J. clin. Path. (1966), 19, 207

What pathology - and pathology for what ?

GEORGE. J. CUNNINGHAM

In this short consideration of some problems inmedical education it is proposed to deal with whatpathology the undergraduate requires and whatpathology is needed in postgraduate study forspecialization. This subject was chosen for tworeasons. First, it appears timely since medical educa-tion in general is actively under review. Secondly,with the recent foundation of the College of Patho-logists it seems likely that the pattern of educationfor pathologists will be formulated and generallyrecognized for the first time. Whatever decisions aretaken are likely to influence the course of clinicalpathology for the next 25 years. But before dealingwith this great problem it might be of value and ofinterest to look at education in pathology in a moregeneral way-indeed to consider its place in medicaleducation.

PLACE OF PATHOLOGY IN MEDICAL SCHOOLSOF THE NINETEENTH CENTURY

At the present time it is difficult to imagine themedical course as it was when the medical schoolswere instituted. Certainly there was great variationin pattern and this was often largely determined bylocal circumstances. In general there were two mainpatterns of medical school in Europe in the nine-teenth century. First, there was the university typewhich grew up in Germany, Holland, and theScandinavian countries. Here the teachers inmedicine and surgery were professors of the univer-sity who taught by giving formal lectures in a con-ventional way. In these universities they were inevery way similar to professors of non-medicalsubjects and were of course employed whole time.They tended to be appointed on the strength oforiginal contributions to their subject and so ithappened that research was emphasized even at thisearly stage. With the development of hospitals whichfollowed the professor became head of the universityclinic to which were attached clinical and researchlaboratories. Many people believe that this form oforganization was responsible for the great contribu-tions made to medicine by the Germans in the lastcentury. Certainly their research was facilitated bytheir access to laboratories in basic scientific subjects.In this connexion it is worth noting that in 1824'This is the slightly abbreviated Presidential address given to the Asso-ciation of Clinical Pathologists on 1 October 1965.

Purkinje had a physiological laboratory in Breslau;in 1825 Liebig had a chemical laboratory in Giessen,whilst in 1856 Virchow had his famous Institute ofPathology in Berlin. The purpose of these details isnot so much to highlight the German system as toprovide a striking contrast to the different methodsemployed in Britain. Here, medical teaching aroseout of hospitals. The student attended the hospitaland observed physicians and surgeons at work. Itwas essentially an education in the practice ofmedicine and really an apprenticeship, and at leastgave the student instruction in the type of work inwhich he would be later engaged. The teachers wereof course employed part-time as they were in privatepractice. It differed from the university system inbeing a clinical training in which little basic scienceeducation was included. Such anatomy and patho-logy as was taught was done by surgeons in thecourse of their clinical teaching. In the same way alittle physiology was taught by other clinicians.Towards the end of the century, with the rapidgrowth of the basic sciences, it became clear thatthey could only be adequately taught by persons whodevoted themselves entirely to these subjects. Thestatus and standard of these teachers was not alwayshigh as the financial resources of the medical schoolswere limited. More important still was the fact thateven though the basic subjects were emerging intheir own right they were still very much the pro-vince of the clinicians and indeed in some schoolscontinued to be so until the first two or three decadesof the present century. Thus the training of studentsin pathology really remained for a long time largelyin the hands of the clinicians. I think that thisdelayed the full recognition of pathology as aseparate subject in Britain. It was not until about1929 that pathology was introduced as a separatesubject in the Final Examination of the ConjointBoard. Up to this time research had lagged behind.The part-time clinicians had little time and fewfacilities. For the students, the only stimulus camefrom questions arising out of the attempted correla-tion of symptoms and signs with the structuralfindings as revealed at necropsy. The vital partplayed by the basic sciences was missing, and anyresearch that was done tended to be clinical ratherthan basic. Later, with the increasing recognition ofthe basic sciences links between the medical school

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and the local university were forged and eventuallythe heads of departments became professors of theuniversity. There was thus a progression towards theuniversity system as cited in the case of Germany,but there was never quite the same emphasis on

research or on the basic sciences.

DEVELOPMENTS BETWEEN THE WORLD WARS AND AFTER

Up to the late 1920s the professor of pathologywas invariably a morbid anatomist since structuralpathology comprised the greater part of the subject.Consequently, the students' course was very heavilyweighted in that subject though there was of course

some bacteriology. Haematology and chemicalpathology were scarcely touched upon and many

students regarded pathology as a whole as a very

lifeless subject the application of which could not befathomed. There was no introductory course inpathology, students being sent to commence theirclinical work on the wards immediately they hadcompleted their examinations in anatomy, physio-logy, and pharmacology. In the period between thewars this situation was dealt with by the introductionof a course in general principles of pathology, givenon completion of the second M.B. and before thecommencement of clinical work. It lasted for threemonths and was instituted at the request of theclinical teachers who maintained that they could notteach basic medicine and surgery to students whoknew no pathology. With the advent of the intro-ductory course some teachers in pathology found itequally difficult to teach their subject to studentswho knew no medicine or surgery. The studentsregarded it as a rather frustrating period and were

anxious to get to grips with clinical material and thusbe 'real doctors'. When these same students returneda year later to do a course in special pathology thetransformation was quite startling. They had ob-tained some clinical experience and were anxious tomake up their deficiencies in pathology. In mostmedical schools in the country it is now the customto give both clinical and pathological instruction inthe preliminary course following completion of thesecond M.B. examination. The lesson to be learnedis that clinical subjects and pathology must be taughttogether and in relation to one another in a course ofgeneral medical education. One is in fact making outa case for pathology as a clinical subject, though thismay be thought unnecessary as in this country it hasalways been regarded as such. Nowadays there is a

tendency to think of it as a basic science andAmerican influence has done much to promote thatview. In most of the main teaching centres inAmerica it is the universal rule that the whole course

in pathology, as taught by the department, is given

in the pre-clinical period. Difficulties must neces-sarily arise and the ways of dealing with them are ofinterest. In one university the teaching of pathologyis supplemented by clinicopathological conferencesrun by the students themselves, none of whom haveever seen a patient, let alone know anything aboutclinical disease. This is most unrealistic but the factthat this method is widely used shows that it ispracticable. It is only fair to say that although not inagreement with this system, it works better than onemight expect. The saving grace is that there aremany clinicopathological conferences during theclinical years which teach the student the applicationof the subject to clinical medicine. It is all very wellto say that pathology is a basic science and to lineit up with anatomy and physiology. But pathologyis much more than that and in planning future educa-tion we must recognize that it is both a basic scienceand a clinical subject.

DEVISING NEW PATTERNS

At the present time it is universally agreed thatmedical education is unsatisfactory. This is well-illustrated by the fact that there have been worldconferences on medical education in 1953 and 1959,the formation in this country of the Association forthe Study of Medical Education in 1958, and in Julyof 1965 the appointment of a Royal Commission onthe subject. It is reassuring to see that one pathologistis a member of the Commission, though a broadsubject such as pathology should surely have meritedrather wider representation.

Broadly speaking the difficulties have arisen in twoways. First, the growth of medicine and surgery hasbeen so rapid that specialization has been forced onthe clinicians. Thus the teaching hospital has ceasedto be a general hospital and it has become increasing-ly difficult to give a student a general clinical educa-tion. He has often gained experience in a few highlyspecialized branches to the complete exclusion ofothers. This is, of course, a problem for the cliniciansrather than pathologists and they have to somedegree overcome this difficulty by arranging forstudents to visit non-teaching hospitals which admitpatients suffering from a wider range of disorders.Probably the greater difficulty, and one which con-cerns pathologists more, is the very rapid growth ofpre-clinical basic science subjects. This part of thecourse has become grossly overcrowded. Attemptsto reduce the amount have not really been successfulbecause the specialists themselves are loathe toreduce their share of teaching time-some becauseof their enthusiasm for their subject, others becausethey fear a loss of prestige. The position has worsenedwith the realization that there are some basic sub-

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jects, such as sociology and psychology, which arenecessary for any student whose whole life may beoccupied in dealings with human beings. It is obviousthat a new approach is essential. Some clinicianshave suggested that the pre-clinical subjects shouldbe reduced by teaching only their applications tomedicine, but this is unacceptable, because the pre-clinical sections should be educational and theclinical sections applied. On reflection there arecertain things of paramount importance. First, thestudent entering medical school must learn how toteach himself: this is probably the greatest difficultyin the changeover from school where one is taughtand university where one should be guided but yetable to teach oneself. Instruction in the use oflibraries would be invaluable. The second importantthing and maybe the more difficult is mind training.This would involve exercises in the use of a criticalfaculty, and the methods of reasoning, and someelementary logic would not be out of place. In thepresent attempts of educators to recast the pre-clinical course completely it has been suggested thata degree in human biology be instituted. A three-year course is to be introduced at the new medicalschool at Keele. This has recently been included ina report of the Steering Committee for the School ofMedicine and Human Biology. Although the core ofthat course will be biology, applied mathematics andstatistics will be included to emphasize the im-portance of quantitative methods in research and inclinical medicine. Less emphasis will be placed onstructure, basic though it must always be, and thefunctional aspects stressed. In addition basic prin-ciples of psychology and sociology will be included.Although much of this is apart from the concern ofpathologists it must be noted that a certain amountof pathology will be included. Many pathologists asthey proceed in their career will have experienced awidening of their interest which takes them into therealms of animal pathology. This drift to comparativepathology and the concepts of the response ofanimals to abnormal genetic and environmentalstimuli have drawn us nearer biology. This approachis merely an attempt to understand the underlyingprinciples of pathology. It is in fact what it is hopedto achieve. In this proposal by the working partythere is no attempt at teaching the application ofpathology to medicine during the course in humanbiology. This must be done in the clinical years, andthis is the fundamental difference between these pro-posals for the teaching of pathology and the presentsystem which exists in America.

If this system becomes adopted the pre-clinicalpart of pathology will be educational and the clinicalpart of it applied. The pre-clinical tuition will becarried out by the department of pathology and the3

amount of applied pathology taught by cliniciansmay vary from centre to centre. Pathologists mustdecide how the application of their subject should betaught, for it would be wrong to expect this to bedone in the clinical departments.

UNDERGRADUATE TRAINING

From the practical point of view, if undergraduateeducation is unsatisfactory in what ways do we findthe average graduate deficient? First, he has neveracquired a knowledge of the general principles of thesubject and it seems that whatever type of work heis destined to do this is of vital importance. Thisdefect can be readily observed in postgraduatestudents. Secondly, although he has learned somestructural pathology, he lacks a knowledge of theapplication of pathology to the clinical subjects. Thisgap is particularly noticeable in young residents inhospitals. They have little idea of how to use thelaboratory tests at their disposal.Many students feel that they have always been

taught that it was vitally important to understandpathology in order to learn the clinical subjects.Everyone seemed to pay lip-service to pathology, yetwhen they came to do it they found it uninspiring:the histology got more and more mysterious, andthey finally sank beneath a flood of round-cell in-filtration which engulfed them from all sides. Thechief complaint is that pathology did not appear tobe a living subject. It would be neither possible nordesirable for all medical students to have an exten-sive course in clinical pathology to remedy thisdefect, for the subject with all its branches hasbecome too vast. He could acquire such knowledgeby having part of his special course in pathologydevoted to the laboratory investigation of specificclinical problems. The increased use of clinico-pathological conferences would also assist in thisapproach. If this were done it would avoid thepresentation of pathology as a series of specializedsubdivisions of the main subject, e.g., haematologyor microbiology, and reveal the applications of it asa whole to clinical problems. It is in this respect thatthe clinical pathologist has so much to offer. Dr.Sidney Dyke, the founder of the A.C.P., says in thepreface to his latest edition of 'Recent advances inclinical pathology': 'In the teaching hospital theDepartment of Clinical Pathology occupies a keyposition in the training of the medical student, towhom it offers conditions available in no otherdepartment to learn the application to medicine ofits basic sciences. In the face of present developmentsit seems inevitable that the rational practice ofmedicine in the future must come to depend moreand more upon the training received by the medical

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student in clinical pathology and the extent to whichthis influence permeates the whole of his hospital.'The student's deficiency in understanding the

general principles of pathology should be remediedin a different way. After passing his second M.B. thestudent should have a very short course (not morethan one month and possibly less) in pathology andin elementary clinical observations. He would learnthe broad differences between an inflammation, adegeneration, and a neoplastic condition. Followinga period of clinical experience his course in specialpathology would follow. The greater part of histologyshould be omitted and emphasis laid on morbidanatomy related to clinical signs and symptoms.Clinical pathology would thus be taught by themethods of investigation of important signs andsymptoms rather than as branches of pathology. Byhis final year the student would be in possession of acertain amount of special and applied pathology.This would be the time to draw together the frag-ments of his knowledge. During the final year a shortrevision course in the principles of pathology shouldbe given. At this stage the average student couldeasily assimilate the principles and be ready to studypathology as a postgraduate student in its applica-tion to the special subject of his choice. According tocurrent views the principles will be taught in the pre-clinical period. What chance of success will one haveof teaching principles in the first or second year whenstudents are now unable to grasp them in the third?How illogical to expect anyone to appreciate theprinciples of disease, a subject with which they haveas yet had no contact? By all means give studentsan introduction to the principles of the subject at anearly stage, but do not expect them to grasp themfully. The revision course in general principles is thereal solution. This suggestion of teaching the prin-ciples of pathology at the end of the course is un-likely to be well-received by medical educators ingeneral. It might be criticized as illogical to teachprinciples late in the course, but the fact remainsthat the present system has not proved satisfactory.

POSTGRADUATE TRAINING

We must now turn our attention to postgraduatepathology. At the present time the requirements aremostly in applied pathology for those specializing inmedicine, obstetrics, and gynaecology and radiology.With surgeons, dentists, and anaesthetists it isdifferent. About 20 years ago the Royal College ofSurgeons first introduced pathology as a subject inits Primary Fellowship examination. The examina-tion was in the principles of pathology. Appliedpathology is asked in the final examination andforms a very limited part of it. Primary Fellowship

students show great enthusiasm for pathology.With their knowledge of special pathology andtheir clinical experience they are able to assimilatethe principles very rapidly. Many say that it is thefirst time that they have ever been able tounderstand the subject at all. Others who havelater proceeded to academic appointments havefound this course of great help in their researchactivities. When this course in basic sciences wasinstituted it was thought by some that ultimatelyspecialists would be required to take a commonprimary examination.As an ideal this would have much to recommend

it. However, in practice it is unlikely that it wouldwork. It would hardly be reasonable to expect apsychiatrist to know the same amount of anatomicaldetail as a surgeon. Pathology does not present quitethe same difficulty yet it is doubtful whether anyonewould expect an anaesthetist to know the sameamount of basic pathology as a physician. Indeed, atthe present time the emphasis on pathology in thePrimary examination for anaesthetists has alreadybeen reduced. During the past year or so the PrimaryFellowship examination has been under review andit was even suggested that pathology be eliminatedfrom it. This would, of course, be disastrous and avery retrograde step. If one felt that every graduatepossessed a sound knowledge of the principles ofpathology then it might be argued that it would bea waste of time repeating it. At present we are stillfar away from that possibility.

TRAINING OF PATHOLOGISTS

The training of pathologists and particularlyclinical pathologists must now be considered. Thedevelopment of a pathological service for non-teaching hospitals in this country has resulted in agreat expansion of clinical pathology over the past30 years. Even after the first world war the subjectwas still in an embryonic state. The founding of theAssociation by Dr. Sidney Dyke in 1927 was instru-mental in the development and recognition of thesubject and a small group of pathologists includingDr. Greenfield, Dr. Cuthbert Dukes, and Dr. W.McMenemey played a very important part in theearlier years. Yet it was a one-sided development forwhilst the service to clinicians was greatly improved,and the status and working conditions of the clinicalpathologist raised, there was really no recognizedmethod of training. At that time the persons whoobtained posts in clinical pathology in non-teachinghospitals were those who had little or no training inthe subject or who trained in an academic depart-ment but had been unsuccessful in obtaining apermanent appointment. This fact, coupled with the

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poor remuneration offered, made pathology anunattractive subject to many. Thus it happened thateven in the 1930s the clinical pathologist simply hadto do his best and many were largely self-taught.However, the young pathologist of those daysobtained much help from the meetings of theAssociation and the laboratory meetings of theSection of Pathology of the Royal Society ofMedicine. Since that time clinical pathology hasgrown to be almost unrecognizable but still thetraining side remains neglected. The average clinicalpathologist as a practical worker in an applied fieldhas left the teaching and training sides to his aca-

demic colleagues. Yet it is an astonishing fact thateven in 1965, apart from the D.C.P. course atHammersmith and also at St. Stephen's Hospital,London, under Dr. Signy, which caters for about25 students per year from all over the world (apartfrom courses for Services personnel), the only otherattempt at providing postgraduate courses for patho-logists has been by the Association. This resultedfrom the foresight and energy of Dr. Cuthbert Dukeswho just after the second world war instituted some

short refresher courses in pathology for consultantswho wished to brush up their knowledge in a specialbranch of the subject. In recent years they havebroadened somewhat and their success has been dueto the willingness of individual members to put theirspecial material at the disposal of others. They entaila lot of work and the Association is indeed fortunateto have so many public-spirited members. In theearly days the courses dealt with problems in histo-pathology, whereas now they include problems fromall of the subdivisions of pathology. Furthermorethey have been extended to registrars in training forwhom a few special courses have been organized, anda secondment project has been launched by Dr.R. C. B. Pugh whereby pathologists can spend a

more extended time in a laboratory learningspecialized techniques. Yet even such progress as hasbeen made falls short of an ideal, for the courses arein no sense complete or organized and there is as

yet no systematic course which can be attended bypathologists in training. Pathologists in training fromabroad frequently express surprise at this gap in our

postgraduate educational programme.This deficiency is of some concern for no hospital

service can be really efficient without a first-classlaboratory. The difficulty is to find a sufficientlylarge number of first-class pathologists for theseposts, and these will not be forthcoming unless an

adequate training programme exists. It seems fairlycertain that the majority of pathologists now intraining will probably end up in clinical laboratorieswhere increasing demands on their skill are beingmade with the rapid advances in medicine and

surgery. This is a sufficiently strong argument forclinical pathologists to interest themselves more thanthey have previously done in postgraduate education.It might be useful to analyse briefly the steps thatmight be taken in an endeavour to raise the standardof clinical pathology. First of all good men andwomen must be obtained for training. Examinationswith all their drawbacks will do much to eliminatethe frailer types, but the problem begins much earlierthan this. It is of the first importance that the initialstep be taken in the undergraduate training period,and it is here that we badly need the co-operation andhelp of our academic colleagues. It must be admitted,though reluctantly, that pathology as it has beentaught in the past has often failed to interest thestudents. The glamour of the clinical subjects and thedrama of surgery and the operating theatre arelacking. Students training to be doctors are apt toregard the autopsy room (with which pathology isoften identified) with distaste as a place in whichthe failures of the clinical side are revealed. It shouldof course be presented to them as the essential train-ing ground for the application of the basic principlesunderlying medicine and surgery. Pathology shouldbe presented as a living subject which is applicable,useful and essential to the patient. Many Americanuniversities have adopted a method of capturing thestudent's interest at an early stage by instituting'elective periods'. For a period of three months hecan elect to work in any department of his choice.The academic pathologists, feeling that the betterstudents were often attracted to the clinical subjects,tried at an early stage to interest them in pathologyby offering them facilities in the laboratory. It hasproved most successful and has resulted in an in-creased recruitment of better students into pathologyin America. This elective period can in some instancesbe carried out in the departments of other univer-sities, or indeed other countries. It must be con-fessed that in many cases American professors werereally trying to increase research potential inpathology. The advisability of this is questionable.It has been contested that students should beinterested in research as early as possible because itis during the earlier years that original ideas aremost likely to be produced. Yet students may becomefascinated by research to such a degree that theyhave difficulty in returning to their basic studies,which then appear humdrum and rather pedestrian.If such a scheme could be widely encouraged inBritain, with the cooperation of our academic col-leagues we should soon not be short of good recruitsfor specialization in pathology. It would not beadvisable to encourage research during this electiveperiod but essential that the vital and exciting partthat pathology plays in everyday medicine and

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surgery should be appreciated. The next problem isthe way in which postgraduate training is to be pro-vided for these recruits. This is more difficult, for itentails the recognition of suitable training centres asthe small number of teaching centres cannot dealwith the large numbers of trainees required. It isreassuring to know that the College of Pathologistsis giving such serious consideration to this problem.The difficulty has, of course, been met to some extentby joint appointments where the trainee spends apart of his time in the teaching hospital and is thenseconded to a routine laboratory of a non-teachinghospital. This scheme is excellent, for pathology isessentially a practical subject and thus one whichcan only be learned by practice. What is requiredof the trainee for a certificate of proficiency will bedetermined by the nature of the examination whichhe will be asked to pass. This point is of crucialimportance with the introduction of the MembershipExamination of the recently-founded College ofPathologists. At the best of times generalizations arehard to make and particularly so in this case. Inmodern times the would-be pathologist commenceshis training without in many cases any clear idea ofwhere he will end up. There are so many possibilities.Amongst these there is clinical pathology which willprobably claim a majority over all the others puttogether. It may be a symptom of advancing yearsthat one would like to see all these people spend atleast two years in obtaining some general knowledge,however superficial, in all the main branches ofpathology. Many would not agree with this, thoughthere is no doubt that the clinical pathologist shouldhave this as part of his training. Apart from the factthat as broad a training as possible is desirable for acareer in clinical pathology, the present organizationof the laboratory service makes it imperative. By nomeans all hospitals have the luxury of a specialist ineach of the four branches of the subject, and in manyplaces two pathologists share the four branches. Toone who in the past has worked in all four branchesit seems wrong that there should be pathologists ina laboratory who have literally no knowledge of twoof the subjects. The present regulations for thePrimary Examination of the College might wellresult in the production of such pathologists. Thiswould be wrong because every pathologist should beable to deal with an emergency in any branch andalso because it would limit his ability to supervisetechnical staff. It would also cause difficulty in pro-viding coverage for holiday periods. Finally, if oneregards clinical pathology as the investigation of aproblem in medicine or surgery the barriers betweenthe branches of pathology break down. The testsrequired for investigation of a clinical case are rarelyconfined to one branch, and one pathologist should

be able to interpret the findings in most instances.With the rare special case obviously more than onespecialist might be required.

These are some of the difficulties in making ageneral plan for a career in which there is so muchscope for divergence. If everyone knew at the outsetof his postgraduate training the exact type of careerwhich he would follow then the problem wouldvanish. But this we all know is only rarely the case-few of us when we enter medicine have any real ideawhere we shall end up.Having agreed that the important part of the

training of a pathologist is to work in a laboratory,are there any other ways in which we might furtherhis training? In an era where the maxim seems to be'have it done for you' rather than 'do it yourself'there is a demand for organized courses in prepara-tion for the examination, and as yet none are avail-able. Courses in laboratory work should not be pro-vided except in regard to rather specialized andunusual techniques. The practical training should beobtained in the laboratory in which the trainee isworking. There might be something to be said for acourse of lectures in the general principles of patho-logy especially in view of the recent News Letter fromthe College of Pathologists in which the high failurerate in the general paper was pointed out. Thisemphasizes the point that has been made about asimilar deficiency which exists in postgraduates whoare training for specialization in surgery andanaesthetics, and therefore presumably all students.If any such course were instituted an evening lecturecourse available in various centres in the countrywould be ideal. It might at the present time bedifficult to find the pathologists who would be pre-pared to give it. Some might wish to go further afieldand make this a basic sciences course.

TECHNICAL TRAINING FOR CLINICAL PATHOLOGISTS

But there is yet another more important aspect ofthe initial training of the clinical pathologist. Formany years it has been customary for clinical patho-logists to be familiar with and competent in thetechnical procedures of the laboratory. In recentyears, however, with the rise in standard of technicalassistance this aspect has become less important forthe pathologist. Indeed at the present time it is quitebeyond one person's capacity to know all the tech-nical procedures, though it would be wrong for thepathologist to abandon them altogether. How muchis left to technicians varies with the branch inquestion, for chemical tests such as for blood sugars,ureas, etc., are essentially technical procedures. Bycontrast although the same may be said for tissueprocessing, the selection of material for histological

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section should be done by the pathologist. It wouldcertainly be difficult for him to criticize processingdefects in the histological sections without anyknowledge of the technical procedures. Most goodpathologists learn it of their own free will. Apartfrom this the pathologist as a consultant on the samelevel as consultants in other branches must provehimself worthy of consultation by his colleagues.This entails interpretation of results and is the realjustification for the existence of the clinical patho-logist. To do this with competence requires a wideknowledge of pathology and of subjects allied to it.He must have a good knowledge of medicine andsurgery and in the assessment of bone or chestdisease some knowledge of radiology will be a greathelp. Knowledge of how to consult should be ob-tained as early as possible and a certain amount willbe learned during the laboratory training. Thismight well be supplemented by clinicopathologicalconferences or by lectures, panel or round-tablediscussions given with the aid of specialists in sub-jects other than pathology. If such supplementaryhelp were to be given to trainee pathologists thenthis would be a wonderful opportunity for theAssociation to fill a gap in postgraduate education.This is a responsibility which we should accept. Thepioneer efforts of the Association in providingrefresher courses for consultants should still be con-tinued, and already discussions by the Council arein process for extending this activity. But a new fieldin providing facilities for pathologists in training lieswide open and the challenge awaits acceptance.

CONCLUSIONS

In this brief survey some of the problems in medicaleducation have been pointed out and the way inwhich they affect pathology. At the moment thestruggle consists of the relative amounts of time thatshould be spent in the pre-clinical or educational and

in the clinical or applied parts of the course. In theearly days it was all applied and now the pendulumhas swung far in the opposite direction, maybe toofar. Educationalists are mostly in the older age groupand at this time of life one's deficiencies in the basicsubjects become even more apparent.

Great emphasis has been laid in some quarters oneducational methods such as visual aids, close-circuit television, teaching machines, and the like.But oddly enough little has been said of the teacherhimself or of any training which might prove bene-ficial. Most of us on reflection about our interest ina particular subject find that we owe it to one indi-vidual who was able in some remarkable way toconvey enthusiasm to us. It is to be hoped that atten-tion will be given to this matter, for even in a tech-nological age where knowledge of new techniquesis essential, the power of personality in the teacheris still an important force. It has often been said thata teacher must have an interest in research and indeedmany teachers have been appointed for their researchability with disastrous results. There are so few reallygood research workers that it is unreasonable toexpect many to be successful. As a result we find somany unsuitable persons trying to do research, andthe few suitable ones hampered by limited resources.It would be much wiser to grant full facilities to thefew.When the College of Pathologists was formed the

most important thing it did was to unite pathologists.Pathology is a wide subject which pervades everymedical field and with increasing specialization in itsbranches it might become too diffuse and lose itsidentity. In educating medical students it is vital thatthey see the importance of pathology as a whole inits application to medicine. Having given considera-tion to these matters and realizing the problems thatwe face can anyone doubt that the Association andits members have a most important role to play inthe future of medical education?

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