STAGE: CORE (C) (PGY 2-4)

Anatomical Pathology: Core

EPA #1 - Initiating ancillary studies at the time of specimen receipt

Key Features:

- This EPA focuses on applying knowledge of ancillary techniques and their contributions to diagnosis in distributing tissue samples between routine pathologic studies (histology/cytology) and ancillary studies to optimize the diagnostic yield of a specimen
- This EPA includes handling specimens and submitting tissues for ancillary studies following institutional SOPs and includes: cytogenetics, molecular pathology, in situ hybridization, immunofluorescence, flow cytometry, and electron microscopy.
- This should be observed at the time of specimen receipt, though simulation may be employed for teaching and assessment purposes.
- At this stage, this EPA does not include test interpretation.
- Training experiences in specialized areas such as neuropathology, pediatric pathology and renal pathology are recommended to achieve this EPA.

Assessment Plan:
Direct observation by pathologist, technologist, pathology assistant or TTP trainee

Use Form 1. Form collects information on:
- Specimen type: [free text]
- Ancillary tests required or anticipated (select all that apply): immunohistochemistry; cytogenetics; molecular; in situ hybridization; immunofluorescence; flow cytometry; electron microscopy
- If “other” please specify test: [free text]
- Lymphoma protocol: yes; no

Collect 5 successful observations
- At least one sampling for electron microscopy
- At least one lymphoma protocol
- At least one example of “flash freezing” fresh tissue
- At least 1 pathologist observer

Relevant Milestones:

1. ME 3.1 Recognize when a specimen might require ancillary studies
2. ME 3.1 Describe the indications, contraindications, risks, and alternatives for a given test
3. ME 2.2 Assess specimen adequacy for ancillary testing
4. ME 3.3 Prioritize routine and ancillary studies when specimen adequacy is limited
5. ME 3.4 Maintain the integrity required for the specific ancillary study (e.g. nucleic acid integrity for molecular testing, cell membrane for flow cytometry, viable cells for cytogenetics, etc.)
6. COL 1.3 Consult with clinical colleagues, when appropriate, to ascertain if ancillary studies would be of value
7. COL 1.1 Receive and appropriately respond to input from other health care professionals (e.g. pathology assistants, technologists)
8. L 2.2 Apply evidence and guidelines with respect to resource utilization in common clinical scenarios

Evaluation:

Direct observation by pathologist, technologist, pathology assistant (PA) or TTP trainee

- Collect 5 successful observations:
· At least one sampling for electron microscopy
· At least one lymphoma protocol
· At least one example of “flash freezing” fresh tissue
· At least 1 pathologist observer

EPA # 2 - Performing gross dissection of routine surgical specimens

Key Features:

- This EPA includes all routine surgical specimens defined as oncologic and non- oncologic, single-organ systems (may include lymph nodes) and/or routine indications.

- This includes:

• Breast: lumpectomy, prophylactic mastectomy, gynecomastia

• Bone & soft tissue: curetting, non-tumor amputations,

• Skin: wide local excisions

• Gynecologic pathology: hysterectomy for endometrial cancers, prophylactic for Lynch syndrome, ovary resection, cone/LEEP, placenta, prophylactic BSO (SEE FIM)

• Gastrointestinal pathology: colectomy for benign/malignant conditions

• Genitourinary pathology: prostatectomy, TURP, partial nephrectomy

• Endocrine: adrenal simple procedures, thyroidectomy, parathyroidectomy

• Head & neck pathology: glossectomy, salivary gland resection

• Lymph nodes and Spleen: lymph nodes, splenectomy

• Neuropathology

• Thoracic pathology: lobectomy, wedge resection, pleurectomy, valves

- The observation of this EPA may be based on direct or indirect observation.
- Direct observation is defined as the supervisor observing all or a component of the grossing of a surgical specimen; this may involve the discussion and elaboration of ‘an approach’ to the surgical specimen between the supervisor and resident, review of surgical specimens at daily grossing rounds, and/or simulations of select gross cases.
- Indirect observation includes the review of a ‘gross description’ by a supervisor after completion of grossing, including correlation with gross photography, mapping of sections, and descriptions; re-review of a surgical specimen with the resident following initial grossing (e.g. additional blocks); and/or discussion of specific protocols or approaches (e.g. College of American Pathologists) as they pertain to specific organ systems.

Assessment plan:

Direct or indirect observation by staff pathologist with feedback from PA or TTP trainee review of gross description.

Use Form 2. Form collects information on:
- Organ system: breast; bone & soft tissue; skin; gynecology; gastrointestinal; genitourinary; endocrine; head & neck; lymph nodes & spleen; neuropathology; thoracic
- Specimen type: [free text]
- Pediatric: yes; no

Collect at least 50 observations of achievement
- A variety of organ systems
- A variety of specimens
- At least 6 in each of breast, skin, gynecology, gastrointestinal, genito-urinary, and head & neck
- At least 8 different observers

Relevant Milestones:

1. ME 2.2 Review clinical history, imaging and other relevant data as necessary
2. ME 3.4 Perform gross dissection, description and sampling of surgical specimens, applying meticulous attention to block selection and mapping using diagrams and images and demonstrating awareness of downstream synoptic reporting and staging parameters, and the need to save tissue for research, tissue bank and othe rindications, as necessary
3. ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite and autopsy suite to minimize occupational risk
4. L 1.1 Participate in quality management by minimizing cross contamination and using standardized grossing templates and protocols as appropriate
5. ME 3.4 Seek assistance as needed
6. ME 3.4 Take high quality photographs of specimens
7. ME 2.2 Formulate a differential diagnosis based on the pathological examination
8. COM 4.1 Communicate findings in a timely fashion, with appropriate documentation

-Evaluation:

Direct or indirect observation by staff pathologists (with feedback from PA or TTP trainee)

· Direct: staff pathologist observing all or a component of the grossing of a surgical specimen, this may involve:

1. Discussion and elaboration of an approach to the surgical specimen
2. Review of surgical specimens at daily grossing rounds
3. Simulations of select gross cases

Indirect: this may involve:

1. Review of gross description by a supervisor after completion of grossing (e.g. correlation with gross photography, mapping of sections and gross descriptions)
2. Re-review of a surgical specimen with the resident following initial grossing (e.g. additional blocks)
3. Discussion of specific protocols or approaches (e.g. College of American Pathologists) as they pertain to specific organ systems

Clinical scenario:

- Designated grossing days

- Days when staff assigns resident to gross, e.g. for gross room overload, urgent patient appointments, rotations without designated grossing days (e.g. derm, head and neck, cardiac, thoracic)

- Type of specimens listed (by specimen type) in EPA core sheet

- Collect at least 50 observations of achievement

· At least 6 in each of breast, skin, gynecology, gastrointestinal, genito-urinary, and head and neck specimens

· A variety of specimens in a variety of organ systems

EPA # 3 - Performing gross dissection of complex surgical specimens

Key Features:

- This EPA includes all complex surgical specimens, defined as oncologic staging surgeries, single organ specimens of complex anatomy, multi organ specimens, specimens for non-routine indications or other unique situations such as those requiring a contextual awareness of the case.

- Examples of complex gross examinations include

• Whipple resections, low anterior resection, abdominoperineal resection, exenteration, esophagectomy, endoscopic mucosal resection, gallbladder cancer with debulking, Hirschprung (pull through), prophylactic gastrectomy

• Neck lymph node dissection, total laryngectomy, oral tumor resections with bone

• Vulvectomy, multigestation placenta, radical hysterectomy

• Post chemotherapy breast resections

• Soft tissue/bone tumor amputations

• Post treatment resections in other organ systems

• Total cystectomy, radical nephrectomy

- The observation of this EPA may be based on direct or indirect observation.

- Direct observation is defined as the supervisor observing all or a component of the grossing of a surgical specimen; this may involve the discussion and elaboration of ‘an approach’ to the surgical specimen between the supervisor and resident, review of surgical specimens at daily grossing rounds, and/or simulations of select gross cases.

- Indirect observation includes the review of a ‘gross description’ by a supervisor after completion of grossing, including correlation with gross photography, mapping of sections, and descriptions; re-review of a surgical specimen with the resident following initial grossing (e.g. additional blocks); and/or discussion of specific protocols or approaches (e.g. College of American Pathologists) as they pertain to specific organ systems.

Assessment plan:

Direct or indirect observation by staff pathologist with feedback from PA or TTP trainee review of gross description

Use Form 2. Form collects information on:

- Organ system: breast; bone & soft tissue; skin; gynecology; gastrointestinal (including hepatobiliary/pancreas); genitourinary; endocrine; head & neck; lymph nodes & spleen; neuropathology; thoracic
- Specimen type: [free text]
- Pediatric: yes; no

Collect 100 observations of achievement encompassing a wide breadth of presentations
- A variety of systems
- A variety of specimens
- At least 15 gastrointestinal
- At least 10 in each of gynecology, genitourinary, and breast
- At least 5 head & neck
- At least 5 pediatric
- At least 8 different observers

Relevant Milestones:

1. ME 2.2 Review clinical history, imaging and other relevant data as necessary
2. ME 3.4 Perform gross dissection, description and sampling of surgical specimens, applying meticulous attention to block selection and mapping using diagrams and images and demonstrating awareness of downstream synoptic reporting and staging parameters, and the need to save tissue for research, tissue bank and other indications, as necessary
3. ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite and autopsy suite to minimize occupational risk
4. L 1.1 Participate in quality management by minimizing cross contamination and using standardized grossing templates and protocols as appropriate
5. ME 3.4 Seek assistance as needed
6. ME 3.4 Take high quality photographs of specimens
7. ME 2.2 Formulate a differential diagnosis based on the pathological examination
8. COM 4.1 Communicate findings in a timely fashion, with appropriate documentation

Evaluation:

Direct or indirect observation by staff pathologists (with feedback from PA or TTP trainee)

· Direct: staff pathologist observing all or a component of the grossing of a surgical specimen, this may involve:

1. Discussion and elaboration of an approach to the surgical specimen
2. Review of surgical specimens at daily grossing rounds
3. Simulations of select gross cases

· Indirect: this may involve:
1. Review of gross description by a supervisor after completion of grossing (e.g. correlation with gross photography, mapping of sections and gross descriptions)
2. Re-review of a surgical specimen with the resident following initial grossing (e.g. additional blocks)
3. Discussion of specific protocols or approaches (e.g. College of American Pathologists) as they pertain to specific organ systems-

Clinical Scenario
Designated grossing days

- Days when staff assigns resident to gross, e.g. for gross room overload, complex specimens needing staff review, urgent patient appointments, rotations without designated grossing days (e.g. head and neck, thoracic, cardiac)

- Type of specimens listed (by specimen type) in EPA core sheet

- Collect 100 observations encompassing a wide breadth of presentations

· At least 15 gastrointestinal specimens

· At least 10 in each of gynecology, genitourinary, and breast specimens

· At least 5 head and neck specimens

· A variety of specimens in a variety of organ systems

Specific Rotations:

None.

EPA #4- Generating diagnostically accurate and complete pathology reports for routine surgical pathology cases

Key Features:

- This EPA focuses on managing a routine surgical pathology case from receipt of the H&E-stained glass slides, to generation of a report.

- A routine case is one with a diagnosis that is common and typically easily rendered, and that has relatively easily assessed reporting elements. Examples of this case type include: routine gastrointestinal, breast core and bladder biopsies, and resection specimens such a simple hysterectomies and breast lumpectomies for benign disease.

- This EPA includes matching the specimen with the requisition, ensuring that the correct patient material has been received with appropriate and accurate documentation, and that the processing has rendered the case satisfactory for interpretation (if not, pre-analytical issues that may have arisen should have been brought to the attention of the staff pathologist).

- This EPA includes using the laboratory and hospital information systems to gather relevant history, using a microscope (including a polarizer) correctly, reviewing the case in a timely fashion, generating a diagnosis and/or differential diagnosis, selecting and interpreting ancillary studies (special/immunostains, levels, etc.) and providing an accurate report ready for verification and review with staff.

- Organization and prioritization of work is an additional feature, and includes appropriate management of urgent cases, critical values and reportable diseases.

- This EPA may include communication with clinicians, or other house staff.

Assessment Plan:

Direct and indirect observation with review of resident’s submission of report by pathologist or TTP trainee

Use form 1. Form collects information on
- Diagnosis: [free text]
- Organ system: breast; bone & soft tissue; skin; gynecology; gastrointestinal; genitourinary; endocrine; head & neck; lymph nodes & spleen; neuropathology; thoracic
- Pediatric: yes; no
- Specimen type: biopsy; resection; other

Collect at least 100 observations of achievement encompassing a wide breadth of presentations
- At least 10 from each breast, gynecology, gastrointestinal, genitourinary, and skin
- At least 5 from each of the other organ systems
- At least 5 pediatric
- A variety of specimens and diagnosis, including malignant and non-malignant, biopsies and surgical resection
- At least 8 different observers

Relevant Milestones:

1. ME 1.3 Apply knowledge of gross and microscopic appearances of tissues in disease states
2. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques
3. ME 2.2 Perform a gross and microscopic pathological examination that is focused and relevant
4. ME 1.6 Seek assistance in situations that are complex or new
5. ME 2.2 Formulate a differential diagnosis based on the pathological examination
6. ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
7. ME 2.2 Establish a final diagnosis that takes into account clinical correlations
8. COM 4.1 Prepare clear, concise, comprehensive, and timely written reports for surgical pathology
9. COM 4.1 Integrate information from ancillary studies and other sources into the pathology report
10. ME 1.4 Complete pathology reports within appropriate turnaround times
11. COL 1.3 Convey information from the pathology assessment to clinicians in a manner that enhances patient management

Evaluation type:
Direct observation and indirect observation by staff

Clinical scenario:
 Signout
 Intraoperative consultation
 Other comments: understanding when to utilize synoptic reporting and demonstrating ability to generate accurate synoptic reports. Understanding AJCC TNM staging and CAP protocols

Specific rotation:
 Main core rotations - GI, breast, lung, gyne, GU, derm, soft tissue, head and neck, CV, LN, peds
 Level of PGY1-3
 Common/routine biopsies and resections specimens (level of community care hospital)

EPA # 5- Generating diagnostically accurate and complete pathology reports for complex surgical pathology cases

Key Features:

- This EPA focuses on managing a complex surgical pathology case from receipt of the H&E-stained glass slides, to generation of a report.

- A complex case is one with a diagnosis that is uncommon, difficult to render or that has reporting elements with considerable inter-observer variability. Cases in which the differential diagnosis cannot be resolved are included in this category. Examples include: skin biopsies for suspicious melanocytic lesions or inflammatory dermatoses, kidney biopsies, most oncologic resections with synoptic reporting protocols, specimens containing multiple organs where the disease process may involve more than one organ.

-This EPA includes matching the specimen with the requisition, ensuring that the correct patient material has been received with appropriate and accurate documentation, and that the processing has rendered the case satisfactory for interpretation (if not, pre-analytical issues that may have arisen should have been brought to the attention of the staff pathologist).

- This EPA includes correlation with relevant clinical history, gross description, diagnostic imaging, laboratory tests, and previous pathology, generation of a diagnosis and/or differential diagnosis, selection and interpretation of ancillary studies (special/immunostains, levels, etc.) and provision of an accurate report, using synoptic reporting as needed, ready for verification and review with staff.

- Organization and prioritization of work is an additional feature, and includes appropriate management of urgent cases, critical values and reportable diseases.

- This EPA may include communication with clinicians, or other house staff, and consultation with other pathologists.

Assessment plan:

Direct and indirect observation with review of resident’s submission of report by pathologist or TTP trainee

Use Form 1. Form collects information on:
- Diagnosis: [free text]
- Organ system: breast; bone & soft tissue; skin; gynecology; gastrointestinal; genitourinary; endocrine; head & neck; lymph nodes & spleen; neuropathology; thoracic
- Pediatric: yes; no
- Specimen type: biopsy; resection; other

Collect at least 100 observations of achievement encompassing a wide breadth of presentations
- At least 10 from each gynecology, gastrointestinal, genito-urinary, breast, and skin
- At least 5 from each of the other organ systems
- At least 5 pediatric
- A variety of specimens and diagnosis, including malignant and non-malignant, biopsies and surgical resection
- At least 8 observers

Relevant Milestones:

1. ME 1.3 Apply knowledge of gross and microscopic appearances of tissues in disease states
2. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques
3. ME 2.2 Perform a gross and microscopic pathological examination that is focused and relevant
4. ME 1.6 Seek assistance in situations that are complex or new
5. ME 2.2 Formulate a differential diagnosis based on the pathological examination
6. ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
7. ME 2.2 Establish a final diagnosis that takes into account clinical correlations
8. ME 4.1 Determine the need and timing of referral to another specialist and/or second opinion
9. ME 1.4 Complete pathology reports within appropriate turnaround times
10. COL 1.3 Convey information from the pathology assessment to clinicians in a manner that enhances patient management
11. COM 4.1 Prepare clear, concise, comprehensive, and timely written reports, for surgical pathology
12. COM 4.1 Integrate information from ancillary studies and other sources into the pathology report
13. COM 4.1 Use synoptic and other standardized reporting formats as appropriate

Evaluation type:

Direct observation and indirect observation by staff

Clinical scenario:
 Signout
 Intraoperative consultation
 Gross review - understanding when the gross specimen needs to be reviewed and what further information (ie additional sections) are required to complete the report

Specific rotation:
 Main core rotations - GI, breast, lung, gyne, GU, derm, soft tissue, head and neck, CV, LN, peds
 Specialty rotations - Neuro, medical kidney, cytology, GI (Liver), ophthalmology
o Level of PGY2-4
o Resections specimens (level of academic centre)
o Biopsies

Other comments:
 Understanding when to utilize synoptic reporting and demonstrating ability to generate accurate synoptic reports. Understanding AJCC TNM staging and CAP protocols
 Understanding when a case may need external consultation
 Integration of CORE EPA 10 (ancillary test to help make diagnosis)

EPA #6- Performing medical autopsies and generating complete and diagnostically accurate reports

Key Features:

- This EPA focuses on hospital autopsy, from receipt of the chart and consent form, to the generation of an accurate, timely and clinically relevant final report.

- This includes performing the external examination, organ evisceration, organ dissection, gross examination including diagnosing any pathology, drafting a preliminary report, ordering ancillary testing when necessary, examining the microscopic slides and drafting the final opinion and report.

- This also includes modifying standard autopsy procedures as necessary.

- This EPA includes limited autopsies (examples: chest, heart or brain only) but does NOT include pediatric/fetal/perinatal cases.

- The observation of this EPA is divided into three parts: initial assessment and preliminary report; organ evisceration; interpretation and final report

Assessment Plan:

Part A: Initial assessment and preliminary report Direct observation by pathologist or TTP trainee

Use form 1. Form tracks information on
- Case details: full; limited
- Provisional/favoured cause of death: cardiac; pulmonary (non-infectious); gastrointestinal; infectious; malignancy; other
- If “other” indicate provisional cause of death: [free text]

Collect at least 6 observations of achievement
- At least 2 different pathologist observers

Part B: Organ evisceration
Direct observation by pathologist, TTP trainee, pathology assistant or autopsy technician Use Form 2.

Collect 5 observation of achievement
- At least 1 pathologist observer

Part C: Interpretation and final report Case review with pathologist

Use form 1. Form tracks information on:
- Case details: full; limited
- Final cause of death: cardiac; pulmonary (non-infectious); gastrointestinal; infectious; malignancy; other
- If “other” indicate final cause of death: [free text] Collect 6 observations of achievement
- At least 2 different pathologist observers

Relevant Milestones:
Part A: Initial assessment and preliminary report

1. ME 3.2 Ensure autopsy consent has been obtained and documented correctly
2. ME 1.3 Apply knowledge of normal anatomy, physiology, and biochemistry
3. ME 1.3 Apply knowledge of gross and microscopic appearances of tissues in disease states
4. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques
5. ME 1.6 Seek assistance in situations that are complex or new
6. ME 2.2 Obtain a relevant clinical history
7. ME 3.4 Perform a complete autopsy, with appropriate full description and diagnosis at gross and microscopic levels
8. ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite, and autopsy suite, to minimize occupational risk
9. ME 3.4 Interpret the findings of autopsy in the context of the relevant clinical history
10. ME 3.4 Document procedures accurately
11. COM 4.1 Prepare clear, concise, comprehensive, and timely written reports for autopsy consultations

Part B: Organ evisceration

1. ME 1.3 Apply knowledge of normal anatomy, physiology, and biochemistry
2. ME 1.6 Seek assistance in situations that are complex or new
3. ME 3.4 Perform organ evisceration
4. ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite, and autopsy suite, to minimize occupational risk
5. COL 1.2 Work effectively with laboratory technologists and pathology assistants, directing their assistance
6. COM 3.2 Communicate and document issues arising from a breach in quality or safety of laboratory practice

Part C: Investigation, interpretation and final report

1. ME 1.3 Apply knowledge of normal gross, light microscopic, and
2. ME 1.3 Apply knowledge of gross and microscopic appearances of tissues in disease states
3. ME 2.2 Perform a gross and microscopic pathological examination that is focused and relevant
4. ME 3.4 Interpret the findings of autopsy in the context of the relevant clinical history
5. COM 4.1 Prepare clear, concise, comprehensive, and timely written reports for autopsy consultations
6. COM 4.1 Integrate information from ancillary studies and other sources into the pathology report

Evaluation type:

 Direct observation and indirect observation by staff - organ block dissection, special dissection techniques
 Direct observation by PA/MA - evisceration, organ block dissection

Clinical scenario:
 Medical autopsy (including weekend call)
 Autopsy signout
o Use of ancillary studies if required - ie molecular, EM, IHC, micro
 Autopsy rounds (ME1.3, 3.4, P3.3)
 Brain cutting sessions - neuro block or hospital autopsy (should not count for more than 1)
 Exams - gross and micro of autopsy cases, autopsy report writing

Specific rotation:
 Medical autopsies - foundation yea

 Weekend call - medical autopsies performed under Forensic Staff

 Neuropathology

EPA #7- Performing routine forensic autopsies and generating complete and diagnostically accurate reports

Key Features:

- This EPA focuses on adult and older child cases, with manner of death including non- suspicious injuries, suicide, sudden natural deaths, intoxications, and complications of therapy.

- This EPA includes correctly performing pre-autopsy assessments, performing the external examination and gross dissection, recognizing and describing evidence of disease and/or injury, obtaining appropriate samples for ancillary testing, preparing autopsy reports, examining microscopic slides, interpreting ancillary results and drafting a final report including final opinion with the cause of death, and recognition of common forensic artifacts.

- This EPA also includes recognizing a case needing forensic autopsy, directing photography and/or taking photographs as appropriate, preparing a forensic autopsy report in the correct format that includes a cause of death statement that may inform determination of the manner of death in routine cases.

- The observation of this EPA is divided into 2 parts: pre-autopsy assessment, dissections and examinations; interpretation and final report

- The observation of this EPA does not require that the resident has participated in both aspects (i.e. resident can interpret and report cases for which they were not the original prosector)

Assessment Plan:

Part A: Pre-autopsy assessment, dissections and examinations
Direct observation by forensic pathologist, pathologist, or forensic pathology subspecialty trainee

Use Form 1. Form collects information on
- Case type: natural death; multiple trauma; decomposed remains; intoxication; hanging; bodies from uncontrolled environments; post-procedure death; other
- If “other” indicate case type: [free text]
- Cause of death: [free text]
- Manner of death: natural; accident; suicide; undetermined
- Special dissections performed: yes; no
- If “yes” specify dissection: [free text]

Collect 6 observations of achievement
- At least 3 case types
- At least 2 different observers

Part B: Interpretation and final report
Direct observation by forensic pathologist, pathologist, or forensic pathology subspecialty trainee

Use Form 1. Form collects information on
- Case type: natural death; multiple trauma; decomposed remains; intoxication; hanging; bodies from uncontrolled environments; post-procedure death; other
- If “other” indicate case type: [free text]
- Cause of death: [free text]

Collect 6 observations of achievement
- At least 3 case types
- At least 2 different observers

Relevant Milestones:

Part A: Assessment, dissections and examinations

1. ME 2.2 Obtain a relevant clinical history
2. ME 2.2 Perform a pathological examination that is focused and relevant
3. ME 2.2 Recognize common forensic artifacts
4. ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
5. ME 3.4 Perform a complete forensic autopsy, including but not limited to toxicological examination and the submission of specimens to the forensic sciences laboratory
6. ME 1.6 Seek assistance in situations that are complex or new
7. ME 3.4 Interpret the findings of autopsy in the context of the relevant clinical history
8. COL 1.2 Work effectively with laboratory technologists and pathology assistants, directing their assistance

Part B: Interpretation and final report

1. ME 1.3 Apply knowledge of gross and microscopic appearances of tissues in disease states
2. ME 2.2 Interpret the findings of autopsy in the context of the relevant clinical history
3. COM 4.1 Prepare clear, concise, comprehensive, and timely written reports for autopsy consultations
4. COM 4.1 Integrate information from ancillary studies and other sources into the pathology report
5. P 3.1 Adhere to requirements related to reportable diseases, including infectious diseases

Evaluation Type:

Direct observation

Clinical Scenario:
Standard Forensic Autopsy (External and Internal examination) with review of microscopic slides and preliminary and final autopsy report compilation

Specific rotation:

First 3 weeks of PGY1 Medical Autopsy blocks, 2 blocks of Forensics (PGY2 and 4) and during on call Saturdays

· For this EPA, I personally think we have abundant opportunities to achieve the required 6 observations as residents are involved in forensic autopsies during first 3 weeks of medical autopsy blocks, 2 blocks of Forensics (years 2 and 4) and during on call Saturdays.

· For the most part, the format of the forensic autopsy should be kept the same as the majority of the features of the EPA can be achieved.

· Residents should communicate with staff in order to obtain some of the milestones that in the past have not been performed regularly by residents in the past (e.g. – selecting ancillary techniques, toxicologic examination and the submission of specimens and examining microscopic slides)

o PGY1 residents during their first 3 weeks should attempt to focus and acquire some of these requirements

o Also residents should do their utmost to obtain microscopic slides from appropriate staff. A better system needs to be in place where the staff communicates with the resident when the slides are out so they are able to preview. The resident should then setup a time to review these slides with staff. They can then add the relevant findings into their preliminary report for final review.

EPA # 8- Performing routine pediatric, fetal/perinatal autopsies

Key Features:

- This EPA focuses on pediatric, fetal and perinatal autopsies, from receipt of the chart and consent form, to the generation of an accurate, timely, and clinically relevant final report.

- This includes performing the external examination, organ evisceration, organ dissection, gross examination including diagnosing any pathology, drafting a preliminary report, ordering ancillary testing when necessary, examining the microscopic slides, and drafting the final opinion and report.

- This also includes modifying standard autopsy procedures as necessary.

- This EPA includes using examination and dissection techniques to exclude common congenital abnormalities and applying knowledge of histology associated with normal fetal and childhood development

- This EPA includes incorporating the examination of the placenta in perinatal cases.

- This EPA excludes brain only autopsies.

- The observation of this EPA is divided into two parts: initial assessment and preliminary report; interpretation and final report

Assessment Plan:

Part A: Initial assessment and preliminary report Direct observation by pathologist

Use form 1. Form collects information on
- Type: fetal; neonatal; pediatric Collect 3 observations of achievement

Part B: Interpretation and final report Direct observation by pathologist

Use form 1. Form collects information on
- Type: fetal; neonatal; pediatric Collect 3 observations of achievement

Relevant Milestones:
Part A: Initial assessment and preliminary report

1. ME 2.2 Obtain a relevant clinical history
2. ME 3.4 Perform a complete pediatric autopsy, with appropriate full description and diagnosis at gross and microscopic levels
3. ME 1.3 Apply knowledge of the principles of embryologic development and common variations of normal development
4. ME 1.3 Apply knowledge of gross and microscopic appearances of tissues in disease states
5. ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
6. HA 1.1 Respond to findings related to inheritable conditions that may be of significance in disease prevention or early detection (e.g. genetic diseases that may affect a sibling)

Part B: Interpretation and final report

1. ME 1.3 Apply knowledge of the principles of embryologic development and common variations of normal development
2. ME 1.3 Apply knowledge of gross and microscopic appearances of tissues in disease
3. ME 2.2 Perform a gross and microscopic pathological examination that is focused and relevant
    
4. ME 3.4 Interpret the findings of autopsy in the context of the relevant clinical history
5. COM 4.1 Prepare clear, concise, comprehensive, and timely written reports for autopsy consultations
6. HA 1.2 Alert treating physicians when potentially detectable inherited conditions are encountered (e.g. genetic diseases that may affect a sibling)

Evaluation Type:
Direct observation

Clinical Scenario:
Standard Pediatric Autopsy (External and Internal examination) with review of microscopic slides and preliminary and final autopsy report compilation

Specific Rotation:
2 blocks of pediatric pathology PGY3 year

· As with forensic autopsies, residents have abundant opportunity to achieve the required 3 autopsies and completing a final pathologic report. 1 resident is on during a double block of pediatrics and is shared amongst 4 pediatric pathologists.

· Direct supervision will be required at first by staff pathologists as residents often observe cases and have limited hands on dissection opportunities especially with the more challenging cases with significant congenital anomalies. Residents should receive some simple training and orientation on the differences and challenges with respect to the Adult v pediatric.

· After with the permission and direct observation of staff, a resident can conduct the full autopsy with the understanding that they may ask for assistance on challenging cases as is with other autopsies

· Residents have ample opportunity to follow up on these cases, review the microscopic slides and compile the preliminary and final report.

EPA # 9- Selecting, interpreting, and integrating molecular test results

Key Features:

- This EPA focuses on the role of molecular pathology in anatomic pathology practice, and includes in situ hybridization, PCR-based testing, cytogenetics, and next- generation sequencing.

- This EPA includes assessing specimen adequacy for molecular testing and suggesting appropriate tests, typically after review of light microscopy, as well as interpreting and integrating the molecular results into the final report.

- This EPA does not include the interpretation of complex raw data (e.g. next- generation sequencing).

Assessment Plan:

Direct observation (i.e. interpreting select molecular tests) and/or case discussion, report review, and case collection by pathologist

Use Form 1. Form collects information on:
- Organ system: breast; bone & soft tissue; skin; gynecology; gastrointestinal; genitourinary; endocrine; head & neck; lymph nodes & spleen; neuropathology; thoracic
- Genetic abnormality type: cytogenetic type; sequence level
- Test type: in-situ hybridization; PCR-based testing; cytogenetics; next-generation sequencing; other
- If “other” please specify test: [free text]

Collect 25 observations of achievement
- At least 5 cytogenetic-type abnormality investigations
- At least 5 DNA sequence-level abnormality investigations

Relevant Milestones:

1. ME 1.3 Apply knowledge of principles of cell biology, immunology, genetics, and pathogenic mechanisms, and the changes that occur in disease states
2. ME 1.3 Apply knowledge of general concepts related to the human genome, human genes, and inheritance of DNA
3. ME 1.3 Apply knowledge of general concepts of inherited and somatic disease
4. ME 1.3 Apply knowledge of the essential elements of adequate analytical validation for genetics-based tests
5. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques
6. ME 2.2 Select additional testing based on an appreciation of the diagnostic possibilities, the clinical context and the relevance and capabilities of available technologies
7. L 2.1 Utilize genetic testing resources effectively to balance costs with potential utility of results
8. ME 4.1 Coordinate the use of multiple diagnostic investigations so as to ensure complementarity and efficiency
9. ME 3.3 Prioritize routine and ancillary investigations when specimen adequacy is limited
10. ME 5.1 Recognize sources of analytical error for various molecular tests
11. ME 2.2 Interpret molecular diagnostic test results together with available clinical and histopathological data
12. COM 4.1 Integrate molecular results into the anatomic pathology report

Evaluation Type:

Direct observation and through informal discussion of cases
Need 25 observations**

Clinical Scenario:

Working one on one with Staff in the Molecular labs at the General and CHEO and working through real pathology cases to integrate molecular learning

Cytogenetic tests (5 observations):

Examples that work for our program:
 At least one simple karyotype interpretation with CHEO cytogeneticists
 At least one FISH interpretation for HER-2 at TOH
 At least one FISH interpretation for MDM2 at TOH
 Remaining two observations can be anything

Molecular tests (5 observations):

Examples that work for our program:

 At least one NGS BRAF V600E interpretation
 At least one NGS EGFR interpretation
 At least one sarcoma fusion panel interpretation
 Remaining two observations can be anything

Specific Rotation:
 Molecular Pathology (General)
 Molecular at CHEO
 Thoracic block (ALK, PDL1, EGFR, ROS1)
 MSK block (sarcoma fusion panel)
 GI block (MSI testing, HER2)
 Gyne block (MSI testing)
 Breast (ER/PR/HER2)

EPA # 10- Selecting, interpreting and integrating ancillary diagnostic techniques other than molecular pathology

Key Features:

- This EPA includes non-molecular ancillary tests including immunohistochemistry, special histochemical stains, flow cytometry, immunofluorescence, electron microscopy.

- This EPA includes assessing specimen adequacy and selecting appropriate studies when indicated, typically after review of light microscopy, as well as interpreting the test, and integrating the results into the final diagnosis and report.

Assessment Plan:

Direct and indirect observation by pathologist

Use Form 1. Form collects information on:
- Organ system: breast; bone & soft tissue; skin; gynecology; gastrointestinal; genitourinary; endocrine; head & neck; lymph nodes & spleen; neuropathology; thoracic
- Specimen type: cytology; other
- Test type: immunohistochemistry; special histochemical stains; flow cytometry; immunofluorescence; electron microscopy; other
- If “other” please specify test: [free text]

Collect 45 successful observations of achievement
- A variety of organ systems
- At least 5 cytology
- At least 10 observations of each: immunohistochemistry, special stains, and flow cytometry
- At least 5 observations of electron microscopy and/or immunofluorescence
- At least 2 different pathologists

Relevant Milestones:

1. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques
2. ME 1.6 Convey diagnostic uncertainty and recommend additional studies when needed
3. ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
4. COM 4.1 Integrate information from ancillary studies and other sources into the pathology report
5. L 1.1 Apply quality management principles such as the use of controls (e.g. internal, external, reagent and tissue) to ensure validity of study findings and apply this understanding to troubleshooting test failure

Evaluation Type:

Direct and indirect observation

Clinical Scenario:

When residents are in the pertinent blocks, they order relevant ancillary tests and can interpret and integrate results into the final pathologic report

Specific Rotation:
Multiple blocks including various surgical pathology blocks, cytology blocks, lymph nodes (flow cytometry), Medical kidney (EM, IF) and dermatopathology (IF)

· Residents should document each time they order immunohistochemistry and special stains in specific surgical pathology blocks especially if they are using that specific pathologist for EPA assessment.

· For the cytology block (s), residents should be assigned to a cytopathologist for at least one week in order to not only sign out but to order appropriate ancillary tests on cell blocks

· EM and IF should be able to be achieved in senior rotations such as medical kidney

EPA # 11- Managing cytopathology specimens within the preparation laboratory

Key Features:

- This EPA focuses on the pre-analytic handling of cytopathology specimens

- This includes advising other physicians on optimal management of specimens, accepting or rejecting specimens based on specimen and requisition adequacy criteria, preparing gynecological and non-gynecological specimens, and applying principles of quality assurance to the processed specimen (e.g. stain quality, appropriate specimen labelling).

- This may include rapid on site assessment and FNA samples performed by a pathologist

- The observation of this EPA is divided into two parts: specimen adequacy and processing; advising healthcare professionals

- The observation of advising healthcare professionals may be a simulated scenario

Assessment Plan:

Part A: Specimen adequacy and processing
Direct observation and/or case discussion by technologist or pathologist

Use Form 1. Form collects information on
- Specimen type: gynecological; fine-needle aspiration (FNA); fluids (pleural fluid, peritoneal fluid, urine, CSF etc.); endoscopic ultrasound (EUS); endobronchial ultrasound (EBUS); other
- If “other” indicate specimen type: [free text]
- Component (select all that apply): adequacy; preparation; assessment of finished product

Collect 10 observations of achievement
- At least 5 of each of the 3 components (adequacy, preparation, assessment of finished product)
- A variety of specimen types (including gynecological and non-gynecological)
- At least 2 different observers

Part B: Advising healthcare professionals Direct observation by pathologist

Use Form 1. Form collects information on:
- Scenario: cervical specimen; other exfoliative specimen; FNA cytology; fluids; possible infectious etiology
- Simulation: yes; no

Collect 5 observations of achievement
- At least 1 for each pre-analytic scenario

Relevant Milestones:

Part A: Specimen Adequacy and Processing

1. ME 2.1 Determine if cytopathology specimens and requisitions meet adequacy criteria
2. ME 2.1 Describe reasons for specimen rejection and the process of rejection documentation
3. ME 5.1 Resolve issues related to specimen misidentification
4. ME 2.1 Identify and explore clinical issues to be addressed in the pre-analytical handling of a cytology case
5. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques in cytopathology
6. ME 3.4 Prepare gynecological and non-gynecological cytopathology specimens, including staining, cover-slipping, triaging and storage
7. ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite and autopsy suite to minimize occupational risk

Part B: Advising healthcare professionals

1. ME 2.2 Ascertain the clinical scenario and the information a clinical team requires from a request for cytopathology testing
2. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques in cytopathology
3. COL 1.3 Provide advice to clinical colleagues regarding specimen procurement and handling
4. COL 1.3 Communicate effectively with physicians and other colleagues in the health care professions

PART A: Specimen adequacy and processing

Evaluation Type:

· Direct evaluation (cytotechnologist – charge and senior)
· Case discussion (pathologist)
· * An adequacy specimen case could be added to the PGY-2/PGY-4 slide examinations

Clinical Scenario:

 Rapid on-site adequacy assessments with cytotechnologist (EUS, EBUS)
· Preparation and staining of assessment slide
 Specimen accessioning in cytology receiving
· Review of requisition documentation
· Review of specimen
· Management of mislabeling
 Specimen processing in the cytology department
· Staining, cover-slipping, triaging, and storage

Specific Rotation:
· Cytology (PGY-2, PGY-4, PGY-5)

PART B: Advising healthcare professionals

Evaluation Type:
 Direct evaluation (pathologist)
 Indirect evaluation (pathologist – through discussion with clinicians if resident physician independently advising)
· * Case simulation/oral examination question could be added to the end-of-rotation PGY-5 examination

Specific Rotation:
· Cytology (PGY-2, PGY-4, PGY-5)
· After-hours on-call responsibilities

EPA #12- Assessing and reporting cytopathology specimens

Key Features:

- This EPA focuses on providing a complete cytopathological interpretation including recommendations, as appropriate.

- This includes examining cytology slides, determining specimen adequacy for assessment, initiating and interpreting additional investigations (typically immunohistochemical and histochemical stains) and integrating all case features (including history) to arrive at an accurate interpretation.

- This EPA includes adherence to accepted reporting classification schema (e.g.

Bethesda System for Reporting Cervical Cytology) as appropriate, and adhering to local procedures regarding turnaround time and critical values in cytopathology.

Assessment Plan:

Direct and indirect (i.e. case discussion and review of cases) observation by pathologist

Use Form 1. Form collects information on:
- Specimen type: pap smear; fine-needle aspiration (FNA); fluid (pleural fluid, peritoneal fluid, urine, CSF etc.); endoscopic ultrasound (EUS); endobronchial ultrasound (EBUS)

Collect at least 60 observations of achievement
- At least 20 pap smears
- At least 10 fluids
- A mix of FNA, EUS and EBUS (at least 10 in total)
- At least 3 different observers

Relevant Milestones:

1. ME 1.3 Apply knowledge of the appearance of normal cells in cytologic preparations
2. ME 1.3 Apply knowledge of cytological appearance of cells in disease states
3. ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques
4. ME 2.1 Identify and explore clinical issues to be addressed in the pre-analytical, analytical and post-analytical handling of a case
5. ME 2.2 Assess specimen adequacy in surgical and cytopathology  specimens
6. ME 2.2 Describe common pitfalls in diagnosis of cytopathological  specimens
7. ME 2.2 Identify and interpret epithelial cell abnormalities of squamous and glandular cells
8. ME 4.1 Determine the need and timing of referral to another specialist and/or second opinion
9. COM 4.1 Prepare clear, concise, comprehensive, and timely written reports for cytopathology consultations
10. COM 4.1 Use standardized terminology for reporting results, as relevant
11. COM 4.1 Convey critical values or unexpected results in a timely manner
12. S 3.4 Integrate best evidence and clinical expertise into decision-making

Evaluation Type:

· Direct (pathologist, cytotechnologist)
· Indirect (pathologist)

Clinical Scenario:

 Cytology case review with cytotechnologist (gynecologic and non-gynecologic specimens)
· Obtain knowledge of normal cytology
· Obtain knowledge of large categories of cytopathology
· Obtain knowledge about approach to cytology screening
· Assess adequacy of cytology specimens
 Cytology case sign-out with staff physician (gynecologic and non-gynecologic specimens)
· Obtaining clinical history via electronic-medical record and/or via clinical consultation
· Determining ancillary diagnostic testing required
· Formulating complete, accurate reports which adhere to reporting classification systems based on specimen type/site
 Simultaneous cytology/surgical pathology cases – case correlations
· Genitourinary Pathology
· Lung Pathology
 Multidisciplinary Rounds
· Correlate cytology and surgical pathology

Specific Rotation:
· Cytology (PGY-2, PGY-4, PGY-5)
· GU, Lung Pathology (see above)
· All rotations (MDR)

EPA #13- Conducting intraoperative assessments

Key Features:

- This EPA focuses on the elements of an intraoperative consultation, from specimen handling to clear and effective communication of results to the clinical team

- This includes gathering the clinical history, handling and triaging the tissue, working effectively with all members of the clinical team (surgeon, technologists, staff pathologist), analyzing the various preparations (touch-preparation, frozen section, etc.), providing a clinically relevant interpretation, and conveying the results to the clinical team.

- Examples of requests relevant to this EPA include intraoperative consultations for tissue adequacy, diagnosis, margins, and lymphoma protocol.

Assessment Plan:

Direct or indirect observation by pathologist or TTP pathology trainee

Use form 1. Form collects information on:
- Observation: direct; indirect
- Organ system: breast; bone & soft tissue; skin; gynecology; gastrointestinal; genitourinary; endocrine; head & neck; lymph nodes & spleen; neuropathology; thoracic
- Type of preparation: frozen section; touch prep; both

Collect 15 observations of achievement
- At least 8 direct observations
- At least 2 neuropathology
- At least 3 intraoperative touch preps

Relevant Milestones

1. ME 2.2 Assess specimen adequacy in surgical and cytopathology specimens
2. ME 3.4 Prepare frozen sections, including imprint cytology specimens when relevant and review for diagnosis
3. COL 1.2 Work effectively with laboratory technologists and pathology assistants, directing their assistance
4. ME 1.3 Apply knowledge of cytological appearance of cells in disease states
5. ME 3.4 Establish and implement a plan for post-procedure handling of tissue
6. COL 1.2 Interact effectively with surgeons during intraoperative consultations
7. COL 1.2 Convey diagnostic uncertainty and discuss deferral of diagnosis when needed
8. COL 1.3 Convey information from the pathology assessment to clinicians in a manner that enhances patient management
9. ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite, and autopsy suite to minimize occupational risk

Evaluation Type:
 Direct and indirect observation (pathologist, senior pathology resident)
 * The creation of a frozen section slide examination could be incorporated into a PGY-4 rotation as part of TTP
 * The creation of an intraoperative communication simulation or oral examination could be incorporated (similar programming created at Harvard by Yael et al)

Clinical Scenario:

 Intraoperative assessment, gross examination
· Orientation of specimen
· Fresh preparation of specimen
 Inking
 Opening
· Gross-only assessment of margin
 Lung wedge
 ENT specimens
· Gross-only diagnostic assessment
 Colectomy for obstruction – confirmation of presence of mass
 Intraoperative assessment, frozen section Pre-frozen section review of operative list clinical history
 Diagnostic (Primary)
· Ovarian mass
· CNS mass

 Diagnostic (Metastases)
o Whipple’s procedure, liver mass
o Colectomy, liver mass
o Gastrectomy, peritoneal mass
o Pathologic fracture
 Margin status
o Whipple’s procedure
o Cystectomy
o Gastrectomy
 Joint infection (neutrophil count)
o Knee, shoulder arthroplasty
 Adequacy
o Lymph node for lymphoma protocol
o Confirmation of parathyroid tissue
 Intraoperative assessment, touch prep
o Diagnostic (Primary Carcinoma or Metastatic)
o Lymph node

Specific Rotation:
· All (direct and indirect observation)
· QA (review of frozen section correlation to permanent sections)

NOTED GAP: There is a high level of variation in the use of touch-prep assessment during intraoperative microscopic assessment of specimens by staff pathologists. Therefore, it may be difficult to ensure a sufficient number of direct observations of touch prep assessment. A small collection of touch-prep slides with corresponding clinical scenarios may serve as an adjunct.

EPA # 14- Teaching health care professionals and colleagues

Key Features:

- This EPA focuses on the skills of critical appraisal as well as presentation and teaching skills.

Assessment Plan:

Direct observation by pathologist

Use Form 1. Form collects information on
- Type of activity: journal club; grand rounds; academic halfday; other didactic sessions

Collect 2 observations of achievement

Relevant Milestones:

1. S 2.4 Develop learning objectives for a teaching activity
2. S 3.3 Critically evaluate the integrity, reliability and applicability of health related research and literature
3. S 3.4 Integrate best evidence and clinical expertise
4. S 2.4 Present the information in an organized manner to facilitate understanding
5. S 2.4 Use audiovisual aids effectively
6. S 2.4 Provide adequate time for questions and discussion

Evaluation Type:
 Direct observation
· Staff pathologist
· Resident physicians, pathology
· Resident physicians, non-pathology
· Medical Students
· Allied Health

Clinical Scenario:
 Academic Day:
· Gross Rounds
· Journal Club
· End-of-rotation subspecialty presentations (GI, Gyne, Breast)
· CanMEDS Non-Medical Expert Role presentations (PGY-2, PGY-3)
· Slide unknown rounds (“Blackbox Rounds”)
· Autopsy case presentations (PGY-1)
· PALM Grand Rounds (PGY-5)
 Research:
· PALM Annual Research Day
· Conference (USCAP, CAP)
· Supervision of medical students, undergraduate students, and other research trainees
 Junior Pathology Resident Teaching by Senior Residents:
· Annual transition orientation presentation
· Review of unknown slides
· Examination preparation
· Fellowship preparation· Informal surgical case review
 Non-Pathology Resident Teaching
· Gross examination teaching
· Intraoperative assessment teaching
· Informal surgical case review
 Off-Service Resident Teaching (pathology resident on clinical service), PGY-1)
· Clinical skill teaching and medical student supervision
· Pathology topic teaching in a clinical context
 Senior Medical Student Teaching
· Gross examination teaching
· Intraoperative assessment teaching
· Forensic pathology autopsy teaching
· Formal review of histology modules
· Informal surgical case review
 Junior Medical Student Teaching
· Gross examination teaching (10 hour observership)
· Pathology Interest Group presentation
· Core curriculum pathology teaching (with staff pathologist)
· Case Based Learning (CBL) teaching
· Physician Skill Development (PSD) teaching

 Allied Health Teaching:
· Pathology Assistant Specimen Review
· Histotechnologist Intraoperative Specimen Review
· Clinical Allied Health Teaching (on-call)
 OR Nursing Staff
 Ward Nursing Staff
Specific Rotation:
· All (see above)

EPA # 15- Participating in quality management activities

Key Features:

- This EPA focuses on the role of the anatomic pathologist as a participant and leader of quality management in the laboratory.

- At this stage, this includes completion of a laboratory management or quality improvement project, as well as responding to individual quality management events and participating in systematic quality management activities

- Individual quality management events include any finding or occurrence that requires action to maintain quality of care or safety. Examples include:

• Critical values
• Breaches in laboratory safety
• Failed immunohistochemical stains

- Examples of systematic quality assurance activities include:

• Cytology-histology correlation rounds
• Case consensus conferences
• Process improvement initiatives
• Validating new tests/methodologies

- The observation of this EPA is divided into two parts: completion of a project; participation in quality management

Assessment Plan:

Part A: Laboratory management or quality improvement project Review of completed project by supervisor

Use form 4

Collect 1 observation of achievement

Part B: Quality management participation
Direct observation or case discussion/presentation) by supervisor
Use form 1. Form collects information on
- Clinical area: surgical pathology; autopsy; cytopathology; molecular pathology; other
- If “other” identify clinical activity: [free text]
- Quality management activity: responding to a finding or occurrence; participating in a systematic quality assurance activity

Collect 5 observations of achievement
- At least 2 responses to a finding or occurrence that requires action to maintain quality of care or safety
- At least 2 participation in systematic quality assurance activities
- At least 2 assessors

Relevant Milestones:
Part B: Quality management participation

1. ME 1.3 Define a critical result (critical diagnosis), and describe how it is documented and handled
2. ME 2.1 Identify and explore clinical issues to be addressed in the pre-analytical, analytical and post-analytical handling of a case
3. COM 3.2 Communicate and document issues arising from a breach in quality or safety of laboratory practice
4. COM 4.1 Convey critical values or unexpected results in a timely manner
5. COL 1.3 Communicate effectively with physicians and other colleagues in the health care professions
6. L 1.1 Describe the metrics and measurement systems (e.g. statistical benchmarking and dashboard construction) used by the laboratory to track lab activities and current practice patterns
7. L 1.3 Manage a suspected specimen mix-up
8. L 1.3 Resolve and analyze diagnostic discrepancies
9. L 1.1 Identify problems, formulate and carry out a plan of action, and reassess the results in the context of quality improvement
10. S 3.4 Apply evidence-based medicine and best practice guidelines
11. P 2.2 Demonstrate a commitment to patient safety and quality improvement initiatives within their own practice environment

Part A: Laboratory management or quality improvement project Review of completed project by supervisor

Evaluation type:
Direct or indirect observation, case discussion

Clinical scenario:
Existing frameworks:
 Projects on QA&QC topics (i.e. participating in a systematic quality assurance activity)
Suggested changes to program: none

Specific rotations:
Cytology, QA&QC block, research block, any rotation where the resident participates in maintaining quality of care or safety

Part B: Quality management participation

Evaluation type:
direct or indirect observation, case discussion

Clinical scenario:

EPA #16- Conducting scholarly work

Key Features:

-This EPA includes active participation in more than one key aspect of performing scholarly work: identification of a question for investigation, literature review, data gathering, data analysis, and reflective critique

-It must include presentation or dissemination of the scholarly work locally or nationally

-This may include scholarly research, quality assurance, or educational projects

-The assessment of this EPA is based on the submission of a completed scholarly project, and may also include observation of the presentation of the scholarly work.

Assessment Plan:

Direct and/or indirect observation by supervisor Use Form 1
Collect one observation of achievement

Relevant Milestones:

1. L 4.1 Organize work to manage clinical, scholarly and other responsibilities
2. S 4.4 Identify, consult and collaborate with content experts and others in the conduct of scholarly work
3. S 4.4 Generate focused questions for scholarly investigation
4. S 3.3 Critically evaluate the integrity, reliability, and applicability of health-related research and literature
5. S 4.4 Collect data for a scholarly project
6. S 4.4 Perform data analysis
7. S 4.4 Integrate existing literature and findings of data collection
8. S 4.4 Identify areas for further investigation

Evaluation type:

Direct or indirect observation

Clinical scenario:
Existing frameworks:
 Direct or indirect observation by the supervisor during the research projects, QA&QC block, journal club presentations
Suggested changes to program: none

Specific rotations:
Research block, QA&QC block, journal club presentations

EPA #17- Maintaining personal learning and career plans

Key Features:

- This EPA focuses on the update of the trainee’s personal learning plan to reflect their progression in their training/career.

- This EPA includes maintaining an accurate logbook and portfolio.

Assessment Plan:
Maintenance and regular review of a log book, portfolio and learning/career plan by supervisor or academic advisor with validation by the program director

Use form 4
Collect at least 6 observations of achievement

Relevant Milestones

1. L 4.1 Set priorities and manage time to integrate practice and personal life
2. L 4.2 Examine personal interests and seek career mentorship and counselling
3. L 4.2 Reconcile expectations for practice with job opportunities and workforce needs
4. L 4.3 Improve personal practice by evaluating a problem, setting priorities, executing a plan, and analyzing the results
5. S 1.1 Create a learning plan in collaboration with a designated supervisor identifying learning needs related to Anatomical Pathology and career goals
6. S 1.2 Identify opportunities for learning and improvement by regularly reflecting on and assessing their performance using various internal and external data sources

Evaluation type:
Direct or indirect observation

Clinical scenario:
Existing frameworks:
 Direct or indirect observation by the program director at 6 month meetings;
 Conducting "end-of-rotation" talks;
 Journal club;
 Gross and web unknown presentations.

Suggested changes to program:

 Identifying the "high yield" entities for Royal College exam which resident should cover during the particular rotation and discuss them with the rotation supervisor.
 In case of rare cases, creating a slide collection (digital or glass slides) for residents to look at and read around.
 At the end of the rotation, discussion about the covered and not encountered during the rotation topics (i.e. "high yield" entities) should be implemented.
 Could consider instituting staff (RPC) advisors for all residents

Specific rotations:
Any surgical pathology or cytology rotation, end-of rotation talks, journal club presentations, gross and web unknown presentations; 6-months meetings with the Program Director.

EPA #18- Participating in direct patient care activities that highlight clinicopathological correlation

Key Features:

- This EPA focuses on the key role of pathology expertise in patient care

- This includes working with patients and clinicians to understand the clinical question and identifying how pathology investigation can further the diagnostic and/or therapeutic management plan

- This may include advising physicians, at the point of care, on approaches to specimen procurement and handling, and on test selection and sequencing, and conveying the results of pathology investigations at the bedside as well as in team meetings such as tumour boards

- This EPA will be observed in clinical settings such as outpatient clinics, the OR, genetics counselling sessions, cancer clinics, endoscopy clinics, and/or colposcopy clinics, and in clinical–pathological conferences (CPC)

- The observation of this EPA is divided into two parts: clinical settings; CPC conferences

Assessment Plan:
Part A: Clinical setting
Direct observation and/or case discussion by supervisor, this may include clinicians, pathologists, or senior trainees (TTP residents, fellows) in clinical or pathology disciplines

Use form 1. Form collects information on:
- Setting: cancer clinic; colposcopy clinic; endoscopy clinic; dermatology clinic; genetics counselling; other [free text]

Collect 3 observations of achievement
- At least 2 different clinical settings

Part B: CPC conferences
Direct observation by supervisor, with input from other CPC conference attendees
Use Form 1. Form collects information on:
- Organ system: breast; bone & soft tissue; skin; endocrine; gynecology; gastrointestinal; genitourinary; head & neck; lymph nodes & spleen; neuropathology; thoracic

Collect 3 observations of achievement
- At least 3 different organ systems

Relevant Milestones:
Part A: Clinical setting

 

1. ME 2.2 Gather and synthesize patient information to establish the clinical question
2. ME 2.2 Select and recommend pathology investigations, including molecular pathology
3. COM 3.1 Convey information to patients and families about pathology tests results clearly and compassionately
4. COL 1.3 Provide advice to clinical colleagues regarding specimen procurement and handling
5. COL 1.3 Convey information from the pathology assessment to clinicians in a manner that enhances patient management
6. COL 1.3 Support clinical colleagues in the development and implementation of a management plan, as appropriate
7. HA 1.1 Respond to individual patient diagnostic needs and issues as part of patient care
8. ME 1.6 Demonstrate insight into their own limits of expertise

Part B: CPC conferences

1. ME 1.4 Synthesize cases for discussion at multidisciplinary rounds
2. COL 1.3 Convey information from the pathology assessment to clinicians in a manner that enhances patient management
3. S 3.4 Integrate best evidence and clinical expertise into decision-making
4. COL 1.3 Support clinical colleagues in the development and implementation of a management plan, as appropriate
5. HA 1.1 Respond to individual patient diagnostic needs and issues as part of patient care
6. P 1.1 Exhibit appropriate professional behaviours
7. ME 1.6 Demonstrate insight into their own limits of expertise

Part A: Clinical setting

Evaluation type:
Direct observation or case discussion

Clinical Scenario:
Existing frameworks:
· Direct observation or case discussion with/about patient at dermatology rounds (ME 1.3, ME 2.2, COL milestones)
Suggested changes/additions to program to consider:
· COM 1.3 roles not met
o Residents attend one half day in clinic on double breast and double GYN pathology blocks

Specific rotations:
· Dermatology
· Breast
· GYN
Part B: CPC Conferences

Evaluation type:
Direct observation

Clinical Scenario:
Existing frameworks:
· Resident coverage of multidisciplinary rounds
Suggested changes/additions to program to consider:
· None

Part B: CPC Conferences
Evaluation type:
Direct observation
Clinical Scenario:
Existing frameworks:
· Resident coverage of multidisciplinary rounds
Suggested changes/additions to program to consider:
· None required

Specific rotations: None