SQU Med J, February 2011, Vol. 11, Iss. 1, pp. 38-44, Epub. 12th Feb 11
Invited Article
Submitted 15th Aug 10
Revision ReQ. 28th Sept 10, Revision recd. 30th Oct 10
Accepted 6th Nov 10

Advances in medicine and health care are influenced by technological achievements, information technology 
and evolving new knowledge and discoveries. 
These, in turn, change the way in which we practise 
and provide health care. The changes not only 
influence the practice within the various medical 
specialities, but they also influence the way those 
specialities interact with each other. The latter can 
not be more obvious than in supporting clinical 
services such as radiology and pathology.

Reasons for Changing 
Trends and Rising 
Challenges within 
Pathology
In addition to the changes outlined above, pathology 
practice has also been faced with its own changes. 
These have both necessitated considering new 

trends and also raised challenges in the way the 
service is delivered.  Among these are: 1) increased 
demand for pathology services;1 in diagnostic 
surgical pathology this has not only been in order 
to deal with the increased number of biopsies, 
but also to comply with guidelines for cancer case 
reporting2,3 and with the various recommendations 
of specimen handling and additional testing;4 

2) the need to improve turnaround time as a 
critical element in clinical management;5 3) the 
need to comply with the statutory requirements 
of the various laboratory accreditation and quality 
assurance regulatory bodies; 4) the rising trend of 
subspecialisation within the clinical specialities;6 5) 
the introduction of the principle of multidisciplinary 
team meetings for the management of cancer 
patients;7 6) the decline in the number of autopsies; 
7) the explosion in the number of rapidly evolving 
new techniques, and 8) advances in information 
technology and digital imaging.8,9

Department of Laboratory Medicine & Pathology, Hamad Medical Corporation, Doha, Qatar.
*Corresponding Author email: h.kamel@btinternet.com

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

مفتاح الكلمات: علم األمراض، التخصص، اجتماعات فريق متعدد التخصصات، تشريح اجلثة، مقاطع مجمدة، علم اخلاليا.

aBStract: The way we provide healthcare is influenced by ongoing experiences, increased knowledge, new 
discoveries and scientific as well as technological advances. The rapid pace of important developments that have 
taken place in recent years have significantly influenced our choices of the ways we provide our health service. 
Like other medical specialties, pathology and its practice have had to respond to the rising needs and challenges 
within the health service in general and those facing the speciality in particular. This article addresses some of the 
challenges, particularly those which are unique to pathology. It discusses the choices that are available to different 
pathology departments depending on their individual circumstances. 

Keywords: Pathology; Specialisation; Multidisciplinary team meetings; Autopsy; Frozen sections; Cytology

SPECIAL CONTRIBUTION

Trends and Challenges in Pathology Practice
Choices and necessities

Hassan MH Kamel



For these reasons, it was inevitable that the 
various aspects of the pathology service would 
need to respond to these challenges and to change 
the way that they deliver their services. Some of 
those challenges and the choices of solutions are 
discussed here as follows: subspecialisation in the 
diagnostic surgical pathology service and cytology; 
frozen sections; the autopsy; multidisciplinary 
team meetings; ancillary techniques; the pathology 
report and some other administrative duties. 
However, first, a brief reference to the pathology 
service users and their contribution in shaping the 
service is warranted.

Pathology Service Users
Any changes to the pathology service should 
ultimately take into consideration the needs of the 
service users. It is appropriate, therefore, to highlight 
first who are the main users of pathology services 
and how they contribute to the changing trends 
and the challenges that face the specialty. The main 
users of the pathology service include surgeons, 
oncologists, gynaecologists, hospital physicians, 
radiologists, general practitioners, students and 
various research groups. 

Surgical specialties, including gynaecology, 
continue to be the major service users of the 
histopathology service and therefore remain the 
main drivers of the changes to service delivery 
and provision. It was the move of general surgery 
into various surgical subspecialties6 that originally 
drove the histopathology service to follow suit. As 
surgical techniques and approaches develop and 
progress, the histopathology service should be able 
to adapt and respond to rising needs and demands. 
This requires close interaction and better sustained 
communications between the pathologists and 
their various surgical colleagues. Equally, newly 
developed techniques and new knowledge within 
the various subspecialties of pathology need to be 
communicated to our surgical colleagues to explain 
how these new developments can contribute to the 
management and care of patients.

Radiologists are not strictly speaking service 
users, but they are increasingly providers of 
pathology material on behalf of other service users. In 
recent decades, they have contributed to important 
changes that happened within histopathology. On 
the one hand, advanced imaging techniques have 

improved significantly the accuracy of premortem 
diagnosis thus significantly decreasing the need 
for hospital autopsies and contributing to the 
decline in autopsy numbers. On the other hand, 
the accessibility by modern radiological techniques 
to various sites in the body and the provision of 
cytology or biopsy material from previously difficult 
10,11 or inaccessible locations has contributed to:  
1) increasing the number of biopsies and 
consequently the pathologist’s workload;  
2) better accuracy and adequacy of sampling of the 
targeted lesion; 3) understanding and unravelling 
of new pathological entities, and 4) better 
pathological staging of cancer cases and improved 
clinicopathological correlation.

The contribution of our oncologist colleagues 
in influencing the way we report cancer cases 
should also not be underestimated. They 
contributed significantly to the present format 
of cancer management and were instrumental 
in the establishment of multidisciplinary team 
meetings. Their input on the required contents 
in synoptic reporting and in minimal data sets 
as well as checklists and guidelines2,3 can not be 
overestimated. 

The Diagnostic Surgical 
Pathology Service
In recent years, one of the most important 
developments that has changed the diagnostic 
surgical pathology service is the move towards 
subspecialisation in departments where the 
pathologists used to provide a general diagnostic 
service. This means that each pathologist now 
provides services only within one or very few 
subspecialties. For example, some pathologists 
report only on breast pathology, others specialise in 
gastrointestinal (GI) pathology or soft tissue diseases 
etc. Pathology subspecialisation has existed for a 
long time in some subspecialties such as paediatrics 
and neuropathology, but it has only recently spread 
into all other subspecialties, particularly within 
large teaching departments and big referral centres.

Subspecialisation in pathology was seen as the 
natural response to the move to subspecialisation 
in surgery and as a solution to the problem of  
increasing workload, whether due to increased 
numbers of biopsies or the increased reporting 
requirements for various cancer and non-cancer 

Hassan MH Kamel

Special Contribution | 39



Trends and Challenges in Pathology Practice 
Choices and necessities

40 | SQU Medical Journal, February 2011, Volume 11, Issue 1

cases.12 It also seemed a natural progression in 
response to the overwhelming increase in our 
knowledge in the past three decades. Overall,  
and if it can be afforded, the advantages of 
subspecialisation outweigh those of the general 
diagnostic service.

The acknowledged benefits and advantages of 
subspecialisation include: 1) increased experience 
and skill of the pathologists at interpreting 
challenging cases within  their own subspecialties, 
thus  allowing timely and accurate diagnosis; 2) 
maximising clinical efficiency through enhanced 
team work and communications with the 
corresponding subspecialised clinical services; 3) 
optimisation of teaching; 4) promotion of research 
efforts in the various subspecialty areas, and 5) 
creation of an environment in which research can 
be successfully planned and performed.

However, subspecialisation has its demanding 
requirements and it can not be applied in all 
pathology laboratories. The main disadvantages 
include: 1) decreased staffing flexibility in 
comparison to laboratories which provide a wider 
general service; 2) increased operational overheads 
with every subspecialty operating as if it were a 
separate unit; 3) difficulties in measuring the equity 
of workload between staff of different subspecialty 
teams;13,14,15 4) difficulties in evaluating the 
efficiency of the pathologists’ work due to weights 
and indicators varying from one subspecialty to 
another,13,14,15 and 5) the need for more staffing 
which remains the biggest factor hindering the 
wider development of subspecialisation. 

Subspecialisation: Choice 
or Necessity? 
Subspecialisation remains largely a choice that 
is dictated by a variety of factors including the 
laboratory setting (service versus academic), 
specimen volume and specimen composition as well 
as level of staffing. For example, subspecialisation 
cannot be afforded by departments that are staffed 
by less than six consultant pathologists. Also, if they 
have a low number of biopsies or range of materials, 
the significant increase in costs and staff cannot 
be justified. On the other hand, subspecialisation 
should be seen ultimately as a necessity for large 
academic and teaching departments with heavy 
workloads. In this case, it will accommodate and 

improve research and optimise teaching obligations, 
in addition to the other benefits of subspecialisation.

The Fate of Cytology in 
Subspecialised Pathology 
Departments
Prior to the subspecialisation trend, cytology 
often constituted an independent department or 
a separate unit, within the pathology department 
while in a small department it was regarded as part 
of the general diagnostic service. As histopathology 
moved to subspecialisation, some institutions opted 
to integrating the various cytological specimens 
into the corresponding or appropriate subspecialty 
histopathology teams; for example, breast fine 
needle aspiration (FNA) was allocated to the breast 
team and so on. Cervical cytology was dealt as 
a separate issue in places where there were large 
screening programmes. Other places continued to 
have an independent cytology service that did not 
integrate into the subspecialty teams. 

There are reasons that favour integrating 
cytology specimens into the corresponding 
histopathology subspecialty: 1) it allows the 
correlation of the histological and cytological 
findings, thus resulting in more accurate diagnoses 
and better patient care; 2) it increases experience 
and improves skill; 3) it enhances team work with 
the corresponding subspecialised clinical services, 
and 4) it optimises teaching and promotes research.

Equally, there are arguments against the need 
for such integration which call for cytology to 
remain independent. These include: 1) existing 
cytopathologists who are experienced across 
the whole of the cytology spectrum. With 
subspecialisation, a major part of their expertise 
would become redundant, lost or underutilised; 
2) unlike histopathology specimens, there could 
be difficulties in assigning and allocating some 
materials: e.g. should ascetic fluid go to the GI  
team or to the gynaecology team? 3) the heavy 
cytology burden in some subspecialties in 
comparison to others, e.g. breast versus GI, and 
4) the nature and amount of material where there 
are cervical cytology screening programmes. The 
reasons for and against integration of cytology seem 
to be equally strong. It therefore seems logical, 
for the time being at least, that the choice should 
depend on the circumstances of each establishment. 



Hassan MH Kamel

Special Contribution | 41

Intraoperative 
Consultation/Diagnosis 
(Frozen Sections)
Most pathologists accept that the frozen section 
procedure is an important and difficult procedure 
that requires experience, knowledge, the ability 
to make quick decisions under pressure and good 
judgement. It is often needed in order to confirm 
the extent of disease, the nature of a pathological 
process, the resection margins and the nature of 
a tissue, such as parathyroid. The procedure has 
its obvious limitations which are mainly time, 
sampling error, lack of consultation, lack of special 
stains/studies, inconsistency in the quality of the 
sections and the type of artefacts particularly ice 
crystal artefacts. 

Changing trends in the practice of pathology 
have significantly contributed to the decline, relative 
or absolute, in the frequency of the pathologists' 
exposure to frozen section materials. The main 
trends responsible for this are subspecialisation and 
the availability of radiologically guided biopsies. 
The former have resulted in the number of available 
frozen sections being thinly distributed among a large 
number of trainee pathologists. The latter means 
that materials that were in the past only accessible 
through frozen sections became less dependent on 
this procedure. In either case, the result is that the 
frozen section procedure has become even more 
challenging for the less experienced pathologist. 
The problem is often further compounded by the 
requesting clinicians being unfamiliar with the 
difficulties and limitations of the procedure, when it 
comes to particular pathological processes such as 
follicular lesions of the thyroid.16 In today's practice, 
therefore, pre- and intraoperative consultation and 
communication between surgeons and pathologists 
are a necessity while the decision to have a frozen 
section for intraoperative diagnosis should 
ultimately be the surgeon's choice and decision.

The Autopsy
The availability of an autopsy service is a necessity 
both within the health and forensic services. The 
reasons for this include cases of unexplained, or 
suspected wrongful deaths in the case of forensic 
service. In the health service, autopsy is required  
in cases of death with no premortem diagnosis 

and for the purpose of auditing and correlating 
premortem diagnoses with those of the autopsy 
findings. 

Various factors have contributed in the last 
three decades to the dramatic worldwide decline in 
the number of autopsies.17,18 These relate generally 
to the increasing public reluctance to give consent 
for an autopsy, exacerbated by the publicity given 
to certain infamous episodes. In addition and 
unfortunately, autopsy practice does not appeal 
nowadays to the majority of pathologists. They 
consider it disruptive to other increasing duties and 
a source of distraction for staff employed to meet 
the clinical needs of live patients. The decline has 
also been accelerated by advanced imaging and 
other diagnostic techniques that have significantly 
improved premortem diagnosis.The unpopularity 
and decline of the autopsy has confronted the 
specialty with the challenge of providing adequate 
training and experience for trainee pathologists.

There is a consensus that autopsy training is 
a necessity since, as outlined above, the autopsy 
service is a necessity. However, while it is essential 
to have proper autopsy training, it is not essential 
that all trainees in pathology should have such 
training. Making autopsy training an “elective” 
subspecialty19 will ensure that only genuinely 
interested trainees are able to get the proper 
experience from the declining pool of autopsies. 
Furthermore, centralisation of the service may be 
the solution in order to maximise the experience 
and exposure of those trainees to a larger number 
and wider spectrum of autopsy cases, improve the 
standard of service and cope with the problem of the 
declining number of pathologists interested in this 
particular subspecialty. It has also been suggested 
that the rigid rules and regulations that determine 
which cases should be considered for hospital 
autopsies need to be relaxed. Instead, requests for 
autopsy needs to be decided on a case by case basis 
and could include the few cases where the relatives 
of the deceased request an autopsy, even when it is 
deemed unnecessary by the treating physicians.

Multidisciplinary Team 
Meetings (MDTs)
To many pathologists, MDTs are looked upon as 
the “best thing” that happened to the speciality 
in recent times. Through participation in clinical 



Trends and Challenges in Pathology Practice 
Choices and necessities

42 | SQU Medical Journal, February 2011, Volume 11, Issue 1

decision making, pathologists gain improved job 
satisfaction and have sense of being appreciated. 
MDTs have increased awareness among other 
health professions of the speciality of pathology 
and its important role in the management of cancer 
patients. They have also improved communication 
with our service users and other health professions 
leading to more accurate, meaningful and 
informative pathology results.20,10 For many, it is 
also regarded as part of continual professional 
development so that although it is a time consuming 
duty it is often welcomed.21 MDTs are undoubtedly 
here to stay as they have proven to be immensely 
useful both to the patients and to all parties involved 
in management and care of cancer patients.20,21,22 

As MDTs are a relatively recent innovation, they 
need to be formally regulated to ascertain who 
should attend, the meeting venue, the technology 
and equipment required and the decision making 
method. MDTs should also be recognised as a 
significant component in the pathologist’s duties 
and job plan.21

Old and New Ancillary 
Techniques
Special stains, enzyme histochemistry, virtual 
slide telepathology, confocal light microscopy, 
immunohistochemistry,  flow cytometry,  electron 
microscopy (with its various modalities including 
transmission electron microscopy [TEM] , scanning 
electron microscopy [SEM], scanning transmission 
electron microscopy [STEM], low voltage electron 
microscopy [LVEM], reflective electron microscopy 
[REM]) and molecular pathology techniques are 
some of the techniques that pathologists utilise 
in their various activities and roles whether for 
diagnosis, prognosis, teaching and/or research. 
Ancillary techniques, including those which are 
new or technologically and scientifically highly 
advanced, are the means to achieve specific aims, 
be it for the diagnostic service or for research. In the 
drive for excellence, the focus on the aims can get 
distracted by the intriguing means to the point that 
the means become aims in themselves. We need 
always to remember to choose and apply techniques 
that answer our questions and address our needs 
rather than searching for irrelevant questions 
in order to adopt fascinating and attractive, yet 
irrelevant, new techniques.

In the recent past, several exciting and 
promising techniques did not match expectations. 
Others eventually occupied an important, yet 
significantly smaller, role than that which was 
originally expected. One example, more than two 
decades ago, was when silver staining for nucleolar 
organising regions was seen a promising tool as 
a proliferation marker; this topic generated an 
enormous number of publications.23,24 A second 
example is electron microscopy in the 1970s and 
1980s which was seen as the "ultimate" means 
for identifying tumour differentiation,25,26 yet it  
has now largely been replaced by 
immunohistochemistry. On the other hand, it 
still makes an essential and major contribution 
to specific topics mainly in kidney and  
neuromuscular diseases.

We should also remember that the pace of 
technological advance far exceeds our ability to 
adopt or implement all newly emerging techniques. 
Before adopting them, we need to identify the 
problems they can address while recognising 
our limitations. Otherwise new technologies can 
have an adverse impact on our basic and essential 
functions. We should also seek opportunities in 
global collaboration as rapid email and transport 
communications make our world increasingly 
smaller.

The Pathology Report
Naturally perhaps, choices are limited when it  
comes to the style of the pathology report. For a 
long time, free text and summary style reports 
constituted the majority of pathology reports. They 
still remain the norm for reporting many non-
neoplastic diseases. In the last two decades, with the 
increase in information requirements,27 synoptic 
reports have become fashionable particularly in 
reporting cancer cases. A mixture of both free text 
and synoptic style reports are also adopted by some, 
but they are often tedious and time consuming to 
compose. Digital images have also found their 
way into the pathology report in many centres 
worldwide, but their value and contribution is often 
questioned.

There is an overwhelming case for adopting 
a standardised synoptic report style especially 
for cancer cases. Their contents and designs are 
based on recommendations and guidelines issues 



Hassan MH Kamel

Special Contribution | 43

by international professional bodies.2,3 Most are 
simple and thorough in their contents, having the 
advantages of consistency, uniformity and being 
quicker to produce while avoiding oversight and 
typographic errors. They are also appealing to the 
service users who seem to recommend them. There 
does not seem to be a case against the synoptic 
report style. As such, it is reasonable to say that 
they should be regarded as a necessity for reporting  
cancer cases and at least a good choice for the 
reporting of non-neoplastic diseases. 

Other Duties that 
Influence Today's 
Pathology Practice
The pathologists’ growing administrative duties 
have increased their work load and responsibilities 
in addition to the clinical duties referred to above. 
The former include the requirements to comply 
with various regulatory bodies for both the 
medical and non-medical aspects of the provision 
of the pathology laboratory service. Issues such 
as accreditation; external and internal quality 
assurances;28 continuing professional development 
activities; various performance indicators including 
appraisal and job planning; continuous internal 
and external audit activities and revalidation and 
participation in clinical governance activities are 
just some of the essential tasks expected of medical 
professionals nowadays. Regardless of whether we 
like them or not, believe in them or not, we have to 
carry them out. They are necessary because: 1) they 
justify our confidence in our practice; 2) they justify 
the confidence of our service users and managers; 
3) they safeguard the standard of our practice,  
and 4) they ensure continuous pathology service 
improvement. 

Conclusion - Maintaining 
the Momentum of 
Pathology Service 
Improvements
Finally, facing and responding to the challenges, as 
well as to the changing trends, are strategies through 
which pathology service improvements continue and 
are ensured. Certain approaches are fundamental 
within any organisation to maintain the momentum 
of ongoing improvement. These include: 1) effective 

communication, the significance of which cannot be 
overstated. This entails communication at all levels 
be it within the department, with other pathology 
departments and institutions or with service users 
and managers; 2) the strong support of service users 
and managers in order for the service to continue 
to thrive and improve; 3) taking radical decisions, if 
deemed necessary for improvements, for example, 
centralisation of some aspects of the service which 
could concentrate expertise and reduce costs; 4) 
participation in regulatory bodies and schemes; 5) 
continuous adaptation to and adoption of useful 
new technology and procedures, and 6) exploration 
of opportunities for collaboration. No organisation, 
regardless of its size, can survive in isolation with 
today’s rapidly changing pace of technological and 
medical advances.

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Choices and necessities

44 | SQU Medical Journal, February 2011, Volume 11, Issue 1

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