PATHOLOGY  

DEFINITION:General Pathology is that branch of medicine concerned with all aspects of laboratory investigation in health and disease. The discipline incorporates both morphological and non-morphological diagnostic techniques in the areas of Anatomic Pathology, Medical Biochemistry, Medical Microbiology, Hematopathology, and Transfusion Medicine.

GENERAL OBJECTIVES:On completion of the education program, the residents will be competent to function as consultants in General Pathology and medical laboratory directors. This will require acquisition of a sufficient level of skill in the separate disciplines of Anatomic Pathology, Medical Biochemistry, Medical Microbiology, Hematopathology and Transfusion Medicine to serve as a consultant within the context of a regional or community hospital.

SPECIFIC OBJECTIVES:At the completion of training, the residents will have acquired the following competencies and will function effectively as:

Medical expert

General Requirements

• Demonstrate diagnostic and therapeutic skills for ethical and effective patient care.
• Access and apply relevant information to clinical practice.
• Demonstrate effective consultation services with respect to patient care, education and legal opinions.

At the completion of training, the residents will demonstrate the diagnostic skills required for ethical and effective patient care and will demonstrate effective consultation skills with respect to patient care, education and legal opinions. The level of knowledge in all areas will reflect the needs of community or regional laboratories. It is not expected that the residents will have the same depth or breadth of knowledge in the laboratory medicine specialties as residents trained in a single discipline. From a functional standpoint the General Pathology residents must be able to recognize and diagnose common morphological and clinical entities. "Common" may be defined as likely to occur one or more times in the course of a year in a laboratory medicine population base of 50,000. The residents must appreciate those clinical situations, cases or specimen types which will require referral to a laboratory medicine specialist working in a tertiary hospital setting.

Specific Requirements

D.     Anatomic Pathology

While the general pathology residents must be familiar with and able to characterize disease processes in a wide range of tissues they must develop particular skills in diagnosing common entities in the realms of dermatopathology, gynecological pathology, breast pathology, male genitourinary pathology, lower urinary tract pathology, gastrointestinal (including hepatobiliary and pancreatic) pathology, thyroid and parathyroid pathology, respiratory tract pathology, autopsy pathology, morphologic hematology (peripheral blood, lymph nodes, bone marrow biopsies and spleen), and cytopathology (both fine needle and exfoliative). The residents will recognize the type of case which, because of tissue type, rarity, complexity, or therapeutic implications will require referral to a tertiary centre. The residents will also appreciate those cases where consultation with General Pathology colleagues would be advisable.

The expected knowledge base will include:

1. Normal anatomy and its common variants with a basic understanding of embryological development.
2. The normal gross and light microscopic appearance of tissues both as intact organs and biopsy material.
3. The principles of tissue fixation and preparation of specimens for microscopic examination.
4. The normal appearance of tissue cells in common fixatives, exfoliated or obtained by needle aspiration.
5. The principles of cell biology, immunology, medical genetics and pathogenic mechanisms with an understanding of changes seen in disease states.
6. The principles of light microscopy including polarization, dark field and fluorescence microscopy.
7. The principles of specialized histology techniques including histochemical, immunocytochemical, flow cytometry, morphometry, and hybridization techniques and their application in diagnosis.
8. The rules regarding retention of specimens and processed surgical material as well as the retention of records.
9. The rules governing consent for postmortem examination and the types of cases which must be reported to the coroner or medical examiner.
10. The definitions of cause, mechanism and manner of death.
11. The sampling of tissues and fluids for the toxicological examination and the legal requirements for the handling of these samples.
12. The recognized standards of workplace safety and the rules governing transportation of dangerous goods.
13. The utilization of ancillary techniques such as biochemical, microbiological, photographic, and radiological studies in surgical and forensic pathology.
14. The principles of quality assurance pertinent to surgical and autopsy pathology.

The residents will develop and be able to demonstrate the following skills by the conclusion of the residency program:

15. To recognize and accurately diagnose a broad range of common inflammatory and neoplastic conditions on both histological and cytological material.
16. To provide appropriate strategies for biopsy (histological and cytological), tissue handling, and reporting to include the features of prognostic and therapeutic importance.
17. To describe appropriate handling, dissection, and sampling of those tissues normally received for examination by regional or community hospital laboratories.
18. To be capable of offering a competent intraoperative consultation (frozen section/ imprint/ cytological) with an understanding of the appropriate use and limitations of these procedures.
19. To obtain satisfactory photomicrographs and photographs of gross specimens.
20. To perform a complete postmortem examination with appropriate descriptions at the gross and microscopic levels and incorporating all clinical information.
21. To be capable of undertaking a complete forensic autopsy in all common situations excluding homicide. This will require knowledge of relevant autopsy techniques and expected findings as well as of the practical aspects of establishing time of death and identifying remains.

E.      Medical Biochemistry

Medical Biochemistry is the study and measurement of biochemical abnormalities in human disease and forms a core component of the training program in general pathology.

In all specialties, but especially those that are technologically driven, there is a rapid evolution to be expected in diagnostic test methodology. In addition, as understanding of biochemical abnormalities increases, there is a constant need to update and expand test menus in order to provide rational and efficient strategies to confirm or exclude disease. The increasing availability of new technologies is also expected to blur the distinction between traditional clinical disciplines, enhance the capabilities of community or regional hospital laboratories, and increase the consultative role of the General Pathologist.

The discipline of Medical Biochemistry as it pertains to General Pathology involves the following major areas of activity:

1. The supervision and direction of the clinical biochemistry laboratory at the level of a community or regional hospital.
2. The provision of consultation services to clinical colleagues with respect to appropriate and effective biochemical testing strategies and their interpretation.

At completion of training, the residents will have a broad knowledge of biochemical testing and laboratory instrumentation pertinent to supervising a community or regional hospital laboratory and offering consultative services to clinical colleagues. The residents must understand the common disorders of, and test strategies pertinent to diagnosis of:

3. Body water and electrolytes
4. Acid-base control
5. Renal function
6. Liver function
7. Lipid disorders
8. Bone disease
9. Pancreatic function and digestive disease
10. Cardiac disease and hypertension
11. Blood sugar control
12. Iron, porphyrin and bilirubin metabolism
13. Endocrine function (especially thyroid, parathyroid, gonadal, pituitary, adrenal)
14. Uric acid metabolism
15. Protein metabolism
16. Common genetic disorders of metabolism

A more basic knowledge of pediatric and prenatal clinical biochemistry, nutrition, cancer-associated biochemical abnormalities, therapeutic drug monitoring, pharmacokinetics, and toxicology is required with special emphasis on testing available in community or regional hospital laboratories.

The residents will demonstrate the following skills by the conclusion of the residency program:

17. Given a clinical scenario, will provide appropriate advice regarding biochemical test selection with a view to optimizing laboratory utilization.
18. Will have a practical knowledge of statistics pertinent to clinical biochemistry. This will include the concepts of sensitivity, specificity, efficacy, precision, accuracy, incidence, prevalence, predictive value, reference ranges, means, standard deviation, variance, parametric and non-parametric distribution, and the control of pre-analytical variables.
19. Will demonstrate knowledge of common analytical techniques and instrumentation in the biochemical laboratory.
20. Will demonstrate an understanding of laboratory equipment selection.
21. Will define the components of a quality assurance program and describe the methods of quality control and their application.
22. Will demonstrate an understanding of the principles of laboratory safety and the regulations as they apply to workplace hazards and transportation of dangerous goods.
23. Will define the basic components of a Laboratory information system and its application to the modern biochemical laboratory.

F.      Medical Microbiology

Medical Microbiology as applicable to General Pathology includes the following major areas of activity:

0. The supervision and direction of the clinical microbiological laboratory at the level of the community or regional hospital.
1. The direction of a hospital infection control program as it pertains to the role and utilization of the hospital laboratory.
2. The provision of consultative services to clinical colleagues regarding appropriate microbiological investigations and their interpretation.

The General Pathologist may be expected to assume some of the responsibilities of an infectious disease consultant depending on the availability of such resources and an understanding of common antimicrobial agents and their appropriate use if required.

The organisms for which a working knowledge is required are those that are normally isolated or otherwise identified in a regional hospital laboratory.

Bacteria: staphylococci, streptococci, Corynebacteriae (including other aerobic and facultative gram-positive rods), Clostridia, Neisseriae (including moraxella), Enterobacteriaceae, Campylobacter, Pseudomonas (and other common gram negative opportunistic bacilli), Hemophilus, Bordatellae, Legionellae, Chlamydiae, Mycoplasmae, and common pathogenic mycobacteria.

Fungi: Candida, Aspergillus, Histoplasma, Coccidioides, Blastomyces, Cryptococcus, Mucor, and Pneumocystis.

Parasites: Malaria, ehrlichia, common helminthic infections (cestodes, Enterobius, Strongyloides, Ascaris), Giardia, Schistosomes, Cryptosporidia, Microsporidia, Entamoeba, Dientamoeba, blastocystis, echinococcus, Trichinella.

For less common bacterial, fungal, and parasitic organisms there should be a general understanding of testing strategies, specimen collection and handling, laboratory safety, and interpretation of diagnostic reports.

A basic knowledge of viral classification and identification techniques is required with particular emphasis on public health and hospital infection control implications.

The residents must know the common bacterial toxins, associated disease implications, and toxin identification techniques.

Hospital infection control must be understood in some depth including prevention and control of infection and epidemics, disinfection and sterilization procedures, appropriate handling and disposal of infectious materials, employee health and laboratory safety issues, and pertinent public health regulations.

The residents must know the common quality control procedures applicable to microbiology.

The residents at end of training must be able to demonstrate the following skills:

3. A practical knowledge of all common bench-level test methods including manual, semi-automated and automated systems.
4. The ability to prepare and interpret Gram, Ziehl-Neelsen and special stains for fungi and parasites.
5. The ability to interpret fluorescence microscopy.
6. The ability to recognize the diagnostic features of common bacterial species on differential media, including common fermentation patterns.
7. The ability to interpret culture data from non-sterile body sites, presuming knowledge of the common components of normal flora.
8. The ability to describe the common etiological pathogens of infectious disease by disease process and body site.
9. The ability to recognize common fungal and parasitic organisms in human tissue and to utilize serologic and culture investigations for diagnosis.
10. The ability to utilize and interpret serological investigations for the diagnosis of bacterial and viral diseases.
11. A working knowledge of the newer molecular diagnostic methodologies and their use in microbiological diagnosis and outbreak investigation.
12. The ability to analyze and interpret antimicrobial sensitivity data and to describe specific techniques for assessing antimicrobial sensitivity.
13. The ability to interpret quality control data applicable to Medical Microbiology.

G.     Hematopathology and Transfusion Medicine

The level of expertise in hematology must reflect the knowledge base required in a regional or community hospital. The discipline as applicable to General Pathology includes the following major areas of activity:

0. The supervision and clinical direction of a hematopathology laboratory as organized at the level of a regional or community hospital.
1. The supervision and clinical direction of a transfusion service in association with provincial and national blood agencies.
2. The morphological assessment and diagnosis of blood, bone marrow and lymph node based disorders with utilization of newer technologies as appropriate.
3. The provision of consultation services with regard to appropriate and effective hematological investigation.
4. The provision of consultation services regarding appropriate use of, and possible alternatives to, blood component therapy.

The General Pathology residents must have a basic knowledge of the following:

5. Normal hematopoiesis and cell biology as it pertains to the structure and function of all hematopoietic elements.
6. The structure and functional relationships of all components of the reticulo-endothelial system.
7. The components of humoral and cellular immunity, the role of complement and its pathways of activation.
8. The components and functional relationship of the hemostatic and fibrinolytic systems including control mechanisms.
9. Immunohematology including major blood group systems and the role of the human leukocyte antigen (HLA) system.
10. Genetics as applicable to blood disorders.

This knowledge base is required as a framework for understanding disorders of hematopoiesis and coagulation and to successfully resolve problems of blood component therapy.

The knowledge base of hematopathological disorders must include the following:

11. Common anemias including diagnostic strategies, morphological findings at the peripheral blood and bone marrow level, clinical associations, complications, and basic principles of management.
12. Major causes of polycythemia including diagnostic strategies, morphological features, clinical associations, complications, and basic principles of management.
13. Common non-neoplastic disorders of leukocytes including reactive, congenital and drug-related abnormalities.
14. Common neoplastic disorders of leukocytes including diagnostic strategies, common classification schemes and the role of cytogenetics, stem cell studies, and flow cytometry.
15. Major categories of lymphoma including common diagnostic strategies, morphological features, ancillary investigations, and prognostic features.
16. Common disorders of thrombocytes including diagnostic strategies, clinical associations and principles of management.
17. Major disorders of coagulation, congenital and acquired, including strategies for investigation, clinical associations and principles of management.
18. Common problems of blood banking including incompatible cross-match, auto- and alloimmune antibodies and their differentiation, neonatal blood banking issues, types and investigation of adverse reactions to blood component therapy and the appropriate use of blood components in the treatment of hematological and coagulation disorders.

At the end of training, the residents will have developed skills in the following:

19. Bench level tests available in a community or regional hospital hematology laboratory. This will include manual, semi-automated, and automated tests in addition to the basic principles of test methodology and instrumentation.
20. Peripheral blood film and bone marrow/lymph node biopsy interpretation. This must include all abnormalities likely to be encountered in a community/regional hospital laboratory practice.
21. Decision-making regarding appropriate use of newer diagnostic methodologies for hematological diagnosis.
22. Constructing test strategies to diagnose common disorders of hematopoesis and coagulation.
23. Bench level testing in the blood bank and recognition of standards as they apply to the testing and release of blood products.
24. Assessing transfusion orders in relation to appropriateness, risks of blood product transfusion, and alternatives to transfusion.
25. Transfusion reaction investigation.
26. Hematology Quality Assurance (QA) and Quality Control (QC) issues and laboratory safety practices.
27. Skill in bone marrow aspiration and biopsy technique should be acquired.

Communicator

General Requirements

• Establish therapeutic relationships with patients/families.
• Obtain and synthesize relevant history from patients/families/communities.
• Listen effectively.
• Discuss appropriate information with patients/families and the health care team.

Specific Requirements

 
Laboratory physicians, as active members of the health delivery team, will establish appropriate relationships with consulting physicians and surgeons. From time to time, especially in the clinical disciplines, the pathologist may find it helpful, in the best interests of patient care, to communicate directly with patients, families, and other health care providers. In this regard the residents must demonstrate skills in communicating, both in verbal and written form, in a manner appropriate to the intended recipient.

The residents must understand effective clinical history taking and must have a broad knowledge of the laboratory basis of diagnosis in order to appropriately advise regarding test strategies and interpretation. Effective communication with clinical colleagues is essential in order to interpret surgical and autopsy pathology findings in the clinical context. The residents must be able to formulate comprehensive and clinically meaningful surgical pathology reports and organize diagnostic summaries to prioritize the features of importance. Diagnostic uncertainty must be clearly expressed with appropriate differential diagnoses and suggestions regarding further studies or ancillary investigations. There must be an awareness of ethical and medico-legal issues regarding the release and dissemination of confidential patient information. The residents must demonstrate awareness of the importance of timeliness, clarity and accuracy in all verbal and written communications.

Collaborator

General Requirements

• Consult effectively with other physicians and health care professionals.
• Contribute effectively to other interdisciplinary team activities.

Specific Requirements

 
The residents must be aware of the strong interface between the laboratory and clinical disciplines. The residents must also develop skills in supporting educational and/or research endeavours of clinical and laboratory colleagues through individual opportunities or group learning experiences.

In the realm of surgical pathology the residents must be aware of, and respond appropriately to, situations in which the laboratory will significantly affect critical patient management decisions. Such situations will include intraoperative consultations, assessment of surgical margins, staging procedures, situations where deferral of diagnosis is recommended, and situations where ancillary investigations or consultation is required for optimal case management. In the clinical disciplines the residents will be able to assist in optimal laboratory utilization appreciating the diagnostic limitations of laboratory tests and the importance of control of pre-analytic variables. The residents will understand the clinical requirements for turnaround time in specimen reporting, the range of testing which should be continuously available in the community/regional hospital and the appropriate laboratory response to critical values.

The residents must understand the value of interdisciplinary and intradisciplinary collaboration in patient management decisions. This includes the need for case review including review by external institutions and agencies. The residents must demonstrate a willingness to seek consultation opinions if so requested by clinical colleagues with modification of subsequent diagnostic impressions if appropriate.

Manager

General Requirements

• Utilize resources effectively to balance patient care, learning needs, and outside activities.
• Allocate finite health care resources wisely.
• Work effectively and efficiently in a health care organization.
• Utilize information technology to optimize patient care, life-long learning and other activities.

Specific Requirements

At the end of training, the residents will understand the basic principles of laboratory management.

Specifically the residents will have some knowledge of:

• Staffing and personnel management.
• Budgeting (personnel, materials, capital equipment)
• Workload measurements.
• Funding structures for laboratories.
• Hospital medical staff organization and roles.
• Quality control, quality assurance and continuous quality improvement.
• Laboratory safety and the transportation of dangerous goods.
• Management styles.
• Principles of optimal laboratory utilization.
• Equipment purchasing and selection.
• Relevant legislation and/or regulations governing the operation of laboratories, including issues of informed consent.
• Relevant legislation and/or regulations governing laboratory operation and informed consent
• Laboratory information systems and components (hardware and software).

It is expected that management issues pertinent to the laboratory will be taught as part of the academic activities of the residency-training program and may be supplemented with specific research activities.

Health Advocate

General Requirements

• Identify the important determinants of health affecting patients.
• Contribute effectively to improved health of patients and communities.
• Recognize and respond to those issues where advocacy is appropriate.

Specific Requirements

As part of an interdisciplinary team of professionals responsible for patient and community health care, the residents will understand those components of the laboratory and its services that are required to:

                             iv.            Respond adequately to community, and hospital service demands including the need for population screening.

                               v.            Respond to hospital, community and regional public health needs to detect and control infectious disease.

                             vi.            Provide sufficient and safe blood bank resources.

The residents will demonstrate the ability to recognize and respond to situations where health advocacy and application of health care resources is required. This will include the introduction of improved instrumentation and methodologies to augment community health care.

Scholar

General Requirements

• Develop, implement and monitor a personal continuing education strategy.
• Critically appraise sources of medical information.
• Facilitate learning of patients, housestaff/students and other health professionals.
• Contribute to development of new knowledge.

Specific Requirements

During the training period, the residents will demonstrate an ability to develop and implement a strategy for learning including a program of continuing education following completion of the residency. There must be a working knowledge of statistics applicable to all aspects of laboratory medicine and the capability of appraising sources of medical information. An important aspect of the role of the general pathologist is the continuing education of laboratory technologists and clinical medicine colleagues. An ability to perform this educational role must be developed by the senior residency years.

Contribution towards new knowledge is a major role of academic laboratory medicine specialists and the General Pathology residents must also be familiar with research methodology. In this regard the residents should have undertaken at least one research project during the 5-year program and must be familiar with the principles of critical appraisal.

Professional

General Requirements

• Deliver highest quality care with integrity, honesty and compassion.
• Exhibit appropriate personal and interpersonal professional behaviours.
• Practise medicine ethically consistent with obligations of a physician.

Specific Requirements

The residents must develop a broad understanding of the role of the physician within the community and hospital structure. The residents must establish a high standard of laboratory medical practice, appreciating personal limitations in diagnostic skill which will require referral of particular types of case in the best interests of patient care. The residents will demonstrate integrity, honesty and compassion in all aspects of the practice of laboratory medicine as well as personal and interpersonal professional behaviours of a high ethical standard. These behaviours will include those relating to confidentiality, respect for others, conflict of interest, codes of conduct, personal and professional boundaries, consent, and the role of professional self-regulation and continuing education.

CONTENT AND ORGANIZATION OF THE RESIDENCY PROGRAM:

There must be an organized program of rotations and other educational experiences, both mandatory and elective, designed to provide each resident with the opportunity to fulfill the educational requirements and achieve competence in the specialty.

The content and organization of each accredited program in general pathology must be consistent with the specialty training requirements.

In addition to offering the components noted in the specialty training requirements all accredited programs in general pathology must offer community-based learning experiences.

The resident must be provided with a graduated increase in individual professional responsibility, under appropriate supervision, appropriate to the level of competence and experience.

RESOURCES:There must be sufficient resources including teaching faculty, the number and variety of patients, physical and technical resources, as well as the supporting facilities and services necessary to provide the opportunity for all residents in the program to achieve the educational objectives and receive full training as defined by the specialty training requirements in general pathology.

In those cases where a university has sufficient resources to provide most of the training in general pathology but lacks one or more essential elements, the program may still be accredited provided that formal arrangements have been made to send residents to another accredited residency program for periods of appropriate prescribed training.

Learning environments must include experiences that facilitate the acquisition of knowledge, skills, and attitudes relating to aspects of age, gender, culture, and ethnicity appropriate to general pathology.

1.

Basic clinical training.

2.

Approved training in anatomical pathology(surgical pathology, autopsy pathology, cytopathology, forensic pathology).