Bridging Pathology Gaps: A Conversation with Dr. Megha Joshi

In the 1980s, Megha Joshi, MD, FCAP, came to the US from India for pathology residency. Impressed by the cutting-edge medicine she saw being practiced and knowing the situation in India first-hand, Dr. Joshi wished to bridge the gap. In 1995, a year out of residency and in her first job, she founded the Association of Indian Pathologists in North America (AIPNA), a non-profit pathology organization, to interact with pathology services outside the US.

We sat down with Dr. Joshi for May’s Asian American and Pacific Islander Heritage Month. Our wide-ranging conversation touches on the health care challenges in India and how pathology can help, as well as her experiences navigating residency in a new country and the challenges facing the current generation of international medical graduates (IMGs).

Growing up in India in the 1960s, most women worked in the home. I wanted to have a professional career. My role models were the few female physicians who exuded power in the male-dominated, patriarchal society back home.

I went into pediatrics after medical school, but my father passed away suddenly during my house posts in pediatrics. I had to support my younger brother, who was still in middle school. Pathology residency in India allowed me to have a steady income during post-graduation, so I switched due to monetary reasons.

Looking back, I think it was a wise decision. I was always a basic science kind of person and could look at histologic sections and blood smears for hours under the microscope. Pathology came naturally to me, and I was fortunate to do my first residency at Tata Memorial Hospital in India, which gave me a strong foundation.

During the application process, I did not discriminate—I sent my resume to all the US pathology programs I could find. It's a 10,000-mile journey away from home, and I didn’t know if I would be accepted anywhere.

I had 17 interviews all together and was very fortunate to get a spot at Hartford Hospital, and, later, Harvard. When I started, I already knew English, which helped, but getting used to American English was a little different. And there were cultural differences working in the laboratories here. Overall, the pace was a little slower. People took the time to say, “Good morning, how are you doing?” instead of getting straight to the point. I also was not accustomed to handshakes; in India there is more emphasis on personal space. But everyone was so nice and very welcoming.

One thing that worked to my advantage: The slides were better quality, and the [microscope] technology was more advanced here than in India. My eyes were trained for more hardship, so having the upgrades made diagnosing much easier. 

While working my first job at a community hospital after residency, I started attending pathology conferences. I met a few other Indian pathologists at these events, but we often felt like fish out of water.

One day after the sessions we decided to go get Indian dinner. It was just so nice [to have] that familiar feeling. During the dinner, one of the other pathologists turned to me and said “Megha, you have to start an association for us.” Just like that, it was my job, and I took it seriously.

This was in 1995, so we created a call for membership letter and sent it to anyone in the CAP directory with a name that looked Indian. We requested a $25 membership fee to help get us started and were surprised at how quickly we started receiving checks in the mail—people wanted to join. I got us non-profit status soon after.

Through AIPNA, I got to know a lot of Indian pathologists all over the US. At that time, there were more Indian pathologists in America than in India. Because of the formation of this association, we were able to find each other. AIPNA also allowed us to collectively interact with pathologists in India through our conferences.

Except for a few outliers, a lot of countries in Asia and the Pacific struggle with preventative care. India, for example, is still very resource poor without enough high-quality hospitals for 1.4 billion people.

One thing that India does well is vaccines. There are fewer cases of things like cirrhosis of the liver now, thanks to the Hepatitis B vaccine. But, for the most part, preventive care—Pap smears, mammograms, all that—is not existent. There’s a shortage of resources, technology, and medical personnel with adequate training. So even if you have the money, it's [preventative care] just not offered, oftentimes. But a change in culture around the practice of medicine and health care is also needed. You don't just go to the doctor when you're sick, you go when you're still well and get all these tests done on a routine basis.

AIPNA helps by connecting Indian and Indian American pathologists in the US with pathologists in India. We recruit experts in different pathology specialties to speak at our annual conferences in India. For instance, one year we got a top tier renal pathologist to present. After [presenting at AIPNA], she went to the Gujarat Medical Institute to train their pathology residents in renal biopsies and how to use an electron microscope.

It's easier for more Indian pathologists to attend and get education and training if we bring the conference to them. We also draw pathologists from elsewhere in Asia, and even as far as Dubai. When they hear about the quality of the education, they make the effort to come, and it's often a shorter flight for them too.

I was invited to participate in a CAP laboratory inspection during my residency at Hartford, and I was struck by how much detail there was to quality assurance—things which were lacking in Indian laboratories, especially back then.

After becoming a member, I quickly learned how much the CAP does to improve the practice of pathology worldwide through its accreditation program, which helps laboratories in so many countries. Many people don’t realize how international the CAP is. The rest of the world—even Europe—looks to the CAP for its cancer protocols.

But the number one reason I've remained so involved is because the CAP has always felt like my organization. It's in the CAP’s DNA to welcome everyone like a family. You don't feel like wallpaper, you feel part of it, and that goes to the credibility of the CAP.

The first big wave of Indian migration to the US started in the 1970s. When I came in the ‘80s, there were still not a lot of people applying as international medical graduates. Now, everyone wants to come to the US to do their residency. So, the competition between them is fierce. Many are board certified with publications to their names, but there are limited spots.

Also, the [visa] requirements have changed. I came over on an immigrant visa and got my green card one and a half years later. Now, IMGs have to have clerkship experience and pass entrance exams, and the exams have gotten tough. Everything is so much harder, but they [IMGs] have a lot of grit and determination.

I think we can make it easier for IMGs to get through their residency requirements when they come here. These are people who've already done residencies in their home countries. Let them take the boards, do 1-2 years of fellowship, and then let them practice. Other specialties like radiology have loosened their requirements for IMGs, and the CAP should be progressive in pushing for [similar measures] with the American Board of Pathology. Because we need pathologists, at the end of the day. There's such a shortage.

Also, we should have more articles spotlighting pathologists who have immigrated to America from around the world. Talk to them about what brought them here, what their experience was like, if they had to learn the language, etc. There are so many of us [immigrants] in the pathology pool. If our stories are captured and seen, we feel visible. They’re also interesting stories for others to read about—they’re magnetic.

A practicing community hospital pathologist in Massachusetts for the past 25 years, Dr. Megha Joshi currently serves as senior staff pathologist at Beth Israel Lahey Health in Winchester, as well as a medical director at one of the hospital’s outreach laboratories. She is the founder and executive vice president of the Association of Indian Pathologists in North America (AIPNA), a non-profit pathology organization. She is involved in several other global pathology initiatives, including serving as a visiting professor at Rural Medical School, Krishna Institute of Medical Sciences in Karad, India, where she teaches residents in a case-based, hands-on format via annual teaching assignments.

Dr. Joshi is an active member of the CAP and has served on several committees, including the Member Engagement Committee, HOD Steering Committee, and the Quality and Clinical Data Affairs Registry. She currently serves on the CAP Foundation Board of Directors.