Hematological Pathology

- The focus of this EPA is the use of clinical and laboratory information systems to extract relevant patient data and present a concise summary of the patient’s medical history and primary issues to the attending staff.

Direct observation and/or case discussion by supervisor Use Form 1. Form collects information on: - Specimen: bone marrow; coagulation testing; peripheral blood film; transfusion antibody panel; transfusion reaction - Observation: direct; indirect Collect 5 observations of achievement - At least 1 of each specimen type - At least 1 direct observation - At least 3 different assessors

Suggested observations: 5

- This EPA focuses on demonstrating an understanding of sources of error and the challenges involved in the pre-analytic, analytic, and post-analytic phases of sample procurement, including the blood component life cycle. - This EPA includes identifying the different types of samples sent to the laboratory, including types of containers, tubes, fixatives, and storage parameters. - This EPA may include filling out an incidence report form and discussing the incident with a supervisor.

Direct observation and/or case discussion and review of report by supervisor, technologist or lab manager Use Form 1. Form collects information on: - Specimen: bone marrow; coagulation – routine; coagulation - special; routine CBC; sample for send out; type and screen for blood bank - Phase of testing: pre-analytic; analytic; post-analytic - Observation: direct; case discussion/review of report Collect 8 observations of achievement - At least 1 of each specimen type - At least 1 of each phase of testing - At least 5 direct observations - At least 3 case discussions with supervisor - At least 3 different assessors

Suggested observations: 8

- This EPA focuses on performing an initial microscopic examination of a specimen, including setting up a microscope, identifying the typical components of a sample, and performing initial quality control (e.g., slide components correspond to sampled tissue or fluid, checking quality of sample). - This EPA includes operating basic digital microscopy equipment and software (e.g., Cellavision(R)).

Direct observation and case discussion by supervisor, Core or TTP resident, or senior charge technologist Use Form 1. Form collects information on: - Specimen: bone marrow; CSF; peripheral blood smear; other body fluid Collect 10 observations of achievement - At least 2 of each specimen

Suggested observations: 10

- This EPA focuses on synthesizing pertinent patient information, both clinical and from the pathology assessment, to develop a differential diagnosis and appropriate recommendations for follow-up. - This includes recognizing when a case is complex or life threatening. - This EPA includes demonstrating an understanding of automated cell counters, technology and quality control, and identifying interferences and artifacts of the investigation.

Direct observation with case discussion or review of final report by supervisor or Core or TTP resident Use Form 1. Form collects information on: - Specimen: body fluid; peripheral blood - Type of disease: neoplastic; non-neoplastic - Disorder: lymphoid; myeloid; non-hematopoietic - Complex or life threatening: yes; no - Demographic: pediatric; adult Collect 10 observations of achievement - At least 1 of each type of disease - At least 1 of each type of disorder - At least 1 complex or life threatening - At least 5 different assessors

Suggested observations: 10

- This EPA focuses on triaging specimens for ancillary studies based on the clinical scenario and directing preservation and distribution of the tissue for further testing. - This includes handling specimens and submitting tissues for ancillary studies in the appropriate medium. - It also includes the identification of sample deficiencies, including sources of pre- analytical errors. - Tests may include: morphology; flow cytometry; molecular testing including next generation sequencing (NGS); cytogenetics including FISH; immunohistochemistry; and microbiology. - This EPA includes executing the lymphoma protocol on fresh lymphoid or other tissue.

Direct observation and/or case discussion by supervisor or Core or TTP resident Use Form 1. Form collects information on: - Specimen: body fluid; bone marrow; lymph node; peripheral blood - Disorder: acute lymphoid; acute myeloid; chronic lymphoid; chronic myeloid; infectious - Lymphoma protocol: yes; no - Testing modality (select all that apply): cytogenetics; flow cytometry; immunohistochemistry; microbiology; molecular; morphology - Referred out: no; yes Collect 10 observations of achievement - At least 2 cases of acute myeloid disorder - At least 2 cases of chronic myeloid disorder - At least 2 cases requiring the lymphoma protocol - At least 2 cases with more than 3 testing modalities required - At least 1 case referred out for testing

Suggested observations: 10

- This EPA includes gathering relevant clinical information, incorporating results of complete blood count (CBC) and associated lab results, and interpreting and providing reports of hemoglobinopathy investigations. - The report must demonstrate an understanding of relevant methodologies, including molecular, and the clinical impact of testing, and effectively communicate results to the clinical team. - This EPA includes triaging and ordering ancillary tests as appropriate. - At this stage, complex diagnoses and red cell membrane disorders/enzyme disorders are not included. That is an EPA of the Core stage.

Direct observation by supervisor or Core or TTP resident Use Form 1. Form collects information on: - Disorder: alpha chain variant; alpha thalassemia; beta chain variant; beta thalassemia - Ancillary studies required: no; yes Collect 5 observations of achievement - At least 3 different disease types - At least 2 hematopathologists - At least 2 different assessors

Suggested observations: 5

- This EPA includes providing advice on routine transfusion management in a variety of clinical settings. - This includes applying evidence-based indications to routine blood component requests, investigating antibodies and transfusion reactions, and providing advice to clinicians. - This may include gathering patient information and discussing risks, benefits, and alternatives to routine blood products with physicians.

Case review by supervisor or TTP resident, with input from requesting clinician and/or transfusion medicine charge technologist/ manager as required Use Form 1. Form collects information on: - Urgency: non-urgent; urgent - Observer role: hematopathologist; transfusion medicine medical director; TTP resident - Demographic: pediatric; adult - Component: cryoprecipitate; plasma; plasma derived product; platelet; red cell; other (write-in) Collect 6 observations of achievement - At least 1 of each named component - At least 1 “other” component - At least 2 by staff hematopathologist - At least 3 different assessors

Suggested observations: 6

- This EPA focuses on an organized and comprehensive patient-centered approach to performing hematology-focused examinations and gathering patient history information, including an appropriate bleeding history or questionnaire. - This EPA includes ordering and interpreting initial lab investigations for common bleeding and clotting disorders, such as hemophilia, von Willebrand disease, platelet dysfunction, liver disease, DIC, and antiphospholipid syndrome.

Direct and or indirect observation by supervisor, Core or TTP resident or technologist Use Form 1. Form collects information on: - Disorder: acquired coagulation disorder; inherited coagulation disorder; acquired hypercoagulable state; inherited thrombophilia; acquired platelet dysfunction; inherited platelet dysfunction Collect 12 observations of achievement - At least 1 in each category of disease - At least 2 different observers

Suggested observations: 12

- This EPA includes: obtaining informed consent or confirming that consent has been obtained; preparing materials; safe handling of instruments, biologic samples, and biohazardous material; performing the procedure; obtaining an adequate sample (determined by visual assessment at the time of the procedure); and managing any immediate procedure related complications. - This EPA may be observed with inpatients and outpatients, in the ward (including ICU), operating room or designated procedure room setting.

Direct observation by supervisor, Core or TTP hematological pathology resident, or hematology resident Use Form 1. Form collects information on: - Demographic: pediatric (<5yrs); pediatric (>5 yrs); adult - Resident obtained informed consent: yes; no Collect 7 observations of achievement - At least 2 pediatric cases <5yrs - At least 1 case in which the resident obtained informed consent - At least 2 observed by either staff hematopathologist or staff hematologist - At least 3 different assessors

Suggested observations: 7

- This EPA focuses on gathering appropriate materials, slides, and photos for the purposes of a presentation or peer review. - This includes summarizing pertinent clinical history, images, laboratory investigations and other ancillary test results. - This includes preparing a presentation including taking digital photos as appropriate. - This EPA does not include presenting the case.

Review of materials by supervisor or TTP resident Use Form 1. Form collects information on: - Type of presentation: departmental rounds; multidisciplinary rounds; peer review; teaching - Case origin: external; internal - Observer role: hematopathologist; TTP resident Collect 5 observations of achievement - At least 2 different types of presentation - At least 1 external case - At least 2 by staff hematopathologist - At least 3 different assessors

Suggested observations: 5

- This EPA focuses on the role of the hematological pathologist in routine quality assurance (QA) and quality control (QC) monitoring of laboratory tests. - This includes the interpretation of quality control data.

Direct observation by supervisor or medical laboratory technologist Use Form 1. Form collects information on: - Lab activity: statistical method; review of qualitative automated QC; review of qualitative manual QC; review of quantitative automated QC; review of quantitative manual QC; other (write-in) Collect 3 observations of achievement - At least 3 different lab activities

Suggested observations: 3

- This EPA focuses on communication and collaboration with other physicians and members of the interprofessional team that may include physicians, technologists, nurses, clinical scientists, and managers, among others.

Multiple observers provide feedback individually, which is then collated to one report Use Form 3. Form collects information on: - Observer role: clinical scientist; lab manager; physician; technologist; other Collect feedback from at least 3 observers on 3 occasions

- This EPA focuses on synthesizing pertinent patient information, both clinical and from the pathology assessment, to develop a diagnosis, and generate a timely and clinically relevant report. - This includes integrating clinical, laboratory, and morphologic findings, selecting and interpreting ancillary testing, and recognizing when further specialized testing for enzyme or red cell disorders is required. - It also includes recognizing critical results requiring communication. - Complex specimen investigations include those with more than one abnormality and those that require at least one ancillary test in addition to morphology.

Direct observation and review of report by supervisor or TTP resident Use Form 1: Form collects information on: - Specimen: blood film; body fluid - Type of disease: neoplastic; non-neoplastic - Disorder: lymphoid; myeloid; non-hematopoietic - Critical results: yes; no - Demographic: pediatric; adult - Ancillary studies required: yes; no Collect 10 observations of achievement - At least 1 of each type of disease - At least 1 of each disorder - At least 2 with critical results requiring communication - At least 3 pediatric cases - At least 5 different assessors

Suggested observations: 10

- This EPA focuses on interpreting clinical, laboratory, and imaging information, ordering ancillary testing as needed (e.g., immunohistochemistry, molecular, cytogenetic and flow cytometry) and integrating the results into the final diagnosis and report. - It also includes recognizing critical results that require direct communication with the clinical team.

Direct observation and/or case discussion by supervisor or TTP resident Use Form 1. Form collects information on: - Specimen: aspirate/biopsy; lymph node; splenic tissue; other - Type of disease: neoplastic; non-neoplastic - Disorder: acute leukemia; bone marrow failure; lymphoproliferative disorder; myelodysplastic syndrome; myeloproliferative neoplasm; non-hematopoietic diagnosis; other diagnostic category - Diagnosis (write in): - Critical results: yes; no Collect 40 observations of achievement - At least 20 bone marrow aspirate and biopsies - At least 10 lymph nodes - At least 2 splenic tissue - At least 2 other specimens - A range of disorders - At least 4 with critical results requiring communication - At least 5 different observers, at least 4 different hematopathologists

Suggested observations: 40

- This EPA includes triaging specimens for testing, reviewing initial investigations, selecting and interpreting ancillary tests as required, and integrating the results into the final diagnosis and report. - This includes correlating the investigations with the clinical history/bleeding score, family history, medication use, and/or other test results as applicable, and recognizing critical results that require direct communication with the clinical team. - It also includes adherence to quality management and quality assurance guidelines.

Direct observation, case discussion or review of report by supervisor or TTP resident Use Form 1. Form collects information on: - Disorder: inherited coagulation; acquired coagulation; non-specific inhibitor(s); specific inhibitor(s); inherited platelet function disorder; acquired platelet function; inherited thrombophilia; acquired hypercoagulable state; anticoagulant monitoring; other (write-in) - Critical results: yes; no - Demographic: neonate; pediatric; adult - Complex case with multiple testing modalities: yes; no Collect 10 observations of achievement - A variety of disorders - At least 1 thrombotic disorder, inherited or acquired - At least 1 platelet disorder, inherited or acquired - At least 2 critical results - At least 1 neonate - At least 1 complex case with multiple testing methodologies and/or test series - At least 3 different assessors

Suggested observations: 10

- This EPA includes reviewing initial investigations, identifying complex cases, triaging specimens for testing, selecting and interpreting ancillary tests, and integrating the results into the final diagnosis and report. - Complex investigations are those requiring additional ancillary or non-routine methods of testing. - This EPA includes recognizing critical results that require direct communication with the clinical team. - It also includes adherence to quality management and quality assurance guidelines. - The observation of this EPA is based on a single case. - This EPA may be achieved in simulation.

Direct observation, case discussion or review of report by supervisor or TTP resident Use Form 1. Form collects information on: - Disorder (select all that apply): alpha globin chain variant; beta globin chain variant; enzymopathy; red cell membrane abnormality; other - Diagnosis (write in): - Critical results: yes; no - Demographic: neonate; pediatric; adult Collect 7 observations of achievement - A variety of disorders - At least 1 with more than 1 globin chain affected (co-inheritance) - At least 1 red cell membrane abnormality - At least 1 enzymopathy - At least 1 pediatric or neonatal case - At least 2 different observers

Suggested observations: 7

- This EPA includes reviewing the clinical request or history, reviewing or integrating morphologic results, triaging specimens for the appropriateness of flow cytometry and panel selection, and integrating the results into the final diagnosis and report. - This includes routine performance of quality control and quality assurance for individual cases.

Direct observation or case discussion and review of report by supervisor or TTP resident Use Form 1. Form collects information on: - Specimen: body fluid; bone marrow; lymph node; peripheral blood; other - Disorder: acute leukemia panel; CD34 enumeration; fetomaternal hemorrhage; immunodeficiency investigation; investigation of platelet disorder; investigation of red cell disorder; lymphoproliferative panel (LPD); paroxsymal nocturnal hemoglobinuria - Demographic: pediatric; adult - Diagnosis (write in): Collect 15 observations of achievement - A variety of specimens - A variety of disorders - At least 1 pediatric case - At least 1 high grade hematolymphoid malignancy - At least 1 reflecting a rare event analysis (e.g., minimal residual disease, PNH) - At least 3 different observers

Suggested observations: 15

- This EPA focuses on the role of molecular pathology in hematological 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 ordering appropriate tests, typically after a review of light microscopy, as well as interpreting and integrating the molecular results into the final report in the context of clinical history, specimen type, and other diagnostic results. - This EPA does not include the interpretation of complex raw data (e.g., next- generation sequencing).

Direct observation and/or case discussion by supervisor or TTP resident Use Form 1. Form collects information on: - Specimen: blood/bone marrow; formalin fixed paraffin embedded (FFPE) tissue; fresh/frozen tissue; other - Testing modality (select all that apply): fluorescence in situ hybridization (FISH) /chromogenic in situ hybridization (CISH); karyotype; next generation sequencing (NGS); ploidy; polymerase chain reaction (PCR) - Disorder: inherited hemostatic disorder; inherited red cell disorder; lymphoid malignancy; myeloid malignancy; stem cell transplant - Demographic: pediatric; adult Collect 15 observations of achievement - At least 2 each of FFPE tissue, fresh/frozen tissue and blood/bone marrow tissue - At least 3 each of NGS, PCR, karyotype, and FISH/CISH - At least 2 with multiple testing modalities - At least 3 myeloid malignancies - At least 3 lymphoid malignancies - At least 3 inherited disorders, including inherited red cell disorder and inherited hemostatic disorder - At least 1 stem cell transplant - At least 2 pediatric cases

Suggested observations: 15

- This EPA includes providing advice on transfusion management in complex scenarios. - Examples of complex scenarios include massive transfusion, transplantation, maternal- fetal medicine, requests for rare blood products, and blood shortages. - This includes gathering patient information, performing relevant laboratory investigations, demonstrating awareness of the blood inventory, identifying issues, and applying evidence-based indications. - This may include discussing risks, benefits, and alternatives for blood products with physicians. - Scenarios regarding blood shortages may be achieved in simulation.

Case review by supervisor, with input from requesting clinician and/or transfusion medicine charge technologist/manager as required Use Form 1. Form collects information on: - Demographic: pediatric; adult - Urgency: urgent; non-urgent - Clinical scenario: blood shortage; massive transfusion; maternal-fetal medicine; request for rare blood products; transplantation; other (write-in) Collect 5 observations of achievement - At least 1 of each clinical scenario - At least 2 by hematopathologist - At least 3 different assessors

Suggested observations: 5

- This EPA includes providing advice on transfusion reactions in a variety of acute and chronic clinical scenarios and directing the management of transfusion-related adverse events. - Examples include allergic reactions, hemolytic reactions, transfusion transmitted infections, TRALI (transfusion related acute lung injury), and TACO (transfusion associated circulatory overload). - This includes directing lab investigations, including safety and surveillance issues related to the transfusion reaction, and giving advice and recommendations to the clinical team about patient management.

Direct observation and case review by supervisor Use Form 1. Form collects information on: - Setting: clinical; simulation - Type of transfusion reaction: allergic reaction; febrile reaction; hemolytic reaction; TACO; TRALI; transfusion transmitted infections; other (write in) Collect 8 observations of achievement - At least 1 of each type of transfusion reaction

Suggested observations: 8

- This EPA focuses on managing the workload of afterhours hematological pathology, including planning for call, time management, coordinating work with lab personnel, and prioritizing and delegating responsibilities appropriately. - This includes being accessible to requests for diagnostic and consultative services from clinical and lab colleagues, ensuring timely responses to requests, seeking additional help/guidance when needed, and maintaining a professional manner in all interactions. - This includes considerations of laboratory utilization and resource stewardship. - This EPA could be observed in the laboratory (both hematology and transfusion) or a clinical experience. - The observation of this EPA is based on an overnight or weekend on call.

Direct and indirect observation by on-call supervisor, with input from MLTs and from those initiating a call or request as required. Use Form 1. Form collects information on: - Practice domain (select all that apply): core hematology lab; flow cytometry; hemostasis; molecular diagnostics; morphology; red cell investigation; transfusion medicine; other (write in) Collect 5 observations of achievement - At least 3 different practice domains - At least 1 transfusion medicine - At least 2 different assessors

Suggested observations: 5

- This EPA focuses on the hematopathologist’s role in communicating hematological pathology related information to a variety of clinical audiences. - This EPA includes preparing and presenting cases, including a review of relevant literature, responding to clarifying questions from the audience and communicating effectively in rounds, peer review sessions, and teaching presentations. - At this stage, the resident is not yet expected to be the sole source of hematological pathology expertise for the session, discussing nuances and participating in problem– solving related to the case. This is an expectation of the Transition to Practice stage.

Direct observation by supervisor, TTP resident, or other clinician Use Form 1. Form collects information on: - Observer role: hematopathologist; TTP resident; clinician - Type of presentation: departmental rounds; multidisciplinary rounds; peer review; teaching Collect 5 observations of achievement - At least 1 multidisciplinary rounds - At least 2 by staff hematopathologist - At least 1 non-laboratory physician - At least 3 different assessors

Suggested observations: 5

- This EPA focuses on the role of the hematological pathologist as a participant and leader of quality assurance (QA) aspects of laboratory management. - This EPA includes daily quality management and laboratory management activities. - Daily quality management includes process improvement initiatives, reviewing SOPs, and validating new tests/methodologies as well as addressing issues that arise, such as trouble-shooting instrument malfunction or error and reviewing breaches in laboratory quality or safety. - Ongoing routine QA monitoring includes proficiency testing, quality indicators (e.g. turn-around-times), and investigation and management of safety events or laboratory errors.

Direct observation and/or case discussion by supervisor, head technologist or laboratory manager Use Form 1. Form collects information on: - Type of activity: development of critical value protocol; instrument/test validation; instrument troubleshooting; occurrence management; selection and implementation of proficiency testing program; standard operating procedure development; other - Practice domain: core hematology lab; flow cytometry; hemostasis; molecular diagnostics; morphology; red cell investigation; transfusion medicine; other (write in) Collect 3 observations of achievement - At least 1 occurrence management activity - At least 3 different activities - At least 2 different practice domains

Suggested observations: 3

- This EPA includes all aspects of performing scholarly work: identification of a question for investigation, literature review, data gathering, data analysis, reflective critique, and dissemination. - The assessment of this EPA is based on the submission of two completed scholarly projects. - Publication is not required for EPA achievement.

Review of resident submission by supervisor Use Form 1. Form collects information on: - Type of work: educational project; research; quality improvement Collect 2 observation of achievement - At least 1 research project - At least 2 different assessors

Suggested observations: 2

- This EPA includes the timely sign out of comprehensive laboratory reports at the level of junior faculty, managing the workload within expected turnaround times, and performing internal and external consultations. - This includes the integration of evidence-based information into reports and practice. - The observation of this EPA is based on a day’s work.

Direct observation or case discussion and review of reports by supervisor, with input from MLT and clinicians Use Form 1. Form collects information on: - Practice domain (select all that apply): core hematology lab; flow cytometry; hemostasis; molecular diagnostics; morphology; red cell investigation; transfusion medicine; other (write in) - Consult (select all that apply): external; internal - Complexity of case load: low; medium; high - Proficiency testing: yes; no Collect 6 observations of achievement - At least 4 different practice domains - No more than 1 caseload of low complexity - At least 1 caseload of high complexity - At least 2 observations of proficiency testing - At least 3 different assessors

Suggested observations: 6

- This EPA focuses on the hematopathologist's role within and contributions to the interprofessional team regarding patient care and management. - The EPA includes discussing case specific nuances of pathology diagnosis, including implications for prognosis and treatment, advocating for the patient and participating in problem-solving. - It also includes advocating for the role of pathology as well as seeking peer review and consensus diagnosis where applicable. - This EPA includes cases wherein there are challenges in finding consensus or where there is a requirement for external consultation.

Multiple observers provide feedback individually, which is then collated to one report Use Form 3. Form collects information on: - Type of rounds (write in): - Observer role: hematopathologist; staff clinician Collect feedback from at least 3 observers on 3 different occasions - At least 1 by staff hematopathologist - At least 2 by staff clinicians

- This EPA focuses on the management of a hematological pathology service in the role of the physician most responsible for patient care and laboratory oversight, including managing blood transfusion services. - Building on the competencies of the Core stage, this includes application of the knowledge, skills and attitudes expected of an independently practicing pathologist. - This EPA includes coordinating clinical and laboratory services, managing issues related to quality and patient safety events, working effectively with the interprofessional team and completing administrative tasks. - The observation of this EPA is based on a day’s work.

Direct observation by supervisor with input from other laboratory professionals Use Form 1. Form collects information on: - Practice domain: core hematology lab; flow cytometry; hemostasis; molecular diagnostics; morphology; red cell investigation; transfusion medicine; other (write in) Collect 5 observations of achievement - At least 2 different practice domains - At least 2 different assessors

Suggested observations: 5

- This EPA focuses on the informal teaching that occurs as part of usual laboratory activities and includes teaching and providing support and feedback, while ensuring the quality of laboratory practices and reports. - This includes initiating and providing observations of EPAs for junior learners. - This EPA may be observed in daily laboratory activities such as preparing and delivering rounds, clinical consultation, or case sign-out.

Direct and/or indirect observation by supervisor, with input from the junior learners being supervised Use Form 1. Form collects information on: - Junior learner stage (select all that apply): Transition to Discipline; Foundations of Discipline; Core of Discipline - Junior learner discipline (write in): - Activity supervised: clinical; laboratory; rounds preparation Collect 5 observations of achievement - At least 1 supervising rounds preparation - At least 3 different junior learners - At least 3 different assessors

Suggested observations: 5