The current status of Pathology education: A survey among Chinese medical students

Recently, Ministry of Education of the People’s Republic of China strongly advocated establishing the system of ‘Golden Online and Offline Courses’, which indicates online courses will play important roles in college education. Furthermore, the number of pathologists has fallen far behind the clinical needs. To solve this health issue and implement the policy from Ministry of Education, improving current Pathology education is necessary, and first is to know students’ opinions on the present courses and their professional choices.

classes. It is more likely for the students who have interests in Pathology to become pathologists. The main obstacles students will not become pathologists are boring work and unsatisfactory salary.

Background
To improve teaching quality, promote the revolution of classroom teaching, and explore the new form Pathology is a discipline bridging basic medicine and clinical medicine, therefore, it is a compulsory course for medical students. Though online Pathology courses are available on some platforms of network education, traditional classroom education is still the main form of teaching and learning nowadays. Online Pathology courses mainly serve as materials for medical students' self-learning or health workers' continue education. Because of the trend that online study will have a higher status in college education, current teaching structure and teaching pattern of Pathology are predicted to be changed.
Pathologists are indispensable roles for diagnosis of diseases in clinic. However, the number of pathologists has fallen far short of numbers needed in clinic. It is estimated that there is a shortage of 90,000 pathologists in China. (2) Similar problem is also raised in United States, Canadian, and United Kingdom. (3-6) Pathology education, especially in undergraduate students, may be the first chance for them to know the roles of pathologists. Therefore, the purpose of teaching activities is not only transferring knowledge of Pathology but also guiding students to set up correct professional sense.
Under these circumstances mentioned above, students' opinions on the present Pathology courses, the condition of their online study, their professional choices, and the underlying reasons are important sources to optimize the current Pathology education. However, up to now, there has been no report offering such kind of information. Thus, we conducted this survey to extensively understand these conditions.

Methods
Two types of questionnaires were developed and implemented for undergraduate students and graduate students respectively. Both addressed topics including students' views on the quality of traditional courses, the attitude towards the online courses, the suggestions for optimizing courses, the experience of online study, the professional choices and the underlying reasons.
Questionnaires were applied via web link (7, 8) to students from Medical School of Southeast University, Medical School of Nanjing University, and Nanjing University of Chinese Medicine. Data was collected two days later. Conventional statistics, classified statistics, and cross-over statistics were carried out for the data analyses. Figures were prepared using Prism version 6 (GraphPad Software).

Demographics of survey participants
Among the 215 medical students who responded to the questionnaires, 60% are undergraduate students, and 40% are graduate students. The reported number of participants was 139, and 76 for female and male, respectively. All the participants have completed Pathology courses in college (see Table 1).

Suggestions for optimizing traditional Pathology courses
As traditional courses are playing a vital role in current Pathology education, we first want to know how students evaluate them. The quality was devided into four levels: excellent, good, pass, and fail.
It is shown that majority of students are satisfied with the current courses, indicated by the total percentage of students choosing "Excellent" and "Good" is higher than 90% (Fig. 1A).
To optimize the traditional Pathology courses, a multiple-choice question was set, with options including teaching content, class atmosphere, and classroom interaction. The result shows that more than 70% of students want to learn more clinical cases based on the basic knowledge, especially the graduate students (79.07%) (Fig. 1B) were asked to choose one option from the given answers. As the Fig. 2A shows, around 80% of students agree that online courses are significant supplements to traditional courses. Only a few think online courses will displace traditional courses, or they are only of benefit to students without sufficient traditional teaching resources, or they are dispensable.
In the investigated population, 68.99% of undergraduate students and 46.51% of graduate students have online study experience (Fig. 2B). Around 10% students underwent online study but not about unspecified courses. However, there are still 17.8% of undergraduate students and 45.3% of graduate students who have never participated in any online course study.
To know which learning pattern students like, an assumption was made to exclude any difference between contents of online and traditional Pathology courses. Even in this situation, students prefer the offline model or mixed model (Fig. 2C). Furthermore, the number of students choosing online model and mixed model is larger in graduate group (70.93%) than it in undergraduate group (54.26%). One explanation is that graduate students need more flexible time, while undergraduate students need more face-to-face interactions with teachers. individual factors. Interestingly, the percentage of students choosing salary or employment status is obviously higher in undergraduate group than it in graduate group. But Option "Interests" stand first in the factors considered by graduate students (Fig. 3).

Factors diminishing students' willingness to become pathologists
As there is a large shortage of pathologists in clinic, we asked why the graduate students, who have decided their vocations, did not choose to become pathologists. Option "Slow development" stands for the slow development of pathology departments in China. Option "Lack of competitiveness" means that pathology department is often less competitive compared with other departments in clinic. The result shows boring work with low personal achievement is the leading influence factor.
Low pay and less attention from society rank second and third, respectively. Deserved to be mentioned, heavy work load is not a major factor. Only 25.58% of students make this option (Fig. 4A).
To the undergraduate students, a cross-over analysis was conducted to illustrate the relationship between their feelings onto Pathology courses and their willingness to become pathologists. As the Fig. 4(B-a) shows, half of the students like Pathology courses, and similar number of students have no strong feeling, while only 1.5% dislike it. In the population of students who like Pathology courses, 50% of them think that it is possible for them to become pathologists. However, the possibility reduced to 18.3% in the population without strong feeling onto Pathology (Fig. 4(B-b)). This is in line with the result from Fig. 3, which indicates that interest has a great impact on students' professional choice.

Discussions
Students are direct subjects of teaching activities, thus, their opinions on the current education and suggestions to optimize it deserve special attention. This survey was designed to know their evaluation on the quality of traditional Pathology courses and their experience of the online study.
Before we guide them to become pathologists, we need to find out the factors encouraging or deprecating them to become pathologists.
The To apply online courses effectively in teaching activities, it is necessary to take students' study models into account. Our results show that an online-offline mixed model is the most acceptable one to both undergraduate students and graduate students. Even the contents of the traditional and online Pathology courses are same, less students chose online model compared with those who chose offline model. In addition, increasing the proportion of traditional courses to undergraduate students is not ignorable, as they need more direct interactions with teachers.
Shortage of pathologists is a global problem and it is inhibiting progress on universal health coverage.
(12) It is reported that heavy workload, low pay, and threat of lawsuits relating to improper diagnoses discourage pathology enrollments. (13) The results from our survey indicate that boring work with low personal achievement, unsatisfactory salary, and less attention from society are noteworthy obstacles. As students who have interests in Pathology are more likely to become pathologists ( Fig. 4(B-b)), developing students' interest should be one of fundamental purposes in Pathology education.
If gender is considered, it is interesting to find that male students are more likely to attend online study than female students. In the population of graduate students, 49.15% of female participants have never attended online study, while the percentage in male group is 37.04% (see Additional file. 1A). Another obvious difference is observed when we analyze the main reasons why they did not become pathologists. More male students chose "Boring work with low achievement", while more female students chose "Less attention form society", "Slow development", and "Heavy workload". It seems that female students concerned more about the work environment (see Additional file. 1B).
In conclusion, this study makes us learn more about the students. Given the small sample size of the survey, it is hard to make a definite conclusion about how to build up a good system of online-offline

Consent to publish
Not applicable.

Availability of data and materials
The questionnaires and datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.  Factors influencing students' professional choices. Students were asked to choose three most important factors they considered when they decide their careers. The result is the ratio of students who chose the specific option to the total number of students.

Figure 4
Reasons underlying the unwillingness of students to become pathologists. (A) The question