Cardiovascular Pathology

Goals and Objectives

Level: PGY-1, PGY-2, PGY-3, PGY-4 and PGY-5

In the CBD cohort, junior residents are considered to be PGY-1 and PGY-2; senior residents are considered to be PGY-3 and PGY-4.  PGY-5 CBD residents are also considered to be senior residents and within the CBD curriculum. The goal is to allow for independence in the form of independent sign out, intraoperative consultations and supervision of junior residents and Pathologist Assistants.  

For surgical sign out in Anatomical Pathology residency training, there is no separation of cases based on complexity.  Due to the nature of Anatomical Pathology (all cases are ultimately reviewed and finalized by a supervising staff), a resident in any training level can review the glass slides and write up a preliminary report on any surgical pathology case.

  • Ordering of any ancillary studies (histochemical stains, immunohistochemical stains, molecular testing) will initially be done under staff supervision for junior residents.  This is done in order to conserve tissue and prevent tissue waste that may limit the staff pathologist's ability to render a diagnosis.
    • Based on the resident's experience and abilities they will eventually be permitted to order additional ancillary stains for straightforward, routine cases without consulting the staff pathologist.
    • Regardless of training level, any challenging case for which the resident is unsure of cell lineage or is unable to formulate a differential diagnosis that would be resolved by ancillary testing, the resident must consult the staff pathologist before ordering any ancillary stains.
    • It is expected that senior residents, including PGY-5 residents, would be able to initiate a preliminary panel of ancillary studies for routine cases.  This is ultimately at the discretion of their supervising staff.
  • Grossing of routine specimens can be handled by a resident at any training level.  Complex specimens, which for cardiovascular pathology include prosthetic valves, hearts with stents, hearts with bypass grafts, hearts with Left Ventricular Assist Device, hearts with valve replacement, hearts with congenital heart disease and hearts that need conduction system dissection, should be done by residents that are able to demonstrate a complete understanding of the anatomical and imaging findings as well as the surgical procedure.  Junior residents must obtain staff approval or be supervised by a senior resident for a complex specimen. 

It is expected that the first cardiovascular pathology rotation by a junior resident will result in the mastery of normal anatomy and histology, knowledge of the various surgical procedures encountered and the ability to diagnose common entities.  PGY1 AP residents will rotate on cardiovascular pathology after successfully completing their hospital autopsy rotation.

It is also expected that the junior residents will review the gross report and correct any typographical errors, assess the completeness of the grossing and correctly report the specimen site, laterality and procedure in the diagnostic section of the surgical pathology report.

Subsequent cardiovascular pathology rotations by senior residents will be built upon the above foundation and include the ability to formulate reasonable differential diagnoses as well as to work up challenging cases.  A senior resident should be able to produce a draft surgical pathology report that includes the elements listed above, along with the appropriate diagnosis, completion of a synoptic report (if indicated) and an appropriately completed microscopic description and/or comment field. a This draft report should also be free of typographical errors. The supervising staff pathologist is expected to provide an appropriate volume of cases for review based on the PGY-1 and PGY-2 resident’s level of training in these areas with the understanding that greater responsibility and workload will be taken on in PGY-3.

A resident is expected to complete a 15 minute end-of-rotation presentation for the one of their cardiovascular pathology rotations.

The PGY-5 year is one of senior leadership and the resident should be able to assume responsibility for organizing the service and supervising junior residents and students. The resident should have mastery of the information contained in standard texts and be prompt in using the literature to solve specific problems. The resident will be responsible for teaching junior residents and students on a routine basis. The PGY-5 should begin to have an understanding of the role of the practitioner in an integrated health care delivery system and to be aware of the issues in health care management facing patients and physicians. 

Based on the Royal College guidelines and recommendations, independent sign out is the current goal for the future CBD PGY-5 resident.

Medical Expert

General Requirements

  • Demonstrate diagnostic skills for accurate pathological diagnosis of cardiovascular and peripheral vascular disease (EPAs: F#2, C#4, C#5, C#6, TTP#1).
  • Access and apply relevant information to clinical practice (EPAs: TTD#2, C#13).
  • Demonstrate effective consultation services with respect to patient care, education and legal opinions (EPAs: C#18).

Specific Requirements

  • Demonstrate the ability to perform the cardiovascular component of post- mortem examination, with appropriate full description and diagnosis at gross and microscopic levels. Residents must be able to interpret their findings in light of the clinical history and communicate these in an effective written and oral fashion (EPAs: F#4, C#6, C#7, C#8, C#9).
  • Demonstrate an in-depth knowledge of the appropriate dissection and sampling of cardiovascular surgical specimens (EPAs: TTD# 1A, F#1, C#2, C#3, C#6, C#7, C#8).
  • Demonstrate knowledge of the indications for ancillary tests (special stains, immunohistochemistry and electron microscopy) and the technical principles underlying these (EPAs:  F#1, F#2, C#10, C#15, TTP#1, TTP#3).
  • Understand the risk factors, morphology, complications and treatment of atherosclerotic coronary artery disease (EPAs: C#4, C#5).
  • Demonstrate the knowledge of the evolution of morphological changes of myocardial infarction and recognize the early and late complications (EPAs: C#6, C#7, TTP#1).
  • Understand the classification and histological features of myocarditis (EPAs: C#4, C#5, C#6, C#7).
  • Understand the distinguishing features of primary and secondary forms of cardiomyopathy (EPAs: C#4, C#5, C#6, C#7).
  • Demonstrate the knowledge of the genetics and pathology of hypertrophic, arrhythmogenic, and restrictive and left ventricular non compaction cardiomyopathy (EPAs: C#4, C#5, C#6, C#7).
  • Understand the etiology, classification, histology and ancillary tests of Amyloidosis related cardiac disease (EPAs: C#4, C#5, C#6, C#7).
  • Discuss the etiology (embryologic basis), pathogenesis, and clinical features of congenital heart disease including cardiovascular shunts (e.g., atrial septal defect (ASD), ventricular septal defect (VSD), atrioventricular septal defect, and patent ductus arteriosus (PDA)) (EPA: C#8)
  • Understand the common benign and malignant cardiac tumors and describe their typical clinical presentations (EPAs: C#4, C#5, C#6, C#7)
  • Demonstrate the knowledge of acute cellular and antibody mediated rejection. Residents should also be able to recognize findings of acute ischemic (preservation) injury, healing and healed previous biopsy sites and lymphocytic infiltrates (Quilty effect) (EPAs: C#4, C#5, C#6, C#7).
  • Understand the etiology, pathology and treatment of valvular heart disease (EPAs: C#4, C#5, C#6, C#7).
  • Understand the classification, clinical features and pathology of vasculitis (EPAs: C#4, C#5).
  • Demonstrate the knowledge of the etiology, pathology and complications of aortic aneurysms (EPAs: C#4, C#5, C#6, C#7).

Communicator

General Requirements

  • Obtain a relevant clinical history, including relevant laboratory and imaging results and interpreting this information in light of the clinical information and providing a summary to the supervising staff pathologist (EPA: TTD#2)
  • Establish effective relationships with consulting physicians and surgeons (EPA: TTP#5, TTP#6).
  • Discuss appropriate information with the health care team relating to the diagnosis and workup of various surgical and autopsy patient cases (EPA: TTP#5, TTP#6).

Specific Requirements

  • Assist in the continuing education of physicians and other members of the hospital staff by presenting at pathology, cardiology, and cardiac surgery rounds (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Act as a consultant to clinical colleagues on the interpretation and relevance of pathological findings, with particular regard to their significance in the management of the patient (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Understand the information pathology should provide in a given clinical situation and be able to communicate it effectively in an oral and written form (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Collaborator

General Requirements

  • Consult effectively with other physicians and health care professionals (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Contribute effectively to other interdisciplinary team activities (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific Requirements

  • Utilize experience in clinical medicine and surgery to achieve a sound understanding of the effects of disease and the role of pathology in its management (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)
  • Demonstrate the ability to advise on the appropriateness of obtaining histologic specimens and following examination of these, to advise on further appropriate investigations (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6)

Manager

General Requirements

  • Utilize resources effectively to balance patient care, learning needs, and outside activities (EPA: C#17, TTP#4).
  • Utilize the resources of the anatomical pathology laboratory to make an accurate and timely diagnosis (EPAs: C#1, C#9, C#10 C#18, TTP#5)
  • Work effectively and efficiently in a health care organization (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Utilize information technology to optimize patient care, life-long learning and other activities (EPA: C#17, TTP#4).

Specific Requirements

  • Demonstrate knowledge of the methods of quality control in the laboratory as it related to ensuring the appropriate methods to allow the evaluation of cardiac and vascular tissues (EPAs: C#15, TTP#3).

Health Advocate

General Requirements

  • Identify the important determinants of cardiovascular health affecting patients (EPAs: C#4, C#5, TTP#1).
  • Identify factors that may need to be relayed for discussion to the consultants in regards to modifiable risk factors for the patient and their family (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Specific Requirements

  • As members of an interdisciplinary team of professionals responsible for individual and population health care, the anatomical pathologist will endeavour to ensure that laboratory practices and test selection are regularly evaluated to determine that they meet these community needs (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).

Scholar

General Requirements

  • Develop, implement and monitor a personal continuing education strategy for continuing medical education in cardiac diseases (EPA: C#17, TTP#4).
  • Critically appraise sources of medical information (EPAs: C#9, C#10, C#15, C#16, TTP#4)
  • Facilitate learning of patients, house staff/students and other health professionals by attending and presenting at rounds at various venues (EPAs: C#14, C#18, TTP#1, TTP#5, TTP#6).
  • Contribute to development of new knowledge (EPAs: C#16, C#17, TTP#4).

Specific Requirements

  • There should be consideration of completing a short research project or case report dealing with Cardiovascular Pathology during an elective. This might be presented at various national, international or local meetings (EPAs: C#16, C#17, TTP#4).

Professional

General Requirements

  • Deliver highest quality care with integrity, honesty and compassion.
  • Exhibit appropriate personal and interpersonal professional behaviours.
  • Practice medicine ethically consistent with obligations of a physician.
  • Demonstrate the knowledge, skills and attitudes relating to gender, culture, and ethnicity pertinent to anatomical pathology.

Specific Requirements

  • Act as an appropriate role model for students and others (EPAs: TTP#2, TTP#6).
  • Demonstrate a professional attitude to colleagues, as well as to other laboratory staff (EPAs: TTP#2, TTP#6).
  • Have an appreciation of the crucial role of the anatomical pathologist in providing quality patient care. This will include knowledge of individual professional limitations and the necessity of seeking appropriate second opinions (EPAs: C#5, TTP#1 TTP#6)
  • Demonstrate an increasing ability to handle more of the clinical workload of the staff pathologist.  It is expected that PGY4 and PGY5 residents are able to handle the full clinical workload of the staff pathologist each day on service (EPAs: TTP#1, TTP#5, TTP#6)

Instructional Tools

The resident will meet with the Cardiovascular subspecialty Lead and go over this document and the overall aspects of the rotation the day before the rotation starts.

Grossing (EPAs: F1, C2, C3, TTP#2)

  • All PGY levels:
  • Gross explant and autopsy heart specimens (hearts with grafts, coronary arteries with stents, cardiomyopathies etc.). 
  • Gross cardiovascular surgical specimens (valves, aortas, tumors etc.).
  • The number of grossed cases will be recorded at the end of the rotation and incorporated in the final evaluation.
  • Senior residents, including PGY5 residents, are expected to supervise and teach junior trainees in the gross room (EPA: TTP#2)

Microscopy

  • The resident will contact the attending pathologist that they are scheduled to sign cases with, the day before in order to arrange time of sign out and distribute cases
  • Retrieve pertinent clinical and radiologic information from the electronic medical records system (EPA: TTD #2)
  • Review all of the slides, recognize normal histology and areas with lesional pathology.  Be able to adequately describe the lesional areas (EPAs: C#4, C#5)
  • Provide a diagnosis or a differential diagnosis of the identified lesion (EPAs: C#4, C#5, TTP#1)
  • Based on the differential diagnosis, be able to provide an ancillary testing panel to work through the proposed differential diagnosis (EPAs: C#5, C#10, TTP#1)

Evaluation

  • The resident will be given an evaluation based on the objectives and PGY level milestones.
  • A test will be given to all residents when they finish the one block rotation. The test will include 10 glass slides and a written part with 8 to 10 Short Answer Questions. This exam has the purpose of identifying the areas that need improvement.

Recommended Reading and Resources

  • Review of Slide Sets/Collections
  • Myocardial infarction and its complications
  • Amyloidosis
  • Myocarditis
  • Cardiomyopathies
  • Cardiac Tumors
  • Vasculitis
  • Recommended Reading
  • Robbins' Pathologic Basis of Disease.
  • Diagnostic Pathology: Cardiovascular by Dylan V. Miller and Monica P. Revelo
  • Diagnostic Pathology: Normal Histology by Matthew R. Lindberg
  • Practical Cardiovascular Pathology by Allen P. Burke MD and Fabio Tavora MD

 

Updated April, 2022

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