Quality Practices of Anatomic Pathology Labs in Vietnam

Vietnam's economic growth has rapidly increased over the past couple of decades. Thanks to positive changes in international diplomatic relations, medicine in general has benefited from meaningful foreign aid, investment, and cooperation. Along with that, education and self-awareness about health and diseases are expanding in the larger population, which is a promising sign. In Vietnam, however, pathology has remained a mysterious medical field, due to inadequate recognition and support. In 2014, we conducted an inspection trip to 16 anatomic pathology labs from northern to southern Vietnam to investigate the current state of the quality practices, and identify the key issues and opportunities for possible solutions. First, in Vietnam, the entire field of pathology is represented by anatomic pathology, with clinical pathology as a subdivision. Laboratory services, including chemistry, microbiology, hematology, cytogenetics, blood banking, and transfusion, are managed by different departments, which often means that the vocabulary of quality practice is unfamiliar to Vietnamese pathologists. In 2014,1 the number of physicians per 10,000 was 7.8, with approximately one pathologist for every 179,000 persons, compared to one for every 19,232 persons in the United States.2 Ha Noi (in the north) and Ho Chi Minh City (in the south) are the only cities that have large teaching hospitals, with six to 10 pathologists in house. These hospitals also serve as referral centers, as patients often bypass provincial hospitals in order to go to the city for care. The remaining centers may have from one to three pathologists; usually there are none in primary hospitals. This paucity of pathologists mainly comes from under-appreciation of the profession.4 The critical value of pathology in patient care3 is not publicly recognized. The interaction between physicians and pathologists is minimal. For example, one hospital installed a new cryostat for intraoperative frozen section but only used it twice a month, as the service was unfamiliar to many clinicians. Medical students do not see pathology as an interesting career option and perceive it to have a low average salary and earning potential. Indeed, there are only two pathology residency programs, located in Ha Noi and Ho Chi Minh City, recruiting a combined five residents per year. Second, as is true for other specialties in Vietnam, completing residency is not a requirement for beginning practice. Postgraduate training degrees are open to all who wish to pursue them, but an orientated-pathology course as little as six months long can qualify someone to practice pathology without supervision. Likewise, continuing medical education courses are available but not mandatory, and the combination of the dearth of staff and distant locations make it difficult for rural pathologists to attend. Therefore, the gap in diagnostic capacity between pathologists working in larger institutions and those in provinces is substantial. Pathologists, and even department directors, seem to have little understanding of how to plan for replacement costs, how to manage for increases in reagent or other costs, and how to pull together more complex arrangements of ownership and repayment for materials and equipment. As a matter of fact, lab management is not a subject in any pathology curriculum in Vietnam. Third, the working environment is unfavorable. The grossing rooms in many hospitals are not properly ventilated, equipped only with old vent hoods or portable fans. Some of those without any type of ventilation system must rely on an open window, to take advantage of natural winds. Infrastructure is insufficient, with lack of refrigeration or air-conditioned rooms. In the majority of labs, staff embed tissues and stain slides manually. Sometimes, critical equipment is non-functional for a long time without foreseeable replacement. For example, quite a few labs have only one microtome. When it breaks, the staff borrows the neighboring hospital's microtome while they wait for theirs to be replaced. One lab in particular has waited for five years. Another lab had no alternative but to continue to use a faulty machine, which produced barely readable slides. Due to limited space, some labs dispose of their specimens as soon as one to two weeks after grossing. In at least one case, the disposal time was so short—in fact, right after grossing—that the specimen was discarded before the slides were examined. Unsatisfactory conditions, inadequate supply chain, and deficient infrastructure lead to specimen compromise and limited diagnostic tools. (Histochemical stains, for example, are almost never performed.) Fourth, the pathology report in general is not standardized and varies from one hospital to another. Often, critical information such as grading or staging is not present. Synoptic reports for cancer cases are rarely used. Active communication between clinicians and pathologists must improve. As soon as cooperation is shown to improve the quality of patient care in diagnosis, treatment, and follow-up, the role of the pathology service will be more appreciated. Recently, we have become aware of several hospitals adopting tumor boards and using multidisciplinary teams to facilitate patient management and communication. To deal with insufficient training, continuing medical education courses should be maintained and extended. In-person attendance would be the best option,4 as these courses provide interaction and collaboration with others.4 However, online courses should also be made available for those who cannot attend due to geographic location or limited funding. An even better option would be for designated teaching pathologists from larger institutions to visit provincial labs to observe their condition, answer questions staff might have in practice, and assist them in solving problems at the scene. These courses should be considered part of the teaching pathologists’ work and be included in their schedules.4 The Ministry of Health has begun linking provincial labs in various districts with partner teaching hospitals with this aim in mind. Visiting lecturers from advanced countries are always welcome. They bring in fresh viewpoints for the local pathologists and explain cutting edge technology, as well as give them a vision of the future in the field. Another fruitful option is the opposite, when Vietnamese pathologists are sent to developed countries for a short trip. The impact from this experience is profound, but is limited. However, it is the best way to show how things are done, can be done, and should be done. Two- to four- week immersive, mentoring lab visits to the United States and Canadian Academy of Pathology (USCAP) are included in G40 travel scholarships, which bring pathologists from developing nations to its annual meeting is a positive organizational step in this regard. Social media is also helpful as a way of connecting people and raising the bar in lab quality. Challenging or interesting cases can be shared, recent news posted, and communication facilitated. Dynamic telepathology (virtual slides)5 is an interesting option that turns any personal computer into a digital microscope with the assistance of the Internet and digital images, and offers great benefits for continuing education regardless of distance. However, Internet stability and bandwidth must be reliable, and the cost of this application is high at the present time. Additionally, lab management courses should be offered for all lab professionals. Financial support from government or foreign aid is a significant factor but not always obtainable or properly prioritized. Self-sustaining funding models2 for quality have more assured availability and success. Government subsidies as part of a national health system or local community are likely practicable and should be considered.2 Checklists and educational materials from reliable sources such as the College of American Pathologists (CAP) or the American Society for Clinical Pathology (ASCP) could be translated into Vietnamese and disseminated to the pathologist population. This action can be achievable promptly at minimal cost. An informative and standardized pathology report would help clinicians tremendously in patient care, bringing many positive chain-reaction effects in physician-pathologist relationships and improved quality practice. Finally, what is most important is the attitude of the pathologists. Instead of thinking, “This is good enough,” the right attitude should be “We can do better.” Pathologists should refuse to be complacent about the status quo and acknowledge the possibility that higher quality can be achieved. Positive changes might take time to become evident, but we believe keeping the right attitude will, step by step, make a difference for the better. We greatly appreciate the help of the U.S. faculty, Vietnamese pathologists, and local medical staff. My grateful thanks to Raymond Franklin, MD, PhD (chairman of the Department of Pathology, Orlando Regional Medical Center); Trung Nguyen, MD, PhD (former chairman of the Department of Pathology, University of Medicine and Pharmacy, Ho Chi Minh City, Vietnam); To Ta, MD (chairman of the Department of Pathology, K Hospital, Ha Noi, Vietnam); Dung Trinh, MD (chairman of the Department of Pathology, 108 Hospital, Ha Noi, Vietnam); Han Pham, MD (Department of Pathology, K Hospital, Ha Noi, Vietnam), Thong Trinh, MD (chairman of the Department of Pathology, Cho Ray Hospital, Ho Chi Minh City, Vietnam); Hoa Tran, MD (chairman of Department of Pathology, C Hospital, Da Nang, Vietnam).

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