INTRODUCTION

Teaching pathology as an image intensive discipline is of the major challenges medical teachers are faced with. This fact also applies to histology teaching in which much effort has been made to boost students’ knowledge retention. Both “traditional” and “nontraditional” methods have been used (^{Hightower et al., 1999}), and modalities such as peer teaching (^{Beck et al., 2016}), audiovisual tools (CamposSánchez et al., 2014) and technological and traditional drawing approaches (^{Cogdell et al., 2012}; ^{Rafi et al., 2017}) have been extensively studied and tested. In addition, virtual microscopy proved to be beneficial in many aspects (^{Herrmann et al., 2015}; ^{Hortsch, 2017}). Understanding of histology is essential for every medical student when doing pathology at medical school. Moreover, integration of histology into clinical context was tested and it proved to be successful (^{Singh, 2011}; ^{Shaw & Friedman, 2012}; MalauAduli et al., 2013). However, more effort is needed to change students’ attitudes toward the clinical importance of histology (^{Moxham et al., 2017}). From pathology point of view, many integrated curricula have been tested and used in an attempt to reach maximal students’ retention of the pathology knowledge they need in their clinical practice (^{Haspel et al., 2012}; Malau-Aduli et al.; ^{Atukorala & Atapattu, 2015}; ^{Lisk et al., 2016}). However, little is known about the actual difficulties the students face when they try to identify morphologic changes in diseased tissues, and these difficulties need to be systematically addressed. Challenges in achieving competencies in practical histopathology may contribute to medical students’ attitudes toward anatomic pathology as a career choice in spite of their awareness of its importance in medicine. Medical students’ perceptions of pathology as a career choice has been debated worldwide (^{Holland & Bosch, 2006}; ^{Hung et al., 2011}; ^{Ghanchi et al., 2017}), and this debate has been linked to population-based consequences. In a study from Canada, for example, the average case load of cancer for pathologists has shown significant increase during the period 1999-2009, and this shortage lead to the conclusion that monitoring the quality of pathology practice is needed (^{Colgan & Geldenhuys, 2012}). From medical students’ perspective, keeping pathology invisible for the graduating medical students makes them ignore pathology and reject pathology residency. This necessitates integrating pathology in the clinical clerkships to better perceive the importance of pathology in clinical practice and the positives of being pathologist (Hung et al.). Taking into consideration that students’ perceptions and feedback have a significant impact on academic progress, our study aims to determine the perceptions of medical students regarding normal and abnormal microscopic morphology and their feedback regarding cumulative effects of the first year general histology course and the sophomore pathology introductory course. In addition, our study emphasizes on students’ perceptions regarding integrating histology and pathology as a future vision of curricular change, especially if this integration starts in the first year. This integration may boost the knowledge retention in histopathology, which may aid in a better view of pathology relative to other specialties and increase the perceived positives of pathology as a career choice.

MATERIAL AND METHOD

This cross-sectional study was conducted at the faculty of medicine, Al-Balqa applied university which is a public university in central Jordan. After obtaining the ethical approval, an anonymous predesigned self-administered questionnaire was given to second-year and third-year medical students in the second semester of the academic year 2017/2018 with more than 200 surveys collected. Informed consent was obtained verbally. The survey comprised questions on students’ affinity for anatomic pathology, the difficulties that they faced in examining histopathology slides, their assessment of practical histology knowledge retention and their perceptions regarding the integration of histology and pathology in integrated courses. A five-point Likert scale was used. Data were analyzed using SPSS v 20 software. Descriptive statistics and Pearson’s chisquared test were used, and P<0.05 was considered significant.

RESULTS

A total of 236 questionnaires were distributed, and 214 students participated in the study (response rate = 90.7 %). There were 93 (43 %) males and 121 (57 %) females, with a male-to-female (M:F) ratio of 0.77:1. The mean age of the participants was 20.12 years (SD = 0.86). Of them, 121 (57 %) were from the second year, and 93 (43 %) were from the third year. Out of the 214 respondents, 156 (72.9 %) found pathology interesting. Moreover, 188 (87.9 %) perceived the importance of pathology in medicine. However, only 33 (15.4 %) thought of pathology as a career choice. When compared to other disciplines, only 73 (34.1 %), 53 (24.8 %) and 43 (20.1 %) of the participants felt pathology was easier than anatomy, physiology, and biochemistry, respectively. In regard to practical pathology, 94 (44.0 %) of the participants found pathology lab sessions interesting. However, 107 (50.0 %) students found morphology of disease more difficult than other aspects of pathology, and 159 (74.3 %) students found microscopic morphology of disease more difficult than gross morphology. Of the participants, only 63 (29.4 %) reported that their grades in practical pathology exams were higher than theoretical exams (Table I).

Table I Participants’ perceptions of pathology and the second year pathology introductory course. 

Regarding the knowledge retention of histology, only 67 (31.3 %) students responded that they remembered normal microscopic morphology well when they tried to identify microscopic disease morphology in the introductory pathology course. One hundred and ten (51.4 %) students reported that they couldn’t identify the normal tissue counterpart in more than half of the practical pathology cases in the introductory course. A significant proportion of the participants 187 (87.4 %) agreed or strongly agreed that supporting pathology microscopic examples by normal tissue counterparts was needed. In addition, 94 (44.0 %) found histology lab sessions of the first year histology course interesting (Table II).

Table II Participants’ perceptions and feedback on the first year histology course. 

There were 129 (60.3 %) students that felt unsatisfied with the practical sessions of the first year histology course. On the other hand, 103 (48.1 %) of the participants felt unsatisfied with the number of pathology lab sessions in the second year pathology course. One hundred and thirty (60.7 %) preferred the integration of histology and pathology lectures and lab sessions in integrated courses starting from the first year instead of separating the first year histology course from the second year pathology introductory course. Moreover, adding case discussions integrating histology and pathology in the first and second years was preferred by 148 (69.2 %) of the participants. In addition, 151 (70.6 %) responded that system approach in general is better tan teaching each discipline alone (Table III). The number of respondents who agreed or strongly agreed with merging histology and pathology in the first year curriculum was significantly associated with the number of those who were with restricting first year histology examples to only what is needed for the pathologic entities (p value = 0.001).

Table III Participants’ perceptions of different methods for improving the teaching of microscopic morphology. 

DISCUSSION

Since histology and pathology are of the basic medical disciplines that are image-intensive, several methods were used to enhance students’ understanding and knowledge retention. At our institution, students complete general histology and introduction to pathology courses by the end of first year second semester and second year first semester, respectively. The second-year pathology course is essential for providing medical students with the knowledge they need on core principles of disease processes. In our study, a large number of students found pathology interesting (72.9 %). This was higher than the number reported in a recent study from Malaysia (55.4 %) and another one from India (64.8 %) (^{Shah, et al., 2014}; ^{Emerald et al., 2016}). However, there were only 15.4 % of the participants in our study considered pathology among their career choices. This attitude toward pathology targeted several studies to address medical students’ perceptions of this specialty (Haspel et al.). The role of the second year pathology course without educating medical students about pathology practice and continuing into the clinical years was reported to have a little effect on students’ attitudes toward pathology (Holland & Bosch). In addition, pathologists input in preclinical years curricula is necessary (^{Gray & El-Kadiki, 2010}). There were 60.7 % of participants who agreed or strongly agreed with the proposed integration of histology and pathology. Moreover, system approach in teaching pathology with other disciplines was preferred by 70.6 %, and was comparable to several studies (Shah, et al.; Emerald et al.). Integrated curricula in teaching laboratory medicine has shown to be effective in medical students satisfaction and better understanding (^{Osman et al., 2013}, 2014). The need to start the integration of histology and pathology in the first year is well highlighted by the ratio of students who were unsatisfied with practical histology of first year (60.3 %), along with the significant proportion of students who were with co-presenting normal and abnormal examples at the same time in the second year pathology introduction (87.4 %). Correlating normal histology of organs with morphology of disease is a major learning outcome that boosts students’ knowledge and understanding (Amin et al., 2016). In addition, combining this integration with new teaching and learning methods such as virtual microscopy needs to be tested (^{Kumar et al., 2006}). However, our results showed that microscopy is still a preferred tool for 44.9 % of students.

CONCLUSIONS

Our experience showed that the curricular integration of histology and pathology in the first year needs to be tested.

In addition, case discussions proved to be successful, and microscope remains an effective and preferred tool for teaching microscopic morphology. However, much effort is needed to increase students’ affinity for anatomic pathology.