Advancing medical laboratory practice in Pakistan: insights from a focus group study on technologists’ training needs

Abstract

Background

The realm of medical laboratory technology (MLT) training and education is unstructured in Pakistan. The primary challenge currently confronting the workforce in MLT is the absence of standardized curricula and assessments in education and training. This was an exploratory study aiming to inquire experiences of trainees, alumni and teaching coordinators regarding the technologist training program in a single institute at Pakistan.

Methods

To gain an in depth understanding of MLT program, three focus group discussions (FGDs) were held at Department of Pathology and Laboratory Medicine, Aga Khan University, Pakistan during Feb-April 2024. A team of pathologists and educationists developed interview guides for FGDs in English. Interviews were bilingual, transcribed verbatim and coded using thematic analysis. Participants included current trainees, alumni, teaching and learning coordinators and moderators for the interview.

Results

A total of 29 participants were engaged; these included current MLT trainees (n = 10), alumni (n = 10), and teaching/learning coordinators and sectional supervisors (n = 9). Five main themes emerged from the analysis of FGDs: (Scott MG, Rifai N, Smith B, Oellerich M, Panteghini M, Apple F et al. The changing face of laboratory medicine: a more service and less academically oriented profession? 2015;61(2):322-9.) Recognition of key features of the MTT program, (Ferraro S, Braga F, Panteghini MJCC, Medicine L. Lab Med new Healthc Environ. 2016;54(4):523–33.) Evaluating curriculum design, (Waheed U, Ahmad M, Wazeer A, Saeed M, Saba N, Rasheed FJMJMS. Medical laboratory science education; shaping competent and skilled healthcare professionals. 2023;1(1):58–63.) Teaching and learning strategies, (Ned-Sykes R, Johnson C, Ridderhof JC, Perlman E, Pollock A, DeBoy JM. Competency guidelines for public health laboratory professionals. 2015.) Addressing the need to improve assessment methods, and (Linder RJJM, Education B. Educating medical laboratory technologists: revisiting our assumptions in the current economic and health-care environment. 2012;13(2):150-4.) Navigating the transition from a trainee to a competent technologist.

Conclusion

Our investigation demonstrated its potential as a valuable needs assessment study, highlighting key strengths, drawbacks, and challenges of the existing MTT program. Importantly, these findings at our institute can inform further research efforts to design competency-based MLT education and training programs in Pakistan.

Background

Medical laboratory technologists (MLTs) constitute the backbone of medical laboratory personnel in any clinical laboratory. They are not only highly skilled allied health professionals (AHPs) but have unique skills to integrate bench skills and scientific and medical knowledge when conducting and interpreting laboratory tests. Given that surveys of evidence-based clinical guidelines indicate that a minimum of 80% of these guidelines, focused on diagnosing or managing diseases, necessitate laboratory testing [1], the role of MLTs as key players in ensuring the operational efficiency of clinical laboratories and effective healthcare delivery to the public is crucial. However, laboratory medicine grapples with the challenge of limited acknowledgment for educational endeavors compared to other medical specialties in Pakistan as is observed worldwide [2]. In addition, increasing automation of laboratory processes has inadvertently led to a misconception that MLTs merely oversee automated systems without actively engaging in the analytical process [3]. While automation streamlines routine tasks, it does not diminish the critical thinking, technical expertise, or troubleshooting skills that MLTs bring to the diagnostic process, highlighting their untapped potential for meaningful contributions in integrated clinical management, research, and discovery [1,2,3].

The primary challenges currently confronting the workforce in medical laboratory technology include recruitment and retention challenges, lack of opportunities for career advancement, insufficient training and professional development, absence of standardized curricula and assessment, and limited access to continuing education and training [4, 5]. With increased automation and technological advancements such as AI and precision engineering in the field of laboratory science, it is imperative that, in addition to emphasizing their subject-specific specialized training, knowledge, and skills in enhancing recent technological advancements, new methods should also be developed. This necessitates a diverse array of courses encompassing scientific, leadership, and managerial development so that MLTs can adopt a more proactive role in clinical laboratories [4]. However, this is further limited due to the nonavailability of resources for education and training.

In the context of Pakistan, the realm of MLT training and education has been severely neglected. Its failure to evolve with the flood of technological innovations in the field is exacerbated by the absence of a regulatory or accreditation system, setting it apart from other established health disciplines in the country, such as medicine, dentistry, nursing, and pharmacy. Thus, the education of MLTs operates in isolation, with more than 30 institutes offering a Bachelor program in MLT of varying standards and durations [6, 7].

According to a rough estimate, there are only 7000 qualified MLTs currently practicing in Pakistan. To address the remaining human resource shortage in clinical laboratories, there is a reliance on technicians who receive less than two years of technical education to provide cheap labor [7]. Additionally, the accessibility and quality of training resources vary across regions, contributing to disparities in the preparedness of MLTs. Furthermore, the integration of practical, hands-on experience in training programs appears to be inconsistent, hindering the application of theoretical knowledge in real-world settings. Although recent developments, such as the passage of the Allied Health Professional Council Bill and the establishment of the Allied Health Professionals and Paramedics Council, offer some promise for the future of medical technology in Pakistan [8], the present situation highlights a significant dearth of attention toward this field of allied health, prompting the need for urgent action.

The Medical Technologist Training (MTT) Program in Clinical Laboratories at AKUH is a one-year program divided into two phases. The first term, which is 31 weeks long, involves rotations in the Clinical Chemistry, Hematology, Histopathology, Microbiology, Molecular Pathology, and Blood Bank and Coagulation sections. The second term, lasting 21 weeks, is specialty specific and focuses on hands-on practical application of knowledge and skills in specific clinical laboratory areas, depending on the trainee’s interest and availability of positions. It was recently revised to align modern technology with the needs of our own clinical laboratory. Though there was informal feedback from the trainees and teachers regarding MLT program, no formal at-length discussion was held with the stakeholders in the recent past.

The purpose of this qualitative study was to explore the shared experiences and perspectives of learners and teachers regarding technologist training program at a clinical laboratory in Pakistan.

Methods

Sampling approach

Three groups of participants were purposefully selected who could provide in-depth insight of the MLT program. These were current and previous alumni along with the teaching and learning coordinators and managers. The intent was to develop multiple perspectives of the training program for representing complexity in the real-world. AKUH was selected as a single study site because of its unique curriculum which offers courses in five different specialties/disciplines during a one-year training program to the laboratory technologists.

Sample size

For maximal variation sampling, we examined 2 trainees and 2 alumni from each of the 5 disciplines making a total of 10 in each group. All 9 teaching coordinators participated in the study. Since cognitive and hands on learning in all 5 specialties is a unique experience, it was anticipated to obtain rich information for MTT program by including trainees from all specialties. Moreover, it was considered that while too many participants struggle for ample airtime to express themselves, too less may be forced to participate more than they would like to do.

Ethical considerations

Written informed consent was obtained from all participants prior to the initiation of the session. Ethical approval was obtained from AKUH’s Ethical Review Committee (ID- 2023-8716-25505).

Data collection approach and piloting

Three moderated focused group interviews were planned, audiotaped and then transcribed.

A core team of four expert pathologists, including one with health professional education and one health professional educationist, developed a semi-structured interview guide for each focus group (Additional file 1). A funnel approach was used during the interview by beginning the discussion with an overarching question to elicit a broader perspective before transitioning to specific questioning. All the questions were open-ended and conducive in a conversational tone facilitating an open exchange of ideas. It was also translated in Urdu for ease of understanding [10]We conducted a pilot focus group with six MLTs from the Clinical Chemistry section to evaluate its language and clarity before initiating the data collection [11]. Data from this focus group were not included in our analysis.

Focus group interviews

Focus group discussions (FGDs) were employed as a method for collecting and assessing data needs, leveraging the advantages of interviewing multiple individuals simultaneously, gaining insights into group behavior (which can contribute to understanding team-based learning), and generating deeper and comprehensive data through the synergy of group interaction [9, 12].

MLTs from Clinical Chemistry, Hematology, Molecular Biology, Histopathology, Blood Bank and Coagulation, and Microbiology were invited to provide valuable insights into their experiences and perspectives regarding the current one-year postgraduate certificate course in medical technology at AKUH. These stakeholders included the currently enrolled trainee technologists and alumni of the MTT program who completed their training over the last four years and who have been working as technologists in their respective sections and as supervisors and training/learning coordinators in their respective sections. We aimed for a homogenous composition of focus groups in terms of the nature of their professional experience to mitigate the influence of any power dynamics [10, 13, 14].

Each group consisted of a lead moderator and two observers who were well versed with the research topic. To encourage open communication and equal participation across the group, the moderator employed the use of various techniques, such as active listening, probing, and paraphrasing responses, to establish clarity, guide the discussion so that participants can build on each other’s comments, and make purposeful use of moments of silence to prompt additional dialog [11, 15]. Before the commencement of each FGD, the lead moderator briefly explained the research topic and reiterated the clause concerning participant confidentiality. All discussions were digitally recorded. No further sessions were conducted after the third focus group, as data saturation was achieved.

Data transcription

The recordings of the FGDs were transcribed verbatim. The initial transcript was bilingual and contained both Urdu and English. The transcript was completely translated to Urdu by the lead moderator, with the aim of maintaining a literal representation of what was said. Translation was subsequently reviewed by all members of the research team for accuracy. Although nonverbal communication was not separately analyzed, it was included in the original transcript to help elucidate the participants’ reactions.

Data analysis

An inductive thematic analysis was used to code the data and identify common themes. First, all members of the core team reviewed each focus group transcript independently to gain a thorough understanding of the data. The data were systematically organized as all correlated statements into codes, forming an initial coding framework. After a comprehensive review by all the researchers, the codes were organized into thematic categories.

An overview of methodology is shown in Fig. 1.

Fig. 1

Flowchart showing an overview of methodology

Results

A total of 29 participants participated in three FGDs for current MLT trainees (n = 10), alumni (n = 10), and teaching and learning coordinators and supervisors (n = 9). The mean duration of discussion was 60.67 ± 3.98 min. The detailed compositions of all the groups can be found in Table 1.

Table 1 Overall characteristics of the FGD participants to gain insight on experience and perspective of MTT program at Clinical Laboratories of AKUH (n = 29)

Five main themes emerged from the analysis of all FGDs: (1) Recognition of key features of the MTT program, (2) Evaluating curriculum design, (3) Teaching and learning strategies, (4) Addressing the need to improve assessment methods, and (5) Navigating the transition from trainee to a competent technologist.

Theme 1: recognition of key features of the MTT program

Participants highlighted key program features, including strengths such as a balance between theoretical and practical exposure. One trainee articulated, “This is a very balanced program; it includes theoretical and practical exposure both.” Similarly, when asked what sets AKUH training apart, another trainee emphasized, “When we meet people from other places, they don’t have a similar level of knowledge about safety and quality control as we do,” while a supervisor said, “I don’t think any other organization here is doing this on a similar level where trainee technologists get to rotate in all sections and receive specialized training.” Supervisors noted the program’s dual benefits for both trainees and the organization, as one of them remarked, “When we train our trainees according to our standards, protocols and policies, they benefit a lot from everything they have learnt here, and our organization benefits in the way that when these trainees get fixed [appointed], [as]they already know everything.” Another supervisor highlighted the academic background of the faculty as a source of innovative ideas.

However, noting the knowledge gaps among trainees, one of the alumni remarked, “Being an MLT [ from a previous 4-year program], I never faced an issue because we are taught diagnostics and clinicals throughout our 4 years of education, and we even do some clinical practical. For the rest of the students who come from different backgrounds [ in AKUH program], it can be quite difficult.” On the other hand, a supervisor highlighted the need for a more authentic certification process: “We need to make our certification more authentic [registration by a national body], but I don’t think we can do that unless we get it approved by a board.”

Theme 2: challenges in the curriculum

Trainees and alumni addressed weaknesses in the curriculum, such as limited practical learning and disconnects between theory and practice. A trainee noted, “We are constantly seeing troubleshooting being done on analyzer, but this is something that was never taught during lectures.” Considering everyone’s diverse academic backgrounds, an alumni mentioned how difficult it was that “they take a lecture [ now] and then observe the practical 6 months later.”

Alumni and supervisors also highlighted the importance of enhanced clinical correlation, with a supervisor noting that “Clinical correlation and integration are crucial, even though it takes time [ to understand].” In addition, supervisors discussed how “issues regarding trainees’ attitudes and punctuality come up” and highlighted the challenge of time constraints in curriculum implementation. As one of them noted, “It is very difficult to implement practically what we have written in the curriculum because the workload is so overwhelming [restricting teacher’s time to trainee].”

Theme 3: teaching and learning strategies

This theme explores teaching and learning strategies within three subthemes:

Subtheme 3 A: enhancing theoretical knowledge and understanding

Participants’ feedback regarding theoretical learning included positive appreciation for engaging and interactive sessions. Both trainees and alumni appreciated lectures in chemistry and in quality control that utilized Kahoot! as well as lectures on biosafety that featured videos and interactive content. Simultaneously, they emphasized issues such as inconvenient lecture timings/schedules, difficulty accessing lecture slides and study resources, and irrelevant assignments. Participants recognized opportunities to improve both lecture content and delivery and explore online lectures and certificate courses.

A supervisor suggested the use of a virtual learning environment (VLE) platform, Moodle, saying that “we can add courses on Moodle where trainees can go through them [in their own free time], and they can be assessed there [on Moodle] too.” Another suggested that “people who are taking lectures should be told that they need to deliver the lecture keeping in mind that the people sitting in front of them are beginners, not subject experts.”

Subtheme 3B: inadequate opportunity for practical learning

Participants believed that learning bench skills or hands on was not feasible due to limited time for demonstrations of skill training, challenges in staff shortages and inadequate access to extensive manual benchwork.

Trainees expressed dissatisfaction with the reliance on reading manuals for practical learning, emphasizing that “the experience that you get from hands-on practice is not something that can be replicated by reading books.” Another trainee noted how staff shortages impede their bench-side learning, saying that “they keep taking us trainees for granted to do all the menial work.”

One alumnus highlighted the challenges of observing manual benchwork in totality due to time constraints; For example, she stated: “if our work starts from day 1 for DNA extraction, so first we send PCR, then we send post PCR, then we run electrophoresis. Therefore, if we only have a rotation of 2 days on that bench, we can only see extraction and PCR and not the rest of the process.”

Subtheme 3 C: enhancing teaching skills/training practices

A key requisite that emerged from overall FGDs was establishing a dedicated teaching faculty for MLTs. Lack of an academic background or teaching skills and managing excessive work burdens by the technologists were identified as barriers for conducive learning environment A trainee noted that “not everyone can be a teacher,” while alumni had a similar opinion, with one highlighting “it’s important to know how to conduct a class.” Supervisors echoed similar sentiments, with one saying: “The way we train technologists, it is important that the instructors are trained too.” Another said, “It is not necessary that a very skilled technologist is a good teacher [too].”

The solutions proposed under this theme included conducting training sessions and workshops, providing incentives to trainers, and developing a skill lab. One supervisor added to the discussion by stating that “Ideally, we should have a skill lab because the technologist who is responsible for patient reporting is also responsible for teaching the trainee, so it is understandable that they prioritize the patient [over teaching].”

Theme 4: addressing the need to improve assessment methods

Participants highlighted several inconsistencies and inadequacies regarding the assessment methods used in the program. In contrast to the current six-monthly assessment, one trainee noted, “It [assessment] can be held after 2 months, or it can be divided department wise.” Furthermore, trainees and alumni emphasized the importance of providing comprehensive feedback. “Rotating trainees in each department should be given the opportunity to evaluate that department once their rotation ends,” a trainee remarked. Similarly, an alumna stressed upon the significance of narrative feedback by the supervisors by saying, “The trainees who are being inducted now, their evaluation forms only have options of good, excellent and such, but there’s no section of narrative remarks.”

Additionally, one alumna noted, “We were given clinical scenarios even though we don’t directly interact with the patients.” Similarly, both trainees and alumni talked about how challenging it was to study entire slides for exams and advocated for assessments that align with their practical work. “Our MCQs are very lecture-based. Our paper should be focused more on our benchwork,” an alumna suggested.

Theme 5: navigating the transition from trainee to a competent technologist

The MTT program was appreciated for instilling confidence in trainees; however, trainees expressed concerns due to the abrupt increase in responsibilities post transition. As one trainee expressed, “We are not given much responsibility as trainees, and now suddenly, we get a lot of responsibility, so it is quite a drastic change for us.” The trainees felt that they did not choose their carrier path, but they were forced to select one as per department needs. This was articulated by an alumna: “When we were trainees, we had a lot of people who wanted to go to molecular… Therefore, it is not possible that 20 trainees at one time get fixed in molecular, right?” Supervisors emphasized that one year of training is insufficient in developing expertise, particularly in esoteric testing. Furthermore, they discussed a high turnover rate among trained technologists as a concern for organizational sustainability. “People tend to leave after they have worked here for 3 years or so for other opportunities, so this may be a loss to our organization,” noted a supervisor.

Discussion

A recurring strength of AKUH’s training program discussed in our FGDs is its provision of exposure to different specialties of pathology. This approach proves to be advantageous for the majority of trainees, fostering adaptability and ensuring that their expertise is not confined to one area [16, 17]. Since our program is designed to fulfill the service needs of our clinical laboratories, this approach also benefits the institution. Trainees can be assessed as potential employees during their rotations, given that most hospitals prefer to hire graduates trained in their own facilities [18].

A core aspect of the MTT program is the enrollment of trainees holding bachelor’s degrees in either basic sciences or medical laboratory science. This leads to a diverse cohort with varied educational backgrounds. On the one hand, this underscores the program’s commitment to inclusivity, a key element that can be further strengthened by strong student support, maintenance of alumni networks, and faculty mentorship. Conversely, this implies the need for our curricula to be redefined to include academically robust content that caters to a range of students and outcomes [5].

It is widely acknowledged by educators and developers of MLT programs that hands-on experience is pertinent to cultivating competence in individuals working in clinical laboratories [16]. Our study revealed comparable results, as most participants expressed appreciation for the practical exposure offered at AKUH. This finding aligns with findings from other studies demonstrating that students’ conceptual and technical understanding of methodologies tends to improve tremendously with practical hands-on training in the laboratory [19].

As evident by our investigation, both students and supervisors recognize the importance of integrating clinical correlation as well as professionalism in the curriculum. This approach is crucial because prior research indicates that MLT interns who receive early clinical exposure demonstrate superior performance compared to their counterparts who do not receive similar exposure. This not only bolstered their knowledge and skills but also contributed to the enhancement of their professional character [20]. Similarly, comprehensive instruction in fundamental and biomedical science, rather than an exhaustive menu of existing tests, may more effectively equip students for continuing academic and professional development [5].

Within the realm of teaching and learning, the biggest obstacles identified by participants were issues related to lecture schedules, lack of engaging delivery format, time constraints and baseline knowledge differences among trainees. In the digital age, we have ample opportunities to address most of these issues using e-learning techniques and virtual learning environment platforms. A growing body of literature proves that there are no significant differences in student learning outcomes between traditional face-to-face classroom teaching and blended or online education. Multiple studies have demonstrated that online MLT students perform as well as their campus counterparts and are prepared to enter the workforce [21, 22]. Additionally, one study showed that MLT students exhibited greater engagement and motivation and achieved higher grades when using online resources, including video recordings with expert feedback for the learning of hands-on techniques [23]. Since overburdened staff and personnel shortages are among the biggest barriers to teaching in diagnostic laboratories, online study resources and blended learning can emerge as innovative solutions to relieve some burden on overworked staff. During our discussions, participants suggested providing incentives to trainers, which could include compelling options such as tuition benefits [24]. Another recurring proposal was the creation of a dedicated teaching entity for MLT trainees. This suggests that to effectively structure our training program and enhance teaching, increased collaboration between academic and laboratory staff is imperative.

Furthermore, our study revealed a significant challenge faced by trainees in bridging the gap between theory and practice. An effective solution to this could be problem-based learning (PBL), as suggested by a Chinese study that reported improved theory test scores, enhanced student feedback scores, and superior performance assessments in students studying clinical laboratory medicine. Since our trainees expressed dissatisfaction with assessments that failed to evaluate real-world application skills, incorporating case scenarios, subgroup discussions, and laboratory procedures through the adoption of alternative education approaches such as PBL would not only cultivate a deeper understanding of theoretical knowledge but also support the development and retention of practical and critical thinking skills [25]. Similarly, to foster a strong learning environment, it is crucial that students not be assessed on knowledge that they have not been previously exposed to. Our findings revealed multiple responses where trainees highlighted disparities in what was taught and assessed. This leads to feelings of inadequacy or a sense of being deceived or overwhelmed in addition to creating an environment where students do not feel psychologically safe [26].

The absence of an accreditation body stands out as the primary obstacle to establishing a structured training program and standardized curriculum. Without such accreditation, it becomes impossible to standardize teaching materials and academic content for any MLT program across various clinical laboratories. An associated drawback is the limited availability of career advancement opportunities for professionals in this field [5]. The launch of graduate degrees, including master’s or doctoral programs, advanced certificates, and online curricula, can strategically contribute to the growth of biomedical careers. This approach also addresses the high turnover challenges identified in our study, as technologists frequently opt out of their laboratory roles due to limited opportunities to pursue further education and training. With further education, medical laboratory technologists can transition to clinical scientists and pursue diverse career paths. They may explore education and training opportunities to teach the next generation of technologists in academic or clinical settings. Alternatively, they can also pursue opportunities in clinical research, pharmaceuticals, or public health. Some can transition into consultant roles, advise on laboratory best practices, or choose to work in industries such as working for medical equipment or reagent manufacturers.

Recommendations

Based on the findings of our study, we propose several recommendations for enhancing the training of technologists. Firstly, it is essential to implement strategies to strengthen inclusivity within the program, including enhanced student support, maintenance of alumni networks, and faculty mentorship. Secondly, there is a need to redefine curricula to incorporate academically robust content that caters to a diverse range of students and outcomes. Furthermore, it is imperative to utilize e-learning techniques and virtual learning environment platforms to address obstacles related to lecture schedules, engaging delivery formats, time constraints, and baseline knowledge differences among trainees. Also, problem-based learning (PBL) should be adopted as it could bridge the gap between theory and practice and cultivate practical and critical thinking skills among trainees. Finally, advocating for the establishment of an accreditation body to standardize training programs and curricula would enhance career advancement opportunities for professionals in the field.

Strengths and limitations

The study provides a deep insight into the training technologist program and an analysis of their core concerns. This is the first ever formal interaction with the stakeholders of the program. However, the findings obtained cannot be generalized to other technologist training program though they may have similar issues for the leaners and teachers.

Conclusion

As our main objective was to perform a gap analysis, our FGDs pinpointed several areas that demand attention for improvement. The MTT programme at AKUH primarily offers service-oriented on-the-job training to MLT trainees, limiting the extent to which academic and structural changes can be implemented in its existing form. To achieve the aim of delivering competency-based education to MLTs in Pakistan, substantial efforts must be made through robust policy development to standardize their training and address disparities in working competencies.