Global Health Training and Education Opportunities
Overseas experience by Massachusetts General Hospital Pathology residents and fellows represents a distinct asset to our training program. Residents gain direct experience that can foster research on unusual pathogens, neglected diseases, public health, diagnostics, and the pathology of global illnesses that affect millions of the world’s population. Many pathology trainees arrive with some prior experience abroad during college and medical school, and many have a strong interest in continuing their involvement overseas in a professional capacity. In the past four years, about 12.5% of the total pathology resident class (five in forty) has traveled to explore volunteer opportunities in the developing world. Many traveled using their own funds because of their strong personal interest in global health. Providing financial support for specific overseas rotations in pathology in the developing world is one area of opportunity going forward.
Overseas Rotations by Mass General Residents
Mbarara University of Science and Technology (MUST), Uganda
Mass General offers a rotation for qualified residents in General Pathology at Mbarara Hospital in Uganda. This program operates in collaboration with rotations by Mass General residents in internal medicine, anesthesia, surgery, and obstetrics, and pairs pathology residents with colleagues practicing pathology in Uganda. MUST is a full service large referral hospital in Western Uganda at which the MGH-CGH has had a longstanding presence. The pathology department there services the more-than-1000 bed hospital and teaches the students at MUST (undergraduates, medical and nursing students, and graduate students). There is a young training program in Anatomic Pathology, training two residents in 2014. There is a full-time staff pathologist from Cuba, a part-time Ugandan pathologist, and a visiting professor from the United States for teaching and supervision. The pathology rotation involves service (including surgical pathology, cytopathology – a robust FNA service, and autopsy pathology) as well as teaching at the University.
There has been increasing interest and activity by pathology residents in global health, which is significant for two reasons. First, it is widely recognized that pathology expertise is sorely lacking in developing countries, and that the United States has one of the highest ratios of pathologists per capita in the world. For example, at Mass General alone, there are about 90 staff members in Pathology, while the country of Uganda has 18 practicing pathologists for a population of 28 million, and Tanzania has 15 pathologists serving 28 million people. Second, involvement by American pathologists in the developing world is not as common as it is in other clinical specialties such as emergency medicine. Activities by Mass General pathology trainees reflect a diversity of research and clinical interests, which are mirrored by its staff's involvements in various parts of the world. Three such resident experiences are summarized below.
General Pathology in Kenya
Darcy Kerr, MD engaged in a combination of research and clinical activities in Kisumu, Kenya during a month-long elective. Kisumu is a major research site for the Kenya Medical Research Institute (KEMRI)/CDC and is located in the Nyanza province of Western Kenya, which holds the highest HIV burden in Kenya.
Dr. Kerr helped organize and optimize the pathology portion of a large study sponsored by multiple organizations including the Kenya Ministry of Public Health that sought to examine the performance and accuracy of verbal autopsy to determine pulmonary tuberculosis mortality. Verbal autopsy heavily informs epidemiologic data throughout sub-Saharan Africa, and comparison with gold-standard post-mortem exam is lacking.
She also had the opportunity to participate in ongoing pathology activities in two distinct settings: a large, government-run hospital (New Nyanza Provincial General Hospital) and a small, not-for-profit hospital (Aga Khan Hospital). These experiences included exposure to FNA clinics, gross and microscopic anatomic pathology, and clinical pathology laboratory capacities. Overall, the elective provided invaluable exposure to the pathology of “diseases of poverty,” problems facing pathology services in the developing world, and the particular challenges of research collaborations in the developing world.
Dermatopathology in Vietnam
Before she started her pathology residency at Mass General, Devon Gimbel had a long-standing interest in global health. Here, she has worked with Dr. Mihm, one of the senior dermatopathologists at Mass General at the time, who made regular visits to Ho Chi Minh City, Vietnam, to a vascular malformation clinic. Dr. Gimbell helped to set up a new microscope and other much-needed donated laboratory equipment. She hopes, in the future, to help a pathologist from Vietnam visit the U.S. for two to three months for advanced training in dermatopathology.
From this experience, Dr. Gimbell gained clinical exposure to pathologic disease entities infrequently seen in Boston, to more advanced stages of skin lesions (e.g. large congenital nevi, large vascular malformations) not often seen in the U.S., and to a different array of infectious diseases with skin manifestations, such as leprosy. In addition, she gained on-the-ground experience in bringing in and installing key equipment for the hospital laboratory, and initial experience in supporting diagnostic Pathology services overseas.
Laboratory Medicine in Kampala
JiYeon Kim came to her residency and fellowship in pathology informatics at Mass General after completing her masters degree in public health, and was particularly interested in the growing research area of health informatics and population health. Dr. Kim wanted to explore how pathology was practiced in resource-poor settings.
In 2010, she visited Mulago Hospital, a 1,500-bed academic tertiary care hospital operating at about 200% capacity, and serving the poorest patients in Kampala, the capital city of Uganda. Mulago is affiliated with Makerere University, one of the premier universities in East Africa. It is an ideal setting to do research and study pathology services in a setting that is comparable to Mass General in terms of volume and complexity of patient care.
During her visit at Mulago Hospital, Dr. Kim completed a detailed needs assessment of the hospital clinical laboratories. In her final report, which was presented to the hospital laboratory leadership, she highlighted areas for improvement in infrastructure, telecommunications, and result reporting. From this experience, Dr. Kim came to realize that a special kind of laboratory information system could potentially be designed to take advantage of the rapidly growing mobile technologies in East Africa. This experience has inspired her to look at ways of developing this technology for her future research in pathology informatics.
Technology & Training Support
Given the vast wealth of diagnostic technology at Mass General and given the tremendous short-fall of technology available to healthcare facilities in developing nations, there is ample opportunity to improve the diagnostic power of Pathology in developing nations.
In co-operation with various departments and committees within Mass General, including biomedical engineering, materials management, and Mass General recycling, the Pathology Service has been able to transfer a substantial quantity of refurbished medical supplies to hospital laboratories overseas. These donations have included very valuable instruments such as multi-headed microscopes, pediatric ventilators, infusion pumps, EKG machines, monitoring equipment for intensive care, and steam sterilizers; as well as much simpler devices such as hematocrit-measuring table-top centrifuges, slide staining jars, and laboratory incubators. Mass General equipment is in use in Ghana, Liberia, Rwanda, Sudan, Uganda and other countries.
In addition, our Pathologists have worked with companies in the biomedical industry to position medical supplies and equipment in hospitals overseas. For example, Mass General has helped to supply the Mulago Hospital in Uganda with laboratory-grade blood bank and pharmacy refrigerators donated by Helmer Inc., a table-top CBC machine from Coulter Diagnostics, and bedside oximeters from Massimo Corporation.
To be successful donations must be carefully selected to match the setting, be in good working order, be sustainable and be directly connected to training on their proper use and maintenance. Overseas travels by Mass General residents and faculty—whether for research or teaching—represent opportunities not only for training sessions and consultation regarding previously donated laboratory equipment, but also opportunities for performing a needs assessment for future donations.
Global Scholars Program in Pathology for Laboratory Professionals
In 2010, Mass General was awarded a grant by the American Society of Hematology to sponsor Mr. Derrick Bengo, Hematology Laboratory Supervisor of the Mulago Hospital (Kampala, Uganda). Mr. Bengo came to Mass General Hospital for five weeks of advanced training in techniques for hematologic diagnosis, including special stains for leukemia sub-typing, bone marrow special stains, basic coagulation testing, and principles of laboratory management.
It is well established that the practice of pathology in the developing world presents a number of challenges in terms of limited resources, shortages of trained personnel, and lack of continuing education programs. Telepathology holds great promise as an avenue for diagnostic support and ongoing training. Mass General Pathology is uniquely poised to offer educational and diagnostic support using telepathology, due to its large number of subspecialty-trained diagnosticians and enthusiasm of its faculty and trainees for educational experiences and sharing of interesting cases.
Dr. Aliyah Sohani, a Mass General hematopathologist and laboratory director, has helped to establish a static asynchronous telepathology program between the Mass General and several hospitals in Kenya, Tanzania, Botswana, and the Kurdistan Region of Iraq, including academic teaching hospitals affiliated with the Aga Khan University and the University of Duhok. Sites lacking the ability to capture digital images of glass slides were each equipped with a multi-headed teaching microscope with a digital camera, and onsite training was provided initially to local pathologists on use of the equipment and image acquisition.
Since the program’s inception in 2008, pathologists overseas have posted more than 160 cases via static asynchronous telepathology using a platform hosted and maintained by the Aga Khan Development Network’s eHealth Resource Centre based in Karachi, Pakistan. Nearly all the responses posted to cases have incorporated the input of Mass General pathologists.
In addition to an opinion about the diagnosis, responses have included a discussion of the differential diagnosis, and additional information such as gross findings, diagnostic pitfalls or publications about the entity, with the combined goals of providing both diagnostic and educational support to the submitting pathologists and clinicians. In more than 90% of cases, static images have been partially or completely diagnostic. In the non-diagnostic cases, factors precluding a definitive diagnosis were mainly related to the absence of confirmatory immunophenotyping studies or to technical issues, suggesting that additional training or building local capacity for basic ancillary testing may overcome such challenges.
Importantly, the program has fostered local, regional, and international collaborations in the clinical, educational, and research realms. The five-headed teaching microscope installed at one of the academic teaching hospitals is used frequently for intra- and interdepartmental teaching and clinicopathological conferences, including a monthly international radiology-pathology conference. Pathologists participating in the program have offered opinions about cases originating from other hospitals within the collaborative network and have posted diagnostically challenging cases for purely illustrative purposes in order to educate their colleagues both regionally and overseas. Finally, a number of abstracts relating to the telepathology program itself or cases posted to the forum have been presented at international meetings, such as the USCAP, the American Society of Dermatopathology, the International Academy of Pathology, and the Association of Pathologists of East, Central and Southern Africa (APECSA). Some of these have resulted in papers published in peer-reviewed journals, with collaborative authorship from African and US-based pathologists, and a number of research projects are ongoing.