In the late 1980s molecular biologic methods had matured sufficiently to allow us to begin to unlock the basis for many diseases at the gene level, and the discipline of molecular pathology was born. Laboratories began to apply these novel techniques to the diagnosis of disease—heritable disorders, cancer, infections—and found that nucleic acid–based methods could provide clinically relevant information not available via other methods, or at faster speeds than traditional assays. These laboratory-developed approaches were ground-breaking, but required expertise not included in traditional medical education, or pathology residency training. To support this new subspecialty, the Association of Molecular Pathology (AMP) was formed in 1994. In time, molecular pathology fellowships evolved from research-based experiences and became fully accredited [Accreditation Council for Graduate Medical Education (ACGME)] programs with certification by the American Board of Pathology (ABPath) and the American Board of Medical Genetics and Genomics (ABMGG) (1999). The early diplomates and laboratory directors came from a variety of backgrounds and interests (microbiology, anatomic pathology/solid tumors, genetics, forensics, hematopathology) that formed the basis for the original subdivisions within AMP, and found great value in working together to define standards of service, quality metrics, and assay performance parameters, to help one another develop and validate new assays, to advocate for better reimbursement, and to train ourselves, our colleagues, and the next generation of pathologists how to best employ molecular methods to improve patient care. Although some laboratory directors were subspecialized, many of us covered molecular oncology, heritable diseases, and microbiology, a range of practice that made sense when unique laboratory spaces, equipment, and a highly specialized workforce was needed to practice molecular pathology.

Thirty-plus years later, the advances in our field are staggering. We have moved from Southern blots with radioactive probes to massively parallel sequencing and point of care PCR. And the explosion of clinically relevant information needed to practice pathology is even more amazing.

Molecular analysis underlies our diagnostic approaches in much of the pathology laboratory today. Molecular methods have moved mainstream in the microbiology laboratory, and have virtually replaced viral culture, allow us to detect microbes as part of syndromic panels, and are fundamental to the rapid characterization of positive blood cultures, antimicrobial resistance, and virulence factors. Human leukocyte antigen and forensic identity testing have evolved into fully molecular, separate disciplines with their own training and certification programs. Anatomic pathology and hematopathology now incorporate significant amounts of molecular data both for the assessment of prognostic and predictive markers as well as for the fundamental diagnosis of many diseases. Each new iteration of tumor classification schemes is based more firmly on the molecular abnormalities underlying those disorders.

This evolution is reflected in the demographics of who sits for the ABPath Molecular Genetic Pathology (MGP) subspecialty examination, and how they use their MGP training. To better understand alignment of MGP fellowship training content with skills needed in practice, ABPath undertook surveys of diplomates participating in Continuing Certification in 2017 and 2018. These data collected from practicing molecular pathologists was compared to corresponding data derived from an AMP survey of MGP program directors conducted in 2020. The Molecular Genetic Pathology Curriculum UPdate (MGPCUP) was formed as an ad hoc AMP working group to fully examine these data. As described by Velu et al in this issue of The Journal of Molecular Diagnostics (1Velu P.D. Cushman-Vokoun A. Ewalt M.D. Feilotter H. Gastier-Foster J.M. Goswami R.S. Laudadio J. Olsen R.J. Johnson R. Schlinsog A. Douglas A. Sandersfeld T. Kaul K.L. Alignment of fellowship training with practice patterns for Molecular Pathologists: A Report of the Association for Molecular Pathology Training and Education Committee.), two thirds of recent MGP diplomates combine their molecular pathology skills with signout of an anatomic pathology subspecialty or hematopathology. This practice differs from the pattern in the early years of molecular pathology, and parallels the pattern of dual fellowships completed by our younger colleagues: two-thirds do MGP paired with AP or Hematopathology. Among other subspecialties, only 9% combine MGP with Microbiology, perhaps because that field has more fully incorporated molecular analysis into their practices and training programs (1Velu P.D. Cushman-Vokoun A. Ewalt M.D. Feilotter H. Gastier-Foster J.M. Goswami R.S. Laudadio J. Olsen R.J. Johnson R. Schlinsog A. Douglas A. Sandersfeld T. Kaul K.L. Alignment of fellowship training with practice patterns for Molecular Pathologists: A Report of the Association for Molecular Pathology Training and Education Committee.).What are the implications of these shifts on the MGP fellowship programs? As noted by Velu et al (1Velu P.D. Cushman-Vokoun A. Ewalt M.D. Feilotter H. Gastier-Foster J.M. Goswami R.S. Laudadio J. Olsen R.J. Johnson R. Schlinsog A. Douglas A. Sandersfeld T. Kaul K.L. Alignment of fellowship training with practice patterns for Molecular Pathologists: A Report of the Association for Molecular Pathology Training and Education Committee.), program directors train fellows broadly in molecular pathology as their graduates will use these skills in a variety of different jobs. Jobs may change, so a broader skillset may have future value. There is value in understanding the analytic and pre-analytic challenges of an assay, even if one is solely engaged in interpretation of the end data produced, not serving full time as director of a molecular laboratory. And the deep understanding of heritable disorders and cancer predisposition syndromes cannot be discounted, even for one who is solely engaged in anatomic or hematopathology molecular signout.

However, from the perspective of the trainee or MGP diplomate, is broad MGP training needed? In my years as a trustee of the ABPath, I have heard from some diplomates and program directors alike that the time spent in molecular microbiology, HLA, identity testing, and clinical genetics is more than needed, and this is recapitulated in the findings of the Workgroup. Though all applications of molecular pathology are valuable and will continue to evolve, many of our trainees today are most interested in the combination of molecular expertise with anatomic or hematopathology. As the field has exploded during the past couple of decades, it is challenging to adequately include all applications of molecular diagnostics in a single year of training. Is it time to re-examine the content of our training programs? Should a core curriculum for MGP fellowships be formally defined, or redefined? Should we consider developing different tracks, for example, so that trainees could customize their experience for their anticipated career? This would require an increasing level of complexity for MGP program directors, revision of MGP program requirements with the ACGME, and deep discussions with ABMGG and the American Board of Medical Specialties (ABMS), as ABMGG has co-sponsored this board since its inception in 1999.

A further consideration is that some institutions are implementing comprehensive signout in anatomic pathology and hematopathology, fully embedding the molecular findings in the diagnostic report, capitalizing on the expertise of both subspecialties. Additionally, practicing anatomic and hematopathologists have become more fluent in the interpretation of molecular data, and in fact may be completing the final interpretation of the NGS data as well. Though some of these professionals have done MGP fellowships, many have pursued on the job training or continuing educational courses to master these skills. Perhaps a standardized curriculum is needed to facilitate such training, along with a certificate of mastery, useful for credentialling purposes. AMP has created a course that may fulfil this training need (AMP Certificate Program: NGS101 v2.0: A Re-Introduction to the Fundamentals of Next-Generation Sequencing, https://educate.amp.org/local/catalog/view/product.php?productid=309, last accessed 4/12/2022). Evidence of competency in interpretation of these complex data, and ongoing professional practice evaluation (OPPE) are needed for participation in this area.

The evolution of molecular pathology will undoubtedly continue at an increasing pace in the coming years. It is exciting to watch as molecular approaches are incorporated into routine diagnostic algorithms in pathology. One of the challenges the pathology community will face is the need to continually update educational curricula for fellows as well as pathology residents to adequately prepare our trainees for the practice of the future.

ReferenceVelu P.D. Cushman-Vokoun A. Ewalt M.D. Feilotter H. Gastier-Foster J.M. Goswami R.S. Laudadio J. Olsen R.J. Johnson R. Schlinsog A. Douglas A. Sandersfeld T. Kaul K.L.

Alignment of fellowship training with practice patterns for Molecular Pathologists: A Report of the Association for Molecular Pathology Training and Education Committee.

J Mol Diagn. ()Article InfoPublication History

Accepted: April 22, 2022

Received: April 14, 2022

Publication stageIn Press Journal Pre-ProofFootnotes

Disclosures: None Declared

No extramural funding

Identification

DOI: https://doi.org/10.1016/j.jmoldx.2022.04.012

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© 2022 Association for Molecular Pathology and American Society for Investigative Pathology. Published by Elsevier Inc. All rights reserved.

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