Supplemental Guide: Pathology - ACGME Home
Supplemental Guide for PathologySupplemental Guide:PathologyOctober 20181
Supplemental Guide for PathologyMilestones Supplemental GuideThis document provides additional guidance and examples for the Pathology Milestones. This isnot designed to indicate any specific requirements for each level, but to provide insight into thethinking of the Milestone Work Group.Included in this document is the intent of each Milestone and examples of what a ClinicalCompetency Committee (CCC) might expect to be observed/assessed at each level. Alsoincluded are suggested assessment models and tools for each subcompetency, references, andother useful information.Review this guide with the CCC and faculty members. As the program develops a sharedmental model of the Milestones, consider creating an individualized guide (Supplemental GuideTemplate available) with institution/program-specific examples, assessment tools used by theprogram, and curricular components.2
Supplemental Guide for PathologyPatient Care:Patient Care 1Overall IntentReporting (Anatomic Pathology/Clinical Pathology [AP/CP]) To ensure resident can generate effective pathology reports for bothsimple and complex cases, while using nuanced language andproviding appropriate recommendationsLevel 1 Examples Lists the key elements of a surgical pathology report: clinical history,source of specimen, surgical procedure, gross description,microscopic description, and diagnosis (AP) Engages with pathology attending to promote timely turnaround timeLevel 2 Examples Develops a report for simple surgical pathology case, such as atubular adenoma (AP), or a peripheral blood smear showing acuteblood loss anemia (CP)Level 3 Examples Develops a surgical pathology report for a more complex specimensuch as a colon resection for cancer, including College of AmericanPathologists (CAP) synoptic templates (AP) Generates a transfusion reaction report for suspected transfusionrelated acute lung injury (TRALI) (CP) with assistance; includeslanguage of uncertainty if case was probable but not definitive TRALILevel 4 Examples Independently develops a surgical pathology report for complex caseof colon cancer in Lynch syndrome, including microsatellite instabilitygenetic testing (AP) Documents discussion of complex transfusion reaction with clinicalproviders (CP) Generates complex interpretations for coagulation studies,integrating multiple test results, and providing recommendations forany follow-up testing (CP)Level 5 Examples Consistently generates complex reports, incorporating biomarkerswith therapeutic implications, Her2/Neu testing for breast cancer,and Nottingham scores (AP) or complex hematopathology reportsincorporating flow cytometry, fluorescence in situ hybridization(FISH), and molecular studies (CP)Assessment Models Review of reports at sign out (real-time or retrospective)or Tools Prospective review of reports Attending evaluation during daily sign outNotes or Resources Cancer Protocol Templates- College of American Pathologists www.cap.org/cancerprotocols Smith SM, Yearsley M. Constructing comments in a pathologyreport: advice for the pathology resident. Arch Pathol Lab Med.2016; 140(10): 1023-1024. Nakhleh RE, Myers JL, Allen TC, et al. Consensus statement oneffective communication of urgent diagnoses and significant,unexpected diagnoses in surgical pathology and cytopathology fromthe College of American Pathologists and Association of Directors ofAnatomic and Surgical Pathology. Arch Pathol Lab Med. 2012;136(2): 148-154. Rosai J, Bonfiglio TA, Carson JM, et. al. Standardization of thesurgical pathology report. Mod Pathol. 1992; 5(2): 197-199.3
Supplemental Guide for PathologyPatient Care 2Overall IntentLevel 1 ExamplesLevel 2 ExamplesLevel 3 ExamplesLevel 4 ExamplesLevel 5 ExamplesAssessmentModels or ToolsNotes orResourcesGrossing (AP) To ensure the resident can skillfully perform tissue triage, grossexamination, dissection, sectioning, section selection, anddocumentation (grossing) for any and all specimen types in a timelymanner while assuring specimen integrity Refers to appropriate anatomy textbooks, grossing aids Rinses utensils between cases; one specimen on grossing bench ata time; triages cases Confirms labeling on requisition, sample, and gross report inlaboratory information system (LIS) Discusses impact of breast fixation time on subsequent testingintegrity Grosses gallbladder, appendix, skin shaves, and/or benign uterus Takes care not to blend inks on breast specimens Appropriately triages to optimize fixation Recognizes need to replace formalin in cassette container atspecified intervals Grosses a colon resection for carcinoma orpancreaticoduodenectomy specimen Triages soft tissue for cytogenetics or lymph node for flow cytometry Submits tumor for tissue banking using departmental protocols Manages tissue to minimize contamination from other samples Proactively submits additional tissue when needed Grosses hemipelvectomy, complex head and neck specimens Identifies specimen mix-up and resolves with histology laboratory Is the person the department turns to for advice about unique anddifficult cases that need grossing Grosses explants from congenital heart disease with markedlydistorted anatomy Direct observation Assessment from pathology assistants Portfolio Competency assessment Surgical pathology report (and/or gross specimen review) todetermine accuracy of dictation and gross description Grossing laboratory metrics review (number of cases/blocks grossedby a resident on a given day) Surgical pathology metrics and quality review (number of floaters,number of poorly fixed specimens and quality trends, by resident) Departmental protocols Susan C. Lester, Manual of Surgical Pathology, 3rd edition, ISBN-13:978-0323065160 CAP Cancer Protocols - www.cap.org/cancerprotocols CAP Guidelines (various) - guidelines/current-cap-guidelines Practical Guide to Specimen Handling in Surgical Pathology, version6.0, revised November 2015 by Lott, R., Tunnicliffe, J., Sheppard, E.,Santiago, J., et al by CAP4
Supplemental Guide for Pathology Practical A Proposed Set of Metrics to Reduce Patient Safety RiskFrom Within the Anatomic Pathology Laboratory, Banks, P., Brown,R., Laslowski, A., Daniels, Y., et al. Lab Medicine 2017; 48; 195-2015
Supplemental Guide for PathologyPatient Care 3Overall IntentLevel 1 ExamplesLevel 2 ExamplesLevel 3 ExamplesLevel 4 ExamplesLevel 5 ExamplesAssessment Modelsor ToolsNotes andResourcesClinical Consultation, including on-call interactions (AP/CP)To provide a high-quality clinical consultation, including intra- andinter-departmental, formal, and informal. Refers to testing algorithm to identify best test to diagnose Lymedisease Refers to test directory to identify procedure to have tissue sent outfor karyotyping or sequencing Recommends performance of enzyme-linked immunosorbent assaytesting to diagnose Lyme disease and if recommends performanceof Western Blot; understands false positives and next steps; sharesthe published research and data with clinician after review withattending Clarifies need for cytogenetic testing on resected surgicalspecimen, recommends fresh tissue, and knows that frozen tissueis unacceptable Explains discrepant test result for Hepatitis B core antibody byclarifying clinical question, gathering and reviewing history and data,reviewing literature, developing a list of possible explanations fordiscrepant results, and recommends next steps to clinician (afterreview with attending) Recommends type and size of specimen for best test on tissue todetermine v-Ki-ras2 Kirsten rat sarcoma mutation, considers othertests, scope of mutations needed, and current published guidelines;shares the published research and data with clinician after reviewwith attending Gathers and reviews history and data of patient with apparent bloodtransfusion reaction; recommends testing and evaluation;recommends management and subsequent transfusion plan to theclinician Attends and appropriately participates in a rapid onsite evaluation ofpatient with apparently transfusion reaction, reviews clinical history;evaluates adequacy of sample collected; generates differentialdiagnosis based on morphology; triages sample appropriately forancillary testing Sought out by attending faculty members and/or clinicians forconsultative expertise Direct observation Portfolio Chart review Review of on-call logs Simulation Consultation can include a variety of interactions:o Clinician to Residento Resident to Residento Student to Residento Nursing, PA, or other health professional to Residento On-call, outpatient, and inpatiento Formal reportso Written or verbal advice and guidance6
Supplemental Guide for Pathology An Analysis of Clinical Consultation Activities in Clinical Pathology:Who Requests Help and Why, Robert L. Schmidt, MD, PhD, MBA,Jeanne Panlener, MT(ASCP), Jerry W. Hussong, DDS, MS, MD, American Journal of Clinical Pathology, Volume 142, Issue 3, 1September 2014, Pages , Published: 09January 20147
Supplemental Guide for PathologyPatient Care 4Interpretation and Diagnosis (AP/CP)Overall IntentTo appropriately use laboratory data to make correct diagnoses todirect effective patient careLevel 1 Examples Correctly uses and interprets basic chemistry and hematology tests,culture, and tissue-based approaches Appreciates normal histology and basic histologic patterns Correctly interprets hepatitis serology, discerns normal frominfection from vaccination Correlates radiologic findings to guide tissue sampling in anatomicpathology Correctly interprets hyperplasia, neoplasia, metaplasia, andinfectious processes Correlates clinical impression and laboratory results to generateand focus a differential diagnosis Identifies hemolysis leading to elevated potassium in blood samplesor underfixed sections in surgical pathology Correctly interprets culture, matrix-assisted laserdesorption/ionization, and molecular methods to detect/characterizea microbe, recommends use of appropriate antibiotic Histologically diagnoses cancer, recommends molecular studiesneeded, and selects an appropriate tissue sample Identifies heterophile antibody or tumor regression followingneoadjuvant chemotherapy Manages complex cases and diagnoses correctly Sought by attending faculty and/or clinicians for diagnostic expertise Attending assessment of daily work encounters Standardized assessments and practical exams Structured case discussions, unknown conferences Clinical management conferences Differential Diagnosis in Surgical Pathology 3rd Edition by Vijaya B.Reddy MD MBA, Paolo Gattuso MD, Odile David MD MPH, DanielJ. Spitz MD, Meryl H. Haber MD ISBN-13: 978-1455770137Level 2 ExamplesLevel 3 ExamplesLevel 4 ExamplesLevel 5 ExamplesAssessment Modelsor ToolsNotes or Resources8
Supplemental Guide for PathologyPatient Care 5Overall IntentLevel 1 ExamplesLevel 2 ExamplesLevel 3 ExamplesLevel 4 ExamplesLevel 5 ExamplesAssessment Modelsor ToolsNotes or ResourcesIntra-Operative Consultation (IOC), including Frozen Section (AP)To provide efficient, high quality intraoperative consultations for bothsimple and complex cases, which are tailored to the individual clinicalsituation and patient Recognizes the need for timely communication with the surgeon andthe implications of the information communicated Recognizes the difference between specimens sent for margins toguide intraoperative strategy versus specimens sent for diagnosis Assesses request for IOC with communication with clinical team forclarification as needed Identifies lesional tissue before sampling Prepares frozen section on straightforward specimen (e.g., margin)with assistance Prepares frozen section on pancreaticduodenectomy resection withassistance Prepares frozen section on straightforward specimen (e.g., margins)without assistance Communicates interpretation of IOC to surgeon with facultyassistance Prepares appropriate slides for squash preps for neurosurgicalcases, touch preps to compare cytology, choosing an en face marginversus a perpendicular margin Appropriately prioritizes tissue allocation in specimens with limitedamount (e.g., submitting tissue for flow cytometry versus permanentversus saving for tissue banking) Prepares frozen section on complex pancreaticduodenectomywithout assistance Communicates interpretation of IOC to surgeon with faculty backupas needed Appropriately triages intraoperative consultations when multiplecases are occurring simultaneously Serves as a resource to others in the gross room in orientingcomplex specimens and identifying optimal sections forintraoperative consultation Independently interprets all IOC (simple and complex) withoutbackup Direct observation in gross room and review of quality of preparedslides for sign out (real time) Correlation of IOC with final diagnoses (real-time) Portfolio review for a range of IOC specimens (retrospective) Powell SZ. Intraoperative consultation, cytologic preparations, andfrozen section in the central nervous system. Arch Pathol Lab Med.2005; 129(12): 1635-52. Intraoperative Consultation, A Volume in the Series: Foundations inDiagnostic Pathology by Alberto Marchevsky and Bonnie Balzer Biopsy Interpretation: The Frozen Section by Jerome B. Taxy MD9
Supplemental Guide for PathologyPatient Care 6Overall IntentLevel 1 ExamplesLevel 2 ExamplesLevel 3 ExamplesAutopsy (AP)To perform complete (routine, complex, unique) autopsies (includingautopsy pre-work, gross dissection, preparation of preliminary andfinal reports, selection of appropriate ancillary studies as needed, andformulation of clinicopathologic correlations) in a timely manner, whileadhering to institutional and regulatory guidelines; use aggregatedautopsy data to inform ongoing patient care and advance medicalknowledge. Concisely summarizes the relevant medical record, presents clinicalinformation on an autopsy case to the faculty members,communicates with the clinical team, and formulates the question(s)to be answered by the autopsy Understands and clearly articulates the value of the autopsy forclinicians and family members Reviews the autopsy consent form prior to starting the case andverifies that autopsy consent form is signed by the legal next of kin(as defined by state law), recognizes limitations to the extent ofautopsy and proceeds accordingly (adheres to autopsy limitations),and is able to properly identify the decedent and recognizediscrepancies in decedent identity Plans for any special techniques or ancillary studies (e.g., cultures)needed for routine autopsy With assistance, performs all aspects of a routine autopsy forsudden death due to myocardial infarction in previously healthyindividual, including autopsy pre-work, gross dissection,tissues/block selection, microscopic evaluation, and preparation ofpreliminary and final reports in a timely manner Consistently meets institutional and regulatory guidelines forexpected autopsy turnaround times, including preliminary and finalreports Identifies cases that need to be reported to Medical Examiner orCoroner, including risk management, patient safety, etc., in whichlegal or institutional processes and/or specific documentation mustbe implemented, such as reporting of previously undiagnosedcommunicable disease, device use, and discusses appropriatesteps with faculty members Performs all aspects of a routine autopsy for sepsis due togangrenous cholecystitis in previously healthy individual, includingautopsy pre-work, gross dissection, tissue/block selection,microscopic evaluation, preparation of preliminary and final reports,and formulation of clinicopathologic correlations independently andin a timely manner With some assistance from an autopsy technician and/or seniorlevel resident and/or faculty member, performs all aspects of acomplex autopsy for a patient with previously undiagnosedmetastatic disease and multiple tumors in multiple organs, includingautopsy pre-work, gross dissection, tissue/block selection,microscopic evaluation, preparation of preliminary and final reports,selection of appropriate ancillary studies (immunohistochemistry on10
Supplemental Guide for Pathology Level 4 Examples Level 5 Examples Assessment Modelsor Tools tumor samples), and formulation of clinicopathologic correlations, ina timely mannerWith guidance from faculty members, consistently followsinstitutional guidelines and regulations regarding all aspects ofautopsy performance and reportingIndependently performs all aspects of a routine autopsy for a patientwith pulmonary embolus due to recent long flight, no inheritedconditions, including autopsy pre-work, gross dissection,tissue/block selection, microscopic evaluation, preparation ofpreliminary and final reports, and formulation of clinicopathologiccorrelations, in a timely mannerIndependently performs all aspects of a complex autopsy for apatient with multiple organ failure and sepsis after a long-standinghospital course, multiple medical interventions, and with multiplepre-existing medical problems, including autopsy pre-work, grossdissection, tissue/block selection, microscopic evaluation,preparation of preliminary and final reports, selection of appropriateancillary studies, as needed, and formulation of clinicopathologiccorrelations, in a timely mannerConsistently follows institutional guidelines and regulationsregarding all aspects of autopsy performance and reporting, withoutguidance (independently)Serves as a reliable departmental resource for complicated andunique autopsies by using advanced knowledge and skills inautopsy pathology (e.g., neonate with multiple congenitalmalformations, genetic testing required, consultation with outsideagencies)Regularly reviews own and/or institutional autopsy data to evaluatefor trends, and contributes to new discoveries and/or implications topatient careDirect observationPortfolioAutopsy Case Log reviewAutopsy pathology report review (includes gross and microscopicspecimen review to determine accuracy of dictation anddescriptions)Written assessments (to evaluate for knowledge about legal andinstitutional guidelines and processes)Autopsy pathology metrics and quality review (number of floaters,adequacy of fixation, turnaround time for reports, correlationstatistics, adequacy of reporting “reportable” incidents, by resident)11
Supplemental Guide for PathologyNotes or Resources CAP Autopsy Topic Center rarchy/autopsy topic center.jspx CDC Public Health Law Program - State Death InvestigationGuidelines ns.html CAP Accreditation Checklists rarchy/accreditation checklists.jspx12
Supplemental Guide for PathologyMedical Knowledge:MedicalKnowledge 1Overall IntentLevel 1 ExamplesLevel 2 ExamplesLevel 3 ExamplesLevel 4 ExamplesLevel 5 ExamplesAssessment Modelsor ToolsNotes or ResourcesDiagnostic Knowledge (AP/CP)To understand the vast body of knowledge required to practicepathology including cellular biology, pathophysiology, normalhistology, abnormal histology, and both old and new testingmethodologies Identifies human papillomavirus (HPV) as a risk factor for cervicalsquamous cell carcinoma (AP) Identifies common causes of microcytic, hypochromic anemia Identifies high risk HPV serotypes and can begin to explain thecellular biology behind its tumorigenesis (AP) Describes pathophysiologic basis of microcytic, hypochromicanemia, and discusses differential diagnosis thereof Explains HPV-driven tumorigenesis independently and recognizesthat other pathways can lead to carcinoma as well (AP) Describes other non-HPV driven pathways (AP) Uses knowledge of molecular pathways
unexpected diagnoses in surgical pathology and cytopathology from the College of American Pathologists and Association of Directors of Anatomic and Surgical Pathology. Arch Pathol Lab Med. 2012; 136(2): 148-154. Rosai J, Bonfiglio TA, Carson JM, et. al. Standardization of the surgical pathology report. Mod Pathol. 1992; 5(2): 197-199.
Vista Pathology Laboratory – User’s Guide 1 Who We Are Reedy, Michael MD Pathology Nixon, Randal MD, PhD Pathology Neuropathology Loudermilk, Allison MD Pathology Hematopathology Wu, Bryan MD Pathology Breast Pathology Dermatopathology Pike, Robin MD Pathology Cy
Pathology: Molecular Pathology Page updated: August 2020 This section contains information to help providers bill for clinical laboratory tests or examinations related to molecular pathology and diagnostic services. Molecular Pathology Code Chart The chart included later in this section correlates molecular pathology CPT and HCPCS
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Subspecialty: Hepatobiliary Pathology, Gastrointestinal Pathology Assistant Professor of Pathology Dr. Kiyoko Oshima is the Director of Clinical Hepatic Pathology and Assistant Professor in the Department of Pathology at the Johns Hopkins Hospital University School of Medicine. She joined the Hopkins faculty in 2017.
Chicago Pathology Society CLINICAL INTERESTS: Neuropathology, Cytopathology, Autopsy, Surgical Pathology pathology.osu.edu Saman SeyedAhmadian, MD is an Assistant Professor - Clinical for Ohio State’s Department of Pathology. Insert photo here THE OHIO STATE UNIVERSITY DEPARTMENT OF PATHOLOGY
ACCREDITATION COUNCIL FOR GRADUATE MEDICAL EDUCATION (ACGME) (CONT'D) FATIGUE Achievements in the first 12 Months In the first 12 months after the July 2003 implementation, ACGME, the RRCs and the residency education community rose to the challenge of applying the duty hour standards to 7,973 accredited specialty and subspecialty programs.
The Accreditation Council for Graduate Medical Education (ACGME) is responsible for the Accreditation of post-MD medical training programs within the United States. Accreditation is accomplished through a peer review process and is based upon established standards and guidelines. The ACGME is a private, nonprofit organization established in 1981.
Introduction to real analysis / Robert G. Bartle, Donald R., Sherbert. -3rd ed. p. cm. Includes bibliographical references and index. ISBN 0-471-32148-6 (a1k. paper) 1. Mathematical analysis. 2. Functions of real variables. 1. Sherbert, Donald R., 1935- . II. Title. QA300.B294 2000 515-dc21 A. M. S. Classification 26-01 Printed in the United States of America 20 19 18 17 16 15 14 13 12 II 99 .
