STAGE: FOUNDATIONS (F) (PGY1)

Anatomical Pathology: Foundations

EPA #1 - Performing gross dissection of simple surgical specimens from accessioning to submission of blocks

Key Features:

- This EPA includes grossing select simple specimens, defined as single organ, routine indications and/or routine surgical specimens.

- Examples include: simple hysterectomy for fibroids, skin ellipses, appendix, gallbladder, reduction mastectomy, panniculectomy, colon for diverticulosis, and tissue biopsies.

- This EPA also includes adherence to safety and quality assurance protocols, and existing grossing protocols.

Assessment plan:

Direct or indirect observation by pathologist, pathology assistant, or Core or TTP trainee

Use form 2. Form collects information on:
- Observation: direct; indirect
- Specimen type: [free text]

Collect 10 observations of achievement
- At least 5 direct observations by a pathologist
- A variety of cases

Relevant Milestones:

1. ME 5.2 Organize work station to ensure safe practices in the laboratory
2. ME 5.2 Take universal precautionary measures to minimize hazardous exposures including potential infectious and chemical agents
3. ME 5.2 Use personal protective measures, including gowns, goggles, and slash resistance gloves
4. ME 1.3 Apply knowledge of normal anatomy and gross appearances of tissues
5. ME 1.3 Apply knowledge of the principles of tissue fixation, decalcification, processing, and the potential impact of improper handling of fresh tissues
6. ME 3.4 Perform appropriate dissection, description, and sampling of surgical specimens for routine and ancillary procedures
7. ME 3.4 Work efficiently, ensuring appropriate fixation in a timely manner
8. COM 4.1 Document using standardized grossing templates and/or descriptions and protocols as much as possible

Evaluation:

• Direct or indirect observation
• Could include a quiz/exam

Clinical Scenario:

• Grossing during surgical pathology block
• Autopsy blocks

Milestones satisfactorily met through rotation:

1. Organize work station to ensure safe practices in the laboratory
2. Use personal protective measures, including gowns, goggles, and slash resistance gloves
3. Apply knowledge of normal anatomy and gross appearances of tissues
4. Obtain a relevant clinical history
5. Met via performing autopsy blocks
6. Work efficiently, ensuring appropriate fixation in a timely manner
7. It would be helpful to receive a ballpark estimate of how long each specimen should ideally take
8. Organize work using strategies that address strengths and identify areas to improve in personal effectiveness

Milestones requiring formal attention:

1. Take universal precautionary measures to minimize hazardous exposures including potential infectious and chemical agents

• A quick safety tour of the gross lab is lacking. It would be helpful to have a brief orientation of what’s clean/dirty, handling formalin, and what to do if something spills.

2. Apply knowledge of the principles of tissue fixation, decalcification, processing, and the potential impact of improper handling of fresh tissues
3. Document using standardized grossing templates and/or descriptions and protocols as much as possible

• Access to voice over is vital and should be automatically set up at the start of residency.

Specific rotations:

PGY1 surgical pathology and autopsy blocks

EPA # 2

Microscopic reviewing and reporting of simple surgical specimens

Key Features:

- This EPA focuses on providing an interpretation of select simple surgical specimens, defined as single organ, routine indications and/or routine surgical specimens

- Examples include: simple hysterectomy for fibroids, skin ellipses, appendix, gallbladder, reduction mastectomy, panniculectomy, colon for diverticulosis and tissue biopsies

- This includes identifying normal and abnormal histology, obtaining additional investigations such as special stains/immunohistochemistry as directed, and using the LIS/EMR to obtain additional clinical information where appropriate.

- It also includes preparing a draft pathology report following the case review with attending staff.

- The case mix should represent simple biopsies, and routine surgical (benign) specimens as suggested by the grossing guidelines (e.g. L4E (level 2 or 3) / or CPT codes (88305)

Assessment plan:

Direct observation by General or Anatomical Pathologist, or TTP trainee

Use Form 1. Form collects information on:
- Organ System: breast; bone & soft tissue; gynecology; gastrointestinal; genito- urinary; head & neck; endocrine; skin; cardio vascular; thoracic; neuropathology; lymph nodes & spleen

Collect 10 observations of achievement
- At least 4 organ systems
- At least 3 different observers
- At least 2 observed by surgical pathologists

Relevant milestones:

1. ME 1.3 Apply knowledge of the principles of tissue fixation, decalcification, processing, and the impact of improper handling of fresh tissues
2. ME 1.3 Apply knowledge of routine histochemical staining
3. ME 1.3 Apply basic knowledge of normal gross and light microscopic appearance of tissues
4. ME 1.3 Apply knowledge of the principles of and indications for immunohistochemistry and special histochemical stains
5. ME 2.2 Perform a pathological examination that is focused and relevant
6. ME 3.4 Seek assistance as needed
7. ME 4.1 Ensure follow-up on results of ancillary tests, as relevant
8. COM 4.1 Document information about patients and their pertinent medical history as it relates to the case
9. COM 4.1 Generate a clear, concise report that enhances patient management
10. COM 4.1 Integrate information from ancillary studies and other sources into the pathology report if applicable
11. S 3.1 Recognize uncertainty and knowledge gaps in clinical and other professional encounters relevant to Anatomical Pathology
12. P 1.1 Complete assigned responsibilities
13. P 2.2 Demonstrate a commitment to patient safety and quality improvement through adherence to institutional policies and procedures
14. P 4.1 Demonstrate an ability to regulate attention, emotions, thoughts, and behaviours while maintaining capacity to perform professional tasks

Evaluation type:
Direct observation

Clinical scenarios:

Milestones satisfactorily met through rotation:

• Adequately addressed during histology week

Milestones requiring formal attention:

1. Apply knowledge of the principles of and indications for immunohistochemistry and special histochemical stains

• Although this material can be adequately learned through academic day and sign out, it would be more efficient to have half an academic day specifically focused for PGY1/2 that focuses on this material.

2. Select and/or interpret investigations
3. Ensure follow-up on results of ancillary tests, as relevant

• A formal academic day to explain what ancillary tests are, how long they take, practically speaking how to do it and where to pick them up, etc

EPA # 3

Assessing patients and integrating clinical information in the evaluation of disease processes

Key Features:

- This EPA ensures the resident establishes the skills and knowledge of clinical medicine in order to effectively function, in later stages, as a pathology consultant for a wide variety of patients and conditions

- This EPA includes performing clinical assessments, including history and physical exam, selecting and interpreting the results of investigations, and collaborating with clinical colleagues to develop a differential diagnosis and treatment or management plan

- It also includes communicating with patients and their families to gather clinical information and convey information about the diagnosis and/or management plan

- This EPA will be observed in the ambulatory or inpatient setting, with adult and pediatric patients, in a range of medical and surgical clinical conditions

Assessment Plan:

Direct observation and/or case review by supervisor

Use Form 1. Form collects information on
- Type of observation (select all that apply): direct observation of history; direct observation of communication with patients; case discussion or chart review
- Setting: Medicine; Surgery; Oncology; Pediatrics; other
- If “other” please indicate setting: [free text]

1. COM 2.1 Use patient-centred interviewing skills
2. ME2.2 Obtain a relevant clinical history3
3. ME 2.2 Perform a physical exam that informs the diagnosis
4. ME 2.2 Select and/or interpret investigations
5. ME 2.2 Develop a differential diagnosis
6. ME 2.2 Synthesize and organize clinical information for clear and succinct presentation to supervisor
7. ME 2.4 Identify and/or monitor key clinical features in the implementation of a management plan
8. COM 3.1 Convey information to the patient and/or family clearly and compassionately
9. COM 3.1 Verify and validate the patient’s and/or family’s understanding of their care
10. COM 4.1 Document the essential elements of a clinical encounter using a structured approach
11. P 1.1 Complete assigned responsibilities

Evaluation type

· This would be a direct observation by a staff from an off-service block, a total of 10 of these evaluations could be done during year one, as specified by the EPA. We would present this information to the staff during their clinic or during an emergency shift.

Clinical Scenario

· Done during the clinic time for an off service block. This would likely be presented after the resident has interviewed the patient and is ready to present the case to the staff

Specific rotation

· Could be done a total of 10 times during year 1 for any of the off-service oncologic blocks, such as gyne onc, med onc, rad onc, gen surg.

· The resident could also choose to present an emergency patient to the staff once all history, physical exam, lab work and imaging has been obtained and offer a treatment plan.

EPA #4

Performing basic tasks in autopsy pathology

Key Features:

- This EPA focuses on the basic tasks of an autopsy including reviewing the consent form, reviewing and summarizing the chart, and performing limited basic procedures.

- This includes: opening the pulmonary vasculature; opening the aorta, identifying and dissecting the main arteries; opening the bowel; dissecting the pelvic block; obtaining quality photographs as directed; completing required forms for ancillary tests (e.g. microbiology requisitions, biochemistry requisitions etc.).

- The observation of this EPA is divided into two parts:

• verification of consent and chart review;
• performing basic procedures related to autopsy

(performing a complete autopsy is a task of the Core stage)

Assessment Plan:

Part A: Verification of consent and chart review Direct observation by pathologist or TTP trainee

Use form 1.

Collect 2 observations of achievement

Part B: Performing basic tasks related to autopsy Direct observation by pathologist or TTP trainee

Use form 2. Form tracks information on
- Task (select all that apply): open the pulmonary vasculature; open the aorta, identify and dissect the main arteries; open the bowel; dissect the pelvic block; obtain quality photographs as directed; complete required forms for ancillary tests (e.g.: microbiology requisitions, biochemistry requisitions etc.); other
- If ‘other task’ is assessed, please specify: [free text]

Collect 2 observations of achievement
- Only 1 “other” task

Relevant Milestones:
Part A: Verification of consent and chart review

1. ME 2.1 Identify and explore clinical issues to be addressed in the pre-analytical, analytical and post-analytical handling of a case
2. ME 2.2 Obtain a relevant clinical history
3. ME 3.2 Describe the provincial and institutional rules governing consent for autopsy
4. ME 3.2 Identify the features of an appropriate autopsy consent
5. COM 4.1 Identify and correct vague or ambiguous documentation
6. ME 4.1 Recognize when a case requires involvement of the medical examiner
7. ME 2.2 Synthesize and organize clinical information for clear and succinct presentation to supervisor

Part B: Performing basic tasks related to autopsy

1. ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite, and autopsy suite, to minimize occupational risk
2. ME 1.3 Apply knowledge of normal anatomy, physiology, and biochemistry
3. ME 2.2 Perform a pathological examination that is focused and relevant
4. ME 3.4 Perform basic procedures in autopsy pathology
5. ME 3.4 Photograph specimens

1. Evaluation type

· Must be direct observation from a staff or senior resident

· Chart review presented to staff before case starts, and the direct observation happens during the entire autopsy case

2. Clinical Scenario

· This would happen during an autopsy case.

3. Specific rotation

· Hospital autopsy block or forensic autopsy block