What Are the Pathology Education Requirements for All Nonpathology ACGME-Accredited Programs in an Academic Center?

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1 What Are the Pathology Education Requirements for All Nonpathology ACGME-Accredited Programs in an Academic Center? Sarah M. Bean, MD, 1 Alisa Nagler, JD, EdD, 2 and Patrick J. Buckley, MD, PhD 1 Key Words: ACGME; Pathology; Education DOI: /AJCPNZEY2MMAG8YX Abstract This study aimed to determine institution-wide graduate medical education (GME) requirements in pathology (exclusive of pathology residency and fellowships) at an academic center. All documents related to residency review committee (RRC) program requirements were searched for the key words pathology, laboratory, autopsy, and morbidity. For each occurrence, it was determined whether a pathology education requirement had been identified. Requirements were categorized and tabulated. The Accreditation Council for Graduate Medical Education (ACGME) lists 135 nonpathology programs; 66 programs exist at Duke University Medical Center, of which 54 (82%) had pathology education requirement(s). Twelve education categories were identified. Teaching/conferences were the most common (52%). Thirty-nine percent required consultation/support. Sixteen programs were required to perform gross/microscopic examination. Trainees in medical genetics are required to have a pathology rotation. Elective rotations should be available for trainees in 6 programs. Pathology departments at academic centers face significant institutionwide pathology education requirements for clinical ACGME programs. Didactic teaching/conferences and consultation/support are common requirements. Opportunities exist for innovative teaching strategies. The Accreditation Council for Graduate Medical Education (ACGME) recognizes that knowledge of pathology is integral to the practice of medicine regardless of whether a physician is a pathologist. Therefore pathology education is mandated by many of its accredited residency and fellowship programs. Pathology education for nonpathologists encompasses many forms of educational delivery such as conferences on microscopy, autopsy, and gross pathology, as well as didactic lectures. At most academic centers, it falls to the pathology department to provide this required postgraduate pathology education to its clinical residents and fellows. Many academic pathology departments commonly receive requests for required conferences, supervised clinical/laboratory rotations, and other teaching experiences. To date, the ACGME requirements for pathology education for nonpathologists have not been characterized and quantified across specialties. The purpose of this study is to determine the institution-wide pathology education graduate medical education (GME) requirements (exclusive of pathology residency and fellowships) in an academic center. Materials and Methods The ACGME residency review committees (RRCs) have established uniform minimum requirements for all accredited GME programs. The RRC program requirements 1 for all nonpathology RRC programs were systematically reviewed. Education requirements for general anatomic pathology and laboratory medicine residencies and all pathology subspecialty fellowships such as cytology Am J Clin Pathol 2012;138: DOI: /AJCPNZEY2MMAG8YX 327

2 Bean et al / Pathology Education Requirements and blood banks were not quantified in this study. GME programs sponsored by the institution and not ACGME accredited were also excluded. To identify pathology-related education requirements, key word searches using the find text function in Adobe (Adobe Systems, San Jose, CA) portable document format (PDF) files for the following terms pathology, laboratory, autopsy, and morbidity were performed on all available documents on RRC program requirements. For every document, each occurrence of pathology, laboratory, autopsy, and morbidity was located, and the surrounding text examined. The context was considered for each occurrence (or hit ) of a key word, and a determination was made as to whether a pathology education requirement had been identified. For example, when the otolaryngology document was searched using the key word pathology, numerous hits were identified, but not all were indicative of pathology education requirements Table 1. The identified pathology education requirements were coded and categorized for all nonpathology ACGMEaccredited GME programs. Categories were determined based on common observed requirements. Table 2 lists common pathology education requirements and provides specific contextual examples for each requirement type identified. Various types of teaching/conferences were identified, including didactic teaching, morbidity and mortality, current case conference, tumor boards, and multidisciplinary conferences. Less common requirements were also identified, including required pathology rotation (medical genetics), residents assigned to the department of pathology (otolaryngology), and shared experiences with pathology residents (pediatric radiology). In addition, some programs require their trainees to obtain copies of autopsy reports. Observed pathology education requirements for all nonpathology ACGME-accredited programs at Duke University Medical Center (DUMC) were quantified using Excel spreadsheet software (Microsoft, Redmond, WA). Results The ACGME lists 135 clinical (ie, nonpathology) programs with RRC requirements. DUMC has 66 of these programs, of which 54 (82%) have pathology education requirements. Of the 66 nonpathology programs, 12 (18%) do not have pathology education mandates Table 3. Twelve pathology education categories were identified Table 4. Teaching/conferences (including didactic teaching, morbidity and mortality, current case conferences, tumor boards, and multidisciplinary conferences) were the most common requirement (52% of programs). Thirty programs require teaching conferences; 8 require morbidity and mortality conferences; 1 requires tumor board; 1 requires current case conferences; and 1 requires a multidisciplinary conference. Six programs, including general surgery, hand surgery, pediatric cardiology, radiation oncology, urology, and vascular surgery, require 2 or more types of conferences. Consultation/support was the second most common requirement; 39% of programs required consultation/support, often in undefined terms. Sixteen programs Table 5 were required to perform gross and microscopic examination of tissues. In addition, ophthalmology requires a minimum of 36 hours. The requirements for child neurology, internal medicine, and neurology stated that clinicopathologic correlation opportunities should be available. Gastroenterology, neurologic surgery, and otolaryngology require that clinical resources be available. Trainees in medical genetics have a required pathology rotation. Elective pathology rotations need to be available for trainees in neuromuscular disease, child neurology, general surgery, neurologic surgery, otolaryngology, and radiation oncology. Other requirements included collaboration with pathologists (n = 10; 15%), must have a pathology department (n = 2; 3%), easy access to the microbiology laboratory (n = 1; 1%), must be provided with knowledge of pathology Table 1 Selected Results of Key Word Search for Pathology Within the Otolaryngology Residency Review Committee Requirements Document Example 1 The educational program should include core knowledge, skills, and understanding of the basic medical sciences relevant to the head, neck, the upper respiratory and upper alimentary systems; the communication sciences, including knowledge of audiology, speech pathology, rehabilitation, and the vestibular system; and the chemical senses, otolaryngologic allergy, endocrinology, and neurology as they relate to the head and neck area. 1. No pathology education requirement. Examples 2 and 3 The program may further include rotations on related services such as neuroradiology, surgical pathology of the head and neck, audiology and vestibular assessment, speech pathology and rehabilitation, radiation oncology, pulmonary medicine, allergy/immunology, and oral and maxillofacial surgery. 2. Pathology education requirement identified; elective rotation. 3. No pathology education requirement. 328 Am J Clin Pathol 2012;138: DOI: /AJCPNZEY2MMAG8YX

3 (n = 1; 1%), appropriate structured experiences in the laboratory including blood banking and tissue banking (n = 1; 1%), and correlation of clinicopathologic aspects of cardiothoracic disorders (n = 1; 1%). One program (vascular/ interventional radiology) requires that at least 1 qualified medical technician be on duty or available 24 hours a day 7 days a week. The mean number of educational category requirements for all programs was 1.9, with a range of 0 to 5. Thirty-nine (59%) programs have 2 or more requirements. General surgery, otolaryngology, and radiation oncology each had 5 requirements. Child neurology, gastroenterology, infectious disease, nephrology, and pediatric anesthesiology each had 4 requirements. Discussion Historically, pathology is steeped in the tradition of teaching and education. At academic centers such as DUMC, pathologists serve as the central hub of medical information. Pathologists teach pathology trainees, nonpathology trainees, medical students, allied health students, and colleagues, and determine valuable laboratory data integral to routine patient care. Together, these responsibilities can be daunting. Realistically, in this modern era of medicine when clinical volumes are steadily increasing and reimbursement decreasing or remaining flat, it may be difficult to have adequate staffing to cover clinical services alone. To date, pathology education requirements for nonpathology programs have not been quantified. This study Table 2 Residency Review Committees Pathology-Specific Education Requirements With Specific Examples * Consultation/ Clinical consults and teaching in the following disciplines as related to sleep disorders: cardiology, neurology, support otolaryngology, oral maxillofacial surgery, pediatrics, pulmonary medicine, psychiatry, and psychology including neuropsychology, pathology, and radiology services (Sleep Medicine, p 16). Assist in the educational program: The teaching staff must include orthopedic surgeons who are engaged in the operative management of sports injuries and other conditions and who are readily available to teach and provide consultation to the residents. Teaching staff from the disciplines of nutrition, pharmacology, pathology, exercise physiology, physical therapy, behavioral science, and clinical imaging also should be available to assist in the educational program. Coaches and athletic trainers also should be included (Sports Medicine, p 5). Teaching/ No fewer than 36 months of the 4-year program must be spent in clinical radiation oncology. (Residents conferences enrolled in the Holman Pathway, a research track designed by the American Board of Radiology to promote a commitment to basic science or clinical research, must complete 27 months in clinical radiation oncology). In addition, the program must provide a 2-month rotation in medical oncology to include adult and pediatric patients, as well as a 1-month rotation in both oncologic pathology and diagnostic imaging. The medical oncology requirement may be met by documented attendance at regularly scheduled multidisciplinary conferences (at least 4 hours per month during the clinical rotations). The pathology and diagnostic imaging requirements may be satisfied through multidisciplinary conferences if pathology and imaging material for both pediatric and adult patients are shown and discussed (at least 1 hour per month during the clinical rotations for each discipline). The remaining months must allow for in-depth experience in individually selected areas applicable to clinical radiation oncology, as described in Section IV.A.5 (Radiation Oncology, p 1-2). Ensure that there are intradepartmental clinical oncology conferences, including new patient conferences, weekly chart reviews, problem case conferences, continuous quality improvement, morbidity and mortality, physics, dosimetry, radiation and cancer biology, and/or journal review (Radiation Oncology, p 8). The resident s time throughout each year beyond the first year (ie, PGY2-PGY4) must include direct care of outpatients and inpatients. This must include clinical conferences and didactic lectures related to patient care, consultations, inpatient rounds, dermatologic surgery, dermatopathology, and other dermatology-related subspecialty rotations. Scholarly activity should be integrated into these clinical activities (Dermatology, p 1). The dermatopathology training should be directed by a physician with subspecialty certification in dermatopathology or its equivalent (Dermatology, p 7). CPC (a) clinical pathologic conferences correlating current pathological material, including material from autopsies, surgical specimens, and other pathology material, with the clinical course and management of patients, or (b) clinical quality improvement (morbidity and mortality) conferences focusing on adverse clinical events on the teaching services. It should analyze the causes and consequences of each event, and should result in proposals for actions to avoid recurrence of similar events (Internal Medicine, p 22-23). Elective pathology No more than 6 months total may be allocated to research or to nonsurgical disciplines such as anesthesiology, rotation internal medicine, pediatrics, or surgical pathology. (Gastroenterology is exempt from this limit if this rotation provides endoscopic experiences.) (Surgery, p 15). Clinical resources There should be clinical resources for the education of neurological surgery residents in anesthesiology, critical care, emergency medicine, endocrinology, ophthalmology, orthopedics, otolaryngology, pathology, and psychiatry (Neurological Surgery, p 12). Gross and micro- Should have a minimum of 36 hours of experience in gross and microscopic examination of pathological specimens, scopic examination including the residents review of pathological specimens of their patients with a pathologist who has demonstrated expertise in ophthalmic pathology. The experience with such a pathologist may take place intramurally or extramurally at a laboratory considered by the Review Committee to be capable of providing such training (Ophthalmology, p 13). CPC, clinical pathologic conferences; PGY, postgraduate year. * Specialties listed with page numbers refer to pages on the PDF documents found in reference 1. Am J Clin Pathol 2012;138: DOI: /AJCPNZEY2MMAG8YX 329

4 Bean et al / Pathology Education Requirements Table 3 Programs With No Pathology Education Requirements Adult cardiothoracic anesthesiology Anesthesiology Child and adolescent psychiatry Emergency medicine Family medicine Internal medicine/pediatrics Sports medicine Pain medicine anesthesiology Palliative medicine fellowship Preventive medicine Psychiatry Surgical critical care Table 4 Programs Required to Perform Gross/Microscopic Examination Cardiovascular disease Child neurology Endocrinology, diabetes, and metabolism Gastroenterology Geriatric medicine Hematology/medical oncology Infectious disease Interventional cardiology Nephrology Neurology Ophthalmology Orthopedic surgery Otolaryngology Pulmonary diseases/critical care medicine Rheumatology Sleep medicine Table 5 Pathology Education Requirements for Nonpathology ACGME Accredited Programs at a Single Academic Center Pathology Education Type No. (%) Consultation/Support 26 (39) Teaching/Conferences 34 (52) CPC 3 (5) Required pathology rotation 1 (2) Elective pathology rotation 6 (9) Clinical resources 3 (5) Gross/microscopic examination 16 (24) Residents assigned to the department of pathology 1 (2) Shared experiences with pathology residents 1 (2) Obtain copies of autopsy reports 11 (17) Assist in the education program 1 (2) Other 17 (26) ACGME, Accreditation Council for Graduate Medical Education; CPC, clinicopathologic correlation. shows that the institution-wide pathology education requirements for nonpathology ACGME programs are tremendous. At DUMC, 82% of the nonpathology ACGME-accredited programs have at least 1 pathology education requirement, and 59% have 2 or more pathology education requirements. Eight (12%) programs have 4 or more pathology education requirements. Twelve types of pathology education were identified. Some of the requirements are vague, such as consultation/support and clinical resources; the definitions of such educational experiences are subject to interpretation by the specific program. Thus, program requests of the pathology department can be minimal or, conversely, time-consuming. Other types of pathology education are less vague and, indeed, require significant amounts of time for preparation and delivery of the educational experiences. Conferences, didactic lectures, clinicopathologic correlation, gross/microscopic examination, and pathology rotations are all labor intensive for the pathology department. Often, as seen at DUMC, nonpathology departments and GME programs request pathology faculty to provide educational experiences to meet ACGME RRC requirements for nonpathology trainees. Thus, pathology departments become responsible not only for the education of pathology trainees but also, at least in part, for the education of the majority of graduate medical trainees in a given institution. This is, of course, in addition to routine pathology clinical care, research endeavors, and medical student teaching. Individually, these requirements may seem negligible. For example, nearly all liver biopsy findings may be reviewed at a weekly conference rather than selected cases so that interdisciplinary attendees may have increased exposure to hepatobiliary pathology. Such a request may seem small, but taken together, as this study has shown, this charge is formidable, especially if pathology departments are expected to fulfill the needs of all nonpathology ACGME programs. An informal survey of the department of pathology faculty at DUMC revealed that faculty currently dedicate over 4,500 hours annually solely for the purpose of educating nonpathology GME trainees. It does not appear that there is another department or service that provides similar intensive educational support at academic centers. Pathologists time, effort, and clinical resources historically have been donated to help nonpathology programs meet the ACGME RRC requirements. Given these data, however, compensation may be reasonable. In fact, 1 DUMC pathology faculty member has used the data presented in this study to obtain compensation for teaching efforts. Compensation commensurate with effort or departmental funds could be directed to individual faculty members. Creative solutions may be helpful. Content applicable to more than 1 program, or even the same among different programs could be offered by using a condensed teaching schedule. In addition to streamlining educational offerings by the pathology department, such interdisciplinary educational experiences could have additional benefits. Technological innovations 2 can be harnessed to streamline the learning process, 3 to decrease the amount of ongoing work required, 4 and to capture a larger audience. For example, didactic lectures provided annually or at some 330 Am J Clin Pathol 2012;138: DOI: /AJCPNZEY2MMAG8YX

5 regular interval in which the content changes very little can be recorded and posted online or on itunes University (Apple, Cupertino, CA) for self-directed learning. If entire courses are captured in this manner, the learning process is streamlined and makes the learner responsible for his/her education, an important transitional step to lifelong learning required for maintenance of board certification. Finally, video-teleconferencing modalities (eg, Skype) could be used to allow for a broader audience to attend patient-centered conferences such as tumor boards. The data presented herein are based on 1 person s interpretation (S.M.B.) of the ACGME RRC requirements. This study is limited by the subjective nature of interpretation of the RRC documents. Nonetheless, this study has shown that pathology education requirements for all nonpathology trainees at DUMC are extensive. In conclusion, pathology departments at academic centers are faced with significant institution-wide pathology education requirements for clinical ACGME programs. At DUMC, 82% of clinical programs have at least 1 pathology education requirement. Studies are ongoing to determine the amount of pathologists time required to fulfill these mandates (estimated at DUMC as 4,500+ hours per year) and to develop innovative educational tools that satisfy the requirements while providing meaningful education and making efficient use of pathology teaching faculty. From the 1 Department of Pathology and 2 Office of Graduate Medical Education, Duke University Medical Center, Durham, NC. Supported by Duke University Graduate Medical Education Office Innovation Grant. Address reprint requests to Dr Bean: Duke University Medical Center, Box 3712, Durham, NC References 1. Accreditation Council for Graduate Medical Education. Residency Review Committees: Program Requirements. Accessed June 27, Cook DA, Levinson AJ, Garside S. Time and learning efficiency in Internet-based learning: a systematic review and meta-analysis. Adv Health Sci Educ Theory Prac. 2010;15: Cook DA, Beckman TJ, Thomas KG, et al. Adapting web-based instruction to residents knowledge improves learning efficiency: a randomized controlled trial. J Gen Intern Med. 2008;23: Andolsek K, Murphy G, Pinheiro S, et al. Efficacy and efficiency of webcast orientations versus live resident orientations: results of a 2-year survey. J Grad Med Educ. 2010;9: Am J Clin Pathol 2012;138: DOI: /AJCPNZEY2MMAG8YX 331

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