects of tumours, the common classification systems, and typing, grading, and stageing are all important. The biology of the cancer cell, its pathological growth properties, cell culture behaviour, chromosomes, DNA-changes, oncogenes, tumour-suppressor genes and hereditary factors, tumour antigens, etc. have to be included. The students must learn something of carcinogenesis: viral, chemical and radiation. Precancerous conditions in man must be touched upon, and the natural course of some important tumours. It is always a problem to decide whether one should, in general pathology, also touch upon the psychological aspects of cancer, the prevention of cancer, etc. Finally, it might be an advantage to describe current hypotheses about the pathogenesis of some important human cancers.

General Pathology of the Circulatory System

The appearances of pathological changes are determined by the anatomy and physiology of the regular structures, metabolism and functions, and should be understood as a transgression of the normal limits of adaption, in either an acute or a chronic situation. The stu-

The definition of ageing in contrast to disease on the one hand, and in relation to physiological hormonal changes (such as the climacteric ones) on the other, should be discussed. The problem of the species specificity of life spans in the animal kingdom should be touched on, with a scientific discussion of theories of the ageing process, involving factors affecting life span. Common diseases and other problems of old age ought to be used only as illustrations, and should preferably be taught in the clinical curriculum, where more weight could be placed on the sociomedical implications of old age.

The Necessary Time for Teaching

As regards the amount of time to be allowed for the teaching of general pathology, most participants

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thought that about 25% of the total time allotted to pathology ought to be devoted to it. Varying teaching methods are used at the different universities: lectures, group discussions, audiovisual teaching, practical courses, histology, autopsy specimens. Each school must exploit its own possibilities. It becomes clear that a relevant course in General Pathology should comprise at least 17 to 19 lectures and some preferably optional topics, plus practical exercises. There is general agreement that too little time is spent on general pathology at almost all universities in Europe. It seems important to change this.

Syllabus Guide in General Pathology The Methods of Pathology (1 lecture) ~ How to describe macroscopical and microscopical specimens and carry out a necropsy. Importance of autopsy, biopsy, frozen sections and exfoliative cytology. ~ A short introduction on why autopsies are necessary and how they are performed. ~ How to prepare a histological slide (general outline), ordinary haematoxylin and eosin staining procedure, and special staining methods for fat, mucus, connective tissue fibrils, tubercle bacilli, etc. Immunohistochemistry. ~ Introduction to ultrastructural pathology, to geographical and to experimental pathology, and to epidemiology. ~ The importance of quantitative pathology: morphometry, stereology, and other more specific and advanced methods used in pathology, e.g. cell kinetic methods. Health and Disease ~ Critical evaluation of WHO's definition of health. Is it really a practical working definition for physicians? Health as a result of an equilibrium, and disease as a result of disturbance of the equilibrium between on the one hand the biological organism "man" and on the other hand his environment (physical, chemical, biological, psychological). ~ Constitution, phenotype and genotype. Biological variation. Homeostasis. Symptoms, signs, complications. Aetiology. Classification of disease. Pathogenesis. The theory of decision-making. Importance of Body Surfaces in Health and Disease (optional) ~ Surface mechanisms that impede penetration of disease-provoking agents. Structures such as keratin, melanin, sebum, sweat - importance for maintenance of health.

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Definition of ulcer, erosion, wound. Surface fluids (mucus, etc.) in respiratory, gastrointestinal, genito-urinary tracts. Importance of ciliary action e.g. in the respiratory tract. Changes in peristalsis and passage through narrow lumina. Stone and calculi formation. Importance of nerve reflexes for the maintenance of health.

Cellular Pathology (2 lectures) ~ The biochemical lesion. ~ The correlation between ultrastructure and biochemistry. ~ Errors in the genetic code. ~ Pathological changes in enzyme content and/or activity. ~ Substrate deficiency and substrate competition. ~ Cell injury (cell surface and organelle injury, ischaemic changes). ~ Morphological changes in the ultrastructure of injured cells. ~ Abnormal accumulation of water in cells (hydropic change, "parenchymatous degeneration"). Mechanisms and causes. ~ Apoptosis - in health and disease. ~ Reversibility and irreversibility of cell changes. ~ Necrosis: single cells, tissues - dry, colliquative. ~ Autolysis: macroscopical and microscopical signs. Post-mortem changes. ~ Phagocytosis, apoptosis and pinocytosis. ~ Specificity of disease-provoking influences for cell differentiation, rate of maturation, and the importance of cell-cycle phases. Growth Disturbances (llecture) ~ Cybernetic principles in the endocrine system and other growth-regulatory mechanisms. Hormones, growth factors and inhibitors (chalones). ~ Fundamental disturbances in cybernetic systems. ~ Labile, stable and permanent cell populations. ~ Physiological and pathological alterations in growth. Atrophy and its causes. Hyperplasia, Hypertrophy. Hypoplasia. Mechanisms and causes. ~ Involution. Metaplasia, different types. ~ Dysplasia, different meanings of the term. "Cervical dysplasia." "Dysplastic kidney." Body, Cell and Society Homeostasis (optional) ~ Different effects of local and systemic disease processes. ~ Prevention of disease in the community.

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Toxicology and environmental pathology. Prevention of infectious diseases: hygiene, vaccination. etc.

Immunopathology (l-2lectures) ~ The immune system and its physiology is assumed to have been learnt earlier. Knowledge of the various types of lymphocytes, macrophages, immunoglobulins, the functional anatomy of the immune system, etc. is taken for granted. ~ Immune deficiency disorders, primary and secondary. Immune responses and immune reactions. Virus-induced reduction of immune defences (HIV and AIDS). ~ Lymphoproliferative diseases. ~ Mechanisms of immunological tissue injury. ~ The 5 basic types of immune reaction with examples. Incidence and clinical significance of each. Urticaria, hay fever, asthma, blood transfusion, erythroblastosis, serum sickness, anaphylaxis, Arthus's reaction. ~ Autoimmunity - the principles of a number of autoimmune diseases, both systemic and organ-specific, with some examples. The types of immune reactions involved in such diseases. ~ Transplantation antigens, host-versus-graft and graftversus-host reactions. ~ Immunosuppression. ~ Tumour immunology. Inflammation and Healing (2 or 3 lectures) ~ Definition of inflammation. Historical summary. ~ Difference between inflammation and infection. ~ Clinical symptoms and signs, classical and modem. ~ Blood vessels' response in acute inflammation: initial vasoconstriction, triple response. Histamine. Axon reflex. Red cell stasis. Thrombosis. Necrosis. ~ Exudation. Exudate and transudate. Cellular response in acute inflammation: Diapedesis, migration, chemotaxis, phagocytosis, pinocytosis, apoptosis, opsonins. ~ Biochemistry of inflammation, "release reactions," exocytosis. ~ Role of vasoactive substances, interleukins. ~ Changes in lymph vessels in response to inflammation. ~ Types and functions of cells involved in the inflammatory response. ~ Mononuclear cell response. Granuloma formation. ~ Beneficial and detrimental effects of inflammation. ~ Suppurative and non-suppurative inflammation. ~ Types of inflammation: catarrhal, serous, fibrinous, membranous, phlegmonous, purulent, pyogenic, haemorrhagic, gangrenous. Acute, subacute, chronic, or chronic-specific (granulomatous). ~ Systemic symptoms and signs of inflammation (fever, headache, leucocytosis, leucopenia, in-

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creased erythrocyte sedimentation rate (ESR), changes in circulating enzymes and gammaglobulins). Causes of inflammation - exogenous and endogenous. Healing, regeneration and repair. Resolution and scarring. Granulation tissue. Bone healing in detail. Wound healing, primary and secondary, in detail. Disturbances in the healing process. Keloid. Causes of impaired healing. Examples of chronic-specific inflammatory disorders: tuberculosis, leprosy, Boeck's sarcoid. Necrosis and calcification in chronic inflammation. Abscess formation and outcome. Virus-induced inflammation. Is malaria an inflammatory disease according to the above criteria?

Infection (optional) ~ The role of pathology in diagnosing the presence of and the causes of infectious diseases (see also inflammation). Thmour, Neoplasia (3 lectures) ~ Definition of benign and malignant tumours. ~ Meaning of the words "malignant" and "benign." ~ Macroscopical and microscopical characteristics of benign and malignant tumours (description of growth). Some morphological characteristics of malignant cells: light microscopic and ultrastructural "The cancer cell," its altered biology, its pathological properties. ~ Classification of tumours. Macroscopic types of tumours (vegetative, ulcero-infiltrating, solid, papillomas, etc.). Microscopic types of tumours, e.g. small cell, large cell, etc. ~ Histological signs of malignancy: anaplasia, atypia, pleomorphism, disorganization, infiltrative growth, destructive growth, permeation, necrosis, metastasis, recurrence. ~ Formation of blood vessels in malignant tumours (TAF). Tumour necrosis factor (TNF). ~ A detailed knowledge of the process of metastasis. Malignant spread through blood and lymph vessels, body cavities, natural passages, inoculation. ~ Cancer incidence related to age, sex, time, geography, living habits, work place, genetic factors. Hereditary cancers and varying sensitivity to carcinogens. ~ Typing, grading, and staging of malignant tumours. Growth kinetics of tumours. Rates of cell birth (mitotic rate) and cell loss (apoptosis, necrosis, migration, surface cell loss). Radiosensitivity.

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Theories of carcinogenesis (emphasis on oncogenes and tumour-suppressor genes). Carcinogenic agents. Life style and environmental factors. Occult and latent carcinomas. "Semi-malignant" tumours and tumours with low-grade or local malignancy. Carcinoma in situ. Pre-cancerous condition. Embryonic tumours. Hamartomas. Local complications of malignant tumours. Secondary, general complications of malignant tumours, including paraneoplastic syndromes. Principles of cancer treatment. Role of pathology in diagnosis of cancer.

Abnormalities of Pigmentation and Abnormal Accumulations (I lecture) ~ Melanin pigment: too much and too little. ~ Haemosiderin, local and systemic accumulations (haemosiderosis and haemochromatosis). ~ Jaundice: forms, causes, effects. ~ Dystrophic and metastatic calcification. ~ Amyloidosis: meaning of the term amyloid, types of amyloidosis, aetiology. ~ Podagra.

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Diseases and Injuries Caused by Physical Agents (I lecture) ~ Hyperthermia: fever, heatstroke, bums. Hypothermia: systemic effects. ~ Frostbite: acute and chronic effects, perniosis (chilblains). ~ Freezing: vascular, cellular and tissue effects. ~ Some harmful effects of excessive noise. ~ Ultraviolet radiation: acute and chronic effects. Carcinogenesis. Reduction of immune defence. ~ Ionizing radiation, radiation pathology: sources of radiation, general effects of ionizing radiation, effects on cells and organs. Oxygen effect, time factor. ~ Radiosensitivity. Effect of radiation on bone marrow, intestinal mucosa, bladder mucosa, skin, kidneys, blood vessels, connective tissue, lung, mature bone, eye, gonads, lymphoid tissue, brain, foetus. Carcinogenesis. Radiation sickness. ~ Principles of cancer treatment by radiation. Disorders of the Circulation (3 lectures) ~ Cardiac hypertrophy and dilatation. Cardiovascular insufficiency. ~ Congestion, principles. Red cell stasis. Shwartzman reaction. ~ Congestion of lung, liver, spleen, kidneys and other organs. ~ Oedema: mechanisms of maintenance of fluid equilibrium in the tissue, formation of oedema.

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General oedema: cardiac oedema, renal oedema, hormonal oedema, starvation oedema. Local oedema: lung, brain and lymphatic oedema. Ascites, fluid accumulation in pericardial and pleural cavities. Bleeding: rhexis and diapedesis bleeding. Mechanism of haemostasis. Mechanism of coagulation (general). The fibrinolytic system. Local and general effects of bleeding (e.g. haematoma, shock). Thrombosis: pathogenesis, types of thrombi, formation of a thrombus, common sites of thrombi, predisposing factors, local and systemic. Fates of thrombi: fibrinolysis, organization, recanalization, calcification. Emboli: types, causes, common sites, effects. Infarcts: anaemic and haemorrhagic. Infarction: mechanism and examples. Infarcts of heart, brain, lung, spleen, kidney, intestine. Ischaemic hypotrophy and atrophy. Gangrene. Atherosclerosis: formation of a vessel wall atheroma in detail. Consequences of atherosclerosis. Lipoproteins, nature of, types of, ultrastructural morphology of. Circulatory risk factors, sites of predilection, specific consequences. M6nckeberg's mediasclerosis. Other changes in vessel walls: arteriosclerosis, necrosis, amyloidosis, inflammation: Aneurysms. Varicosities. Phlebitis. Arterial hypertension, essential, benign, malignant. Neurogenic, endocrine, renal hypertension. Pulmonary and portal hypertension. Shock: types of shock, causes, tissue changes in shock. Changes in lymphatic circulation: lymphangitis, acute and chronic obstruction, lymphatic fistula, elephantiasis, local oedemas.

Developmental Abnormalities (optional) ~ Congenital, hereditary and familial types. ~ Incidence of congenital defects. Teratogenic influences. Gene alterations and chromosome abnormalities. Methods of intrauterine diagnosis. Changes Associated with Ageing (optional) ~ Factors known to affect life span. ~ Common diseases of old age. ~ Theories to explain the ageing process. Summary of Lecture Time 17 to 19 lectures, plus 5 optional topics.

250 . O. H. Iversen

III. Organ Pathology in European Undergraduate Education Programs in Medicine

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The Time Allotted to the Teaching of Specific Subjects

It is recommended that within the time available for teaching organ pathology, a 6-hour limit has to be the rule. The 6 hours are only a guideline, and are only meant to cover pathology proper. It was, however, taken as a fact that in most medical schools a lot of pathology is taught together with the clinical teaching, so that in fact pathology has much more than 6 hours in certain fields. Pathology is also taught in the clinical courses.

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The Heart and Blood Vessels

The teaching of cardiovascular pathology should aim at acquiring an understanding of the basic mechanisms that underlie the major clinical syndromes. The latter, therefore, serve as a point of departure to introduce the pathophysiologic principles and related pathomorphology. For instance, atherosclerosis is introduced by considering a patient with unstable angina, emphasizing the principal role of the coronary arteries in meeting the metabolic demands of the myocardium.. This approach dictates close interaction with clinicians, but once achieved is a highly effective from an educational point of view. Within this setting the lecturer should not (and cannot) strive for an all-encompassing survey of the topic. A problem-based approach is encouraged, but needs a skillful lecturer and well prepared students motivated towards self-directed study (textbooks, journal articles, audiovisual aids, computerized educational programs, etc.). The following is a suggestion for the 6 hours of teaching: ~ Pathophysiologic mechanisms. Cardiac adaptation is the main topic. Dilation of cardiac chambers and hypertrophy of myocardium need careful discussion, in the light of unfavourable sequelae, such as changes in wall tension, oxygen consumption and transmural myocardial perfusion. Understanding of these basic principles is crucial. ~ Atherosclerosis. This lecture is devoted to the atherosclerotic lesion and its complications, with particular emphasis on the coronary arteries. The pathology of the lesions in patients with stable angina, unstable angina and those with myocardial infarction is considered. An understanding of the changing profile of these lesions is vital for the un-

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derstanding of the pathophysiology of these major clinical syndromes and interventional therapies. Myocardial ischaemia, infarction and complications. This session is devoted to the myocardial changes that vary from reversible to irreversible. The major complications are considered, such as electrical disturbances (rhythm and conduction problems) and pump failure (including myocardial ruptures and papillary muscle dysfunction). The reparative process and its relationship with ventricular rhythm disturbances is clarified. Valve diseases. In this section emphasis is given to degenerative valve diseases (including mitral valve prolapse) and infectious endocarditis. Rheumatic valve disease is mentioned, but receives less attention than commonly practiced. The relationship between degenerative valve diseases and endocarditis is emphasized and discussed. The destructive nature of infectious endocarditis is stressed. Cardiomyopathy and myocarditis. The definition of cardiomyopathy is given according to the classification suggested by the WHO. The possible relation~ ship between viral myocarditis and dilated cardiomyopathy is discussed. The basis mechanisms involved in myocarditis are considered, with emphasis on the more common forms of infectious agents and the clinical pathologic correlations. Non-atherosclerotic aortic diseases. This chapter is devoted to age-related changes that occur in the aorta (arteriosclerosis of the elderly). The differences with atherosclerosis are clarified. Dissecting aneurysm of the aorta, with its complications, is considered along these lines. Congenital heart disease cannot be omitted from a curriculum, since a steadily growing cohort of patients with surgically "corrected" congenital heart disease needs special care. In other words, somewhere within the curriculum, the pathology of congenital heart disease has to be included.

The Respiratory System

The topics to be taught could be chosen on several grounds: (a) "common" diseases that the students will see in practice - these may, of course, vary by location. Mortality Figures for England and Wales, for example, show neoplasms> chronic obstructive airways disease > pneumonias > pulmonary embolism > pneumoconioses > tuberculosis > congenital and perinatal diseases, while morbidity figures would show a different pattern; b) aetiological categories, or (c) pathological mechanisms. The value of clinico-pathological correlation and pulmonary anatomy and lung function tests in relation to pathology appears to be inadequately emphasised.

The Teaching of Pathology in Undergraduate Education Programs . 251

For a 6-hour course the following program is suggested: Lectures: ~ Introductory: Mortality figures, review of anatomy and physiology. ~ Inflammation: pulmonary defence mechanisms, pneumonias, abscess, tuberculosis, sarcoid, bronchiectasis, diffuse alveolar damage and interstitial fibrosis. ~ Neoplasia: Tumours of bronchi, lung and pleura. ~ Exogenous: Pneumoconioses (inorganic and organic dusts), obstructive airways disease (acute, chronic). ~ Circulatory: emboli, infarction, haemorrhage, pulmonary hypertension. ~ Congenital: perinatal disease, mucoviscidosis. ~ Metabolic effects of uraemia, drugs and radiation. ~ Bronchopneumonia, tuberculosis, pulmonary fibrosis (asbestosis), chronic bronchitis, infarction. ~ Squamous carcinoma, oat cell carcinoma, carcinoid tumour. Bone Marrow, Blood and Lymphoreticular Tissues ~ Anemias. Polycythemias. Hemorrhagic diathesis. Leukemias. Lymphocytic sarcoma. Richter's syndrome. ~ The functional anatomy of lymph nodes. Immune disorders. ~ Reactive hyperplasias. Progressively transformed germinal centre. Vascular disturbances. ~ Inflammatory (granulomatous, necrotic) lymphadenitis. Benign and malignant histiocytosis. Rosai-Dorfman disease. ~ Lymphomas. Cyto-histogenetic classification. ~ B-cell non-Hodgkin lymphoma, T-cell non-Hodgkin lymphoma, Hodgkin lymphoma. Its relation to the non-Hodgkin lymphomas. The Alimentary Tract and Pancreas ~ Oesophagus. Diverticles, achalasia, Barret, oesophagitis. ~ Gastric ulcer and gastritis. Gastroenteritis acuta. ~ Gastric carcinoma and pre-neoplastic lesions. ~ Colitis - ischaemic, granulomatous, pseudomembraneous, and ulcerative. ~ Intestinal polyposis. Colorectal carcinoma. Carcinoid. ~ Pancreas. Acute and chronic pancreatitis. Carcinoma of the pancreas. Disease of the Liver and Biliary Tract As a general principle teaching pathology of the liver should not be restricted to formal lectures and microscopy sessions. Some of the time should at least be spent in small group discussions and be supplemented by self-teaching exercises, i.e. posters, tape/slides,

video programmes and set questions: rewards might be offered to stimulate interest. Undergraduate medical students need not, and in reality, cannot be expected to acquire a diagnostic ability in histopathology. They do need, however, an understanding of the nature of tissue changes and their relevance to clinical medicine. ~

Introduction. Correlation of laboratory tests and imaging techniques with structural changes in the liver and the uses and limitations of biopsy diagnoSIS.

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Liver disease in infants and children, metabolic disorders, their outcome. Acute liver disease. The three main topics, viral hepatitis, drug injury and mechanical biliary obstruction should be dealt with in this order of priority. Chronic liver disease. a) Chronic hepatitis: viral, drug-induced, auto immune; b) cirrhosis; c) chronic biliary disease. Alcoholic liver disease. By far the most important in almost all parts of Europe. Tumours of the liver.

Kidneys and Urinary Tract ~ Glomerular diseases (2 lectures). ~ Tubulo-interstitial disease and urinary tract infections (2 lectures). ~ Diseases of blood vessels. Hypertension, benign and malignant nephrosclerosis, renal artery stenosis, endotheliotropic vascular diseases. ~ Tumours of the kidney and urinary tract. As an alternative, especially for programmes which pay limited attention to organ transplantation during the study of general pathology, a suggestion has been made for the inclusion of a one-hour small group discussion about the pathology of renal allograft transplantation. It might be an optional part of the course or could be included as a regular part instead of tumours of the kidney and urinary tract. These could extensively be discussed at seminars (practicals). Renal homotransplantation, now practiced widely with a high success rate, provides an opportunity for lively discussion about the extreme heterogeneity and frequent coincidence of lesions of various origins including renal damage preceding transplantation, surgical complications, toxicity and other side effects of immunosuppressive therapy, graft damage by host's original disease and immune-mediate rejection. The Endocrine System 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.

252 . O. H. Iversen ~

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Introductory lecture, with a review of the physiological and biochemical principles of hormones, their regulation and actions, and the pathophysiological mechanisms. 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. 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, tumors. Special emphasis on practical histology, showing the application and interpretation of changes in hormones and neuroendocrine markers located by immunochemical methods.

The Nervous System and the Muscles ~ Demonstration of unfixed, fixed of plastinated 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). ~ 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 (denervation, dystrophy, myositis), and a discussion of special staining methods in neuropathology (Bodian, Luxol, GFAP, NFP). The Male Reproductive System ~ 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. ~ Three hours teaching with the following subjects: for the penis congenital anomalies, phimosis, inflammations, condyloma acuminatum, verrucous carcinoma, carcinoma in situ and carcinoma; for the testis and 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, 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 ~ The first lecture should be used as an introduction to the female reproductive tract, beginning with describing the general cyclical changes which occur in the internal genitalia, and emphasizing the close interaction between the ovary and endometrium. ~ 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 third lecture should deal with lesions of the uterine cervix: cervicitis, ectopia and squamous metaplasia, hyperplasia, and neoplasia, including cervical intraepithelial neoplasia (CIN), micro-invasive carcinoma and invasive carcinoma. ~ 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 fifth lecture should deal with infertility and pregnancy. 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. ~ Two 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 important diseases can be classified as non-neoplastic diseases (inflammation 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. Paget's disease of the nipple should also be described. Diagnostic methods are important: cytology, needle biopsy, frozen section diagnosis and hormone receptor determination. The Skin, Bones and Joints In many medical schools the pathology of these organs is not taught as part of the pathology course, but

The Teaching of Pathology in Undergraduate Education Programs . 253

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. ~

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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 nonmelanocytic 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. For orthopaedic pathology, important subjects should be the cell types in soft tissues and their reaction patterns, with survey of soft tissue tumours and tumour-like conditions, and the properties of bone tissue, 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.

Eye, Ear, Nose and Throat Pathology These organs are also frequently dealt with in connection with clinical courses only. This is a very good solution. ~

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The core curriculum in ENT pathology should cover the ear with otitis externa and media (mastoditis, 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.

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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 angiglaucoma, 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. 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

There is 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 principles 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. Pathology is under threat today and 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." The best method of attack is to cultivate friendly relations with clinicians and to encourage a spirit of cooperation among the entire body of undergraduate teachers. Our curriculum is based on a minimum of 80 teaching hours, around 20 for general pathology and 60 for organ pathology. The recommended curriculum represents an absolute minimum. 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

254 . O. H. Iversen

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 together, 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 per cent for undergraduates and to postpone the rest to post-graduate education. This cuts down on the time available for undergraduate pathology. 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. The proposed curriculum was a minimum core curriculum, that 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 pathologicy, and others are taught as part of the clinical curriculum, albeit often by clinicians rather than pathologists. Nevertheless this leaves more time for the study of the pathology of the large organ systems.

Teaching hours* allotted to core curriculum for pathology in Europe

General pathology Organ pathology Total pathology

Obligatory

Optional

17-19 63

5-7 20-26

80-82

25-33

Sum

22-26 83-89

105-115

* One hour =45 minutes lecturing time

medicine, this must be combined with a humane and professional attitude towards patients. Undergraduate pathology examinations in Europe vary considerably. Some universities have a separate examination after the initial course in general pathology, others have not. Some have continuous evaluation of the students, but most have only a final examination that takes place towards the end of the pathology course. The ideal situation, a combined oral and practical examination with questions in general and organ pathology, description of microscopical specimens, and fresh or fixed macroscopical specimens, is not common. Schools with large numbers of students are forced to have multiple choice examinations.

Evaluation of Pathology and Student Performance in the United States Medical schools in the United States use several methods to evaluate student performance in pathology. At the national level most medical schools require successful completion of a standard examination, the United States Medical Licensing Examination, sponsored by the National Board of Medical Examiners. Despite the variety of curricular programs in pathology and the methods of evaluation at the undergraduate level, there seems to be no significant difference in the performance of students from different schools. There have been many changes in teaching and examination methods recently, due to economic and educational forces which are currently in conflict with each other. The following evaluation methods are used at different medical schools; multiple-choice examinations, practical examinations, oral examinations, "fill-in the blanks," essays, and subjective evaluation. Each method has its advantages and disadvantages, which have been discussed in detail.

Written Examinations:

IV. Quality Assurance - Discussion of the Validity and Reliability of various Forms of Examination Introduction With the increasing cooperation between the peoples of Europe it seems logical to try to coordinate both the training and the requirements for the final examination for physicians throughout Europe. Both the content and the form of an examination have an educational value. The aim of a pathology course is to teach the students enough pathology to function well as general practitioners, and, in addition, acquire a scientific attitude to biology and medicine in general. As in every branch of

Short Written Questions Versus Essays and Oral Examinations. Should an Elective Examination Consisting of a Written Report on a Problem in Pathology by One or a Group of Students Be an Option? Surprisingly little has been published about the correlation between the marks in the final pathology examination and any other performance variable. This is difficult to establish because morbid anatomylhistopathology is examined together with clinical pathology. The usual pattern for the final pathology examination in the UK consists of four components, intended to cover knowledge, written and oral expression, observation and description, logic and attitude. In practice the student must write 3-4 sheets of A4 paper for each of two

The Teaching of Pathology in Undergraduate Education Programs . 255

essays on morbid anatomy and histopathology topics. They must answer 60 multiple-choice questions in one hour, and 50 short practical questions. Lastly there is an oral examination totalling 50 minutes with two examiners. Each of the four sessions offer a maximum of 100 marks. Pass mark = 200. There are advantages and disadvantages to all the methods. The written essays are generally poorly written and extremely tedious to read for the examiner. Oral examination in pathology is considered to be a valuable assessment tool and a useful educational experience which all students should have. Individual or group reports may be appropriate for in-core assessment, but not as a final examination. Practical Examination (Gross Specimens and Histology) in Pathology

Some kind of practical examination as part of the final examination ought to be a requirement in pathology, and it should be influenced by the way of teaching. Great emphasis can be put on autopsy demonstration in the final examination, conducted by a single teacher. It is, in fact, a combined practical and oral examination in which students are expected to recognize and correctly describe the alterations observable in the assigned organ, either macroscopically or in a microscopic slide, and give a list of the diseases which might lead to similar alterations or lesions. There are several advantages to this type of examination, since it can be problembased, assesses clinical orientation, requires interactive communication, and allows the examiner to gain a good impression of the student's factual and conceptual knowledge, and to evaluate the student's ability and skill in accurate observation, visual understanding and recognition, correct description and deductive reasoning. Hence, it provides valuable information about the student's intellectual capacity and ability to synthesize, and with none of the drawbacks of the multi-choice type examination, which is, however, a third part of the final examination. The disadvantage of this type of examination is that it is not standardized. Some students are presented with easy cases and some with difficult. It may also be more stressful for the students, and has a strong subjective element. If possible, continuous evaluation during the course should be combined with a final examination. Attendance at practical demonstrations and the interest and activity level of each student ought to be noted. The final mark of the results of all three components is a grading in 5 classes, with 1 =insufficient, 2 =sufficient, 3 =average, 4 =good, 5 =excellent. The student's activity and performance at the demonstrations during the courses is also taken into consideration. Pass and fail marking alone removes the element of healthy competition.

Steeplechase or Spot Examination as an Alternative in Pathology?

In Copenhagen steeplechase examinations have a long tradition in gross anatomy and histology, and have been used as a supplement to the oral anatomy examination since 1947. The students pass a sequence of stations, e.g. 20, with a fixed period time of 2-4 minutes for each, to diagnose one or two specimens and record their diagnosis on their answer sheet before proceeding to the next station. Small supplementary questions may be asked at each station. In pathology the test subjects may include gross anatomical structures with specific lesions, X-rays, CTs, or other diagnostic images. Students may be asked to determine the stage of a disease and to suggest a diagnosis from studying an affected organ. Histological diagnoses may be either the specific disease or a description of the observed deviations from the normal. Microscopes with fixed pointers are used to indicate single cells for diagnosis, e.g. ReedSternberg cells. A test like this provides an all-round evaluation of the student's skill in visual recognition and diagnosis. Answering the questions requires knowledge, accurate observation and deductive reasoning. In anatomy it is considered an indispensable supplement to oral and/or written examinations, and it is also useful for informal interim evaluations. It is accepted by the students, who find it a fair and relevant, no-nonsense test of their all-round diagnostic skills. This principle has also been introduced in clinical medicine in the form of an Objective Structured Clinical Examination (OSCE).

Multiple-Choice Examination: An Effective Form of Evaluation?

The advantages of MCE are standardization, low cost, computer adaptability and reliability in testing factual knowledge. The disadvantages are that it requires many questions, the questions are difficult to create, they tend to cue the answer, and it is difficult to evaluate higher levels of knowledge. A new format has overcome some of the major disadvantages of the system, especially its inability to evaluate higher levels of learning. The new format is called the clinical vignette type of question. Here the question contains clinical information about a patient, including physical symptoms and signs, laboratory data, and certain pathological findings, and can include photographs of gross macroscopic findings. From this information a certain level of knowledge is needed to reach an acceptable conclusion. The clinical vignette format seems to be a useful and effective way to evaluate students.

256 . O. H. Iversen

MCE: A Degenerative Disease or a Malignant Tumour? MCE falls short of reasonable standards of quality as regards both teaching and examination systems. It leads in practice to esotericism. The student network is so highly organized that lists of MCE questions are compiled after each central examination and are made available for general consumption. Thus the examination institution is forced to be constantly inventive. This results in a tendency towards esoteric questions, increasingly divorced from the reality of everyday medicine. The adoption of MCE has very good logistical reasons. It is illusory to contemplate any form of examination other than MCE if you have more than 500 students annually in one faculty. MCE has therefore become a logical consequence and a cheap answer to overfilled medical schools. The convenience of MCE is a prime example of the Emperor's new clothes syndrome. We seek to defend the indefensible because other alternatives are unacceptable. It is impossible to examine more than 500 students annually using the vastly superior system of short questions and essay format. In addition MCE can become an exercise in semantics. It has more to do with the intricacies of language than with the question of knowledge, not to mention ability. The more a candidate knows about a subject, the more impossible it is to answer in a simplistic yes/no term. Moreover, good examination technique can compensate for inadequate ability in a particular subject. Hence, far from representing the pedagogical zenith of medical education, MCE is not commensurate with the intellectual demands and the moral responsibility of deciding who is competent to embark on the practice of medicine. During the discussion on this topic, it was pointed out that some students are test-wise, and others rapidly become test-wise, Le. they develop an intuitive feeling for the answer most likely to be correct, usually because of the form of the question. Thus, a student who knows nothing at all, will still produce a certain number of correct answers. Since we in fact want the students to know the

core of pathology, "core" MCE questions and answers should be published, and hence it makes no sense to keep creating new ones. Summing up The examination system must be suited to the traditions of the particular medical school, the teaching system, and the number of teachers available to administer and run the examinations. Hence, any of the abovementioned systems may be used. If the teaching ofgeneral pathology takes place early in the curriculum, it is an advantage to have an examination specifically in general pathology at the end of the introductory course. There is no doubt that students only really make an effort to learn when an examination has to be passed. It was agreed that the final examination in pathology ought to take place relatively late in the curriculum when the students have a reasonable amount of clinical experience. There have been lively arguments about the value of MCE, but there seems to be general agreement that if it has to be used, it should only form one part of the examination. It was also pointed out that it could be modified by the Clinical Vignette type of questions. Alternatives to MCE are short answers to specific questions, or steeplechase examinations, although the logistics of the latter is time-consuming. In grading the results the majority seem to be in favour of a more detailed system than merely pass and fail.

Received: February 17, 1997 Accepted: April 9, 1997 Address for correspondence: Olav Hilmar Iversen, M.D., Ph.D., Professor emeritus, University of Oslo, Institute of Pathology, Rikshospitalet (The National Hospital), 0027 Oslo, Norway; Tel.: ++47-22868574, Fax: ++47-22112261