Neuropathology
Royal College of Physicians and Surgeons of Canada · 1.0 · 23 EPAs
Also available in French.
Every EPA in the published guide, shown as the form DebriefMD fills in, with its fields and answer options.
Transition to Discipline
TTD-1
Participating in basic specimen handling
Key features and assessment plan
- This EPA includes the use of the basic knowledge covered in the orientation to the laboratory in order to: match requisition and container and/or specimen; systematically verify the adequacy of patient and clinical information (requisition adequacy and completeness such as documentation of ischemic time) to initiate laboratory evaluation of a specimen; assess and prepare selected simple surgical specimens which are defined as single organ, routine indications and/or routine surgical specimens (e.g., appendix, gallbladder, simple hysterectomy for fibroids/uterine prolapse, colon for diverticulosis, ischemic small bowel) for fixation; select and recognize the appropriate fixative type (formalin, alcohol) and assess whether the quantity and size of the specimen container is appropriate; match slides, blocks, and requisition. - The observation of this EPA is divided into two parts: specimen handling; and assessment of knowledge. - The assessment of knowledge will consist of a structured oral or a written multiple- choice quiz, designed and administered by the supervising pathologist, on content related to the topic of specimen handling.
Part A: Specimen handling Direct observation or case review by pathologist, TTP trainee, histotech, or pathology assistant (prosector) Use Form 1. Form collects info on: - Specimen type (write in): - Fixative: fresh; formalin; alcohol Collect 5 observations of achievement - A variety of specimens Part B: Assessment of knowledge Evidence of satisfactory completion of a structured oral or written quiz administered by the supervising pathologist Use Form 4. Collect 1 observation of achievement
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Medical Expert
- Part A: ME 1.3 Apply knowledge of normal anatomy, physiology, and biochemistry
- Part A: ME 1.3 Apply knowledge of principles of cell biology, immunology, genetics, and pathogenic mechanisms, and the changes that occur in disease states
- Part A: ME 1.3 Apply basic knowledge of normal gross appearance of tissues
- Part A: ME 2.2 Identify basic principles of specimen adequacy as they apply to surgical and cytopathology specimens
- Part A: ME 3.3 Recognize and discuss the importance of the triaging and timing of a procedure or therapy
- Part A: ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite, and autopsy suite to minimize occupational risk
Communicator
- Part A: COM 4.1 Organize information in appropriate sections within an electronic or written medical record
Collaborator
- Part A: COL 2.1 Respond to requests and feedback in a respectful and timely manner
Leader
- Part A: L 1.2 Demonstrate knowledge of laboratory safety initiatives
- Part A: L 1.4 Describe the data available from health information systems to optimize patient care
Professional
- Part A: P 1.1 Demonstrate punctuality
- Part A: P 1.1 Complete assigned responsibilities
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
TTD-2
Summarizing relevant clinical information for clinicopathologic correlation
Key features and assessment plan
- This EPA focuses on extracting clinical information, including clinical history and relevant laboratory and imaging results, from a number of different sources (including electronic sources), interpreting this information in light of the clinical question, and providing a summary. - This EPA may be observed in surgical pathology, cytopathology, or autopsy pathology.
Case discussion and/or review of written clinical summary by supervisor (may include pathologist or Core or TTP trainee) Use Form 1. Form collects information on: - Location: surgical pathology; cytopathology; autopsy pathology; other (write in) Collect 3 observations of achievement - At least 1 autopsy pathology
Suggested observations: 3
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Location
- surgical pathology
- cytopathology
- autopsy pathology
- other (write in)
Medical Expert
- ME 1.3 Apply knowledge of normal anatomy, physiology, and biochemistry
- ME 1.3 Apply knowledge of principles of cell biology, immunology, genetics, and pathogenic mechanisms, and the changes that occur in disease states
- ME 2.2 Obtain a relevant clinical history
- ME 2.2 Interpret history and relevant investigations in light of the clinical question
- ME 2.2 Synthesize and organize clinical information for clear and succinct presentation to supervisor
- ME 2.2 Assess the need for pathological investigation given the patient’s presentation and clinical context
Communicator
- COM 2.1 Seek and integrate relevant information from other sources
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
TTD-3
Demonstrating basic skills in microscopy
Key features and assessment plan
- This EPA focuses on using a microscope correctly and troubleshooting its principal problems. - This includes setting up the microscope (turning it on, adjusting the focus) using a polarizer and micrometer and understanding ergonomic setup; performing basic microscope maintenance such as changing objectives and bulbs; and viewing the slide. - The observation of this EPA is divided into two parts: microscopy; and assessment of knowledge. - The observation of microscopy is based on the resident driving the double/ multi- headed microscope in the review of slides. - The assessment of knowledge will consist of a structured oral or written multiple- choice quiz or short answer written response, designed and administered by the supervising pathologist, on content related to the topic of microscopy.
Part A: Microscopy Direct observation by supervisor Use Form 2. Collect at least 1 observation of achievement Part B: Assessment of knowledge Evidence of satisfactory completion of a structured oral or written quiz administered by the supervising pathologist Use Form 4. Collect 1 observation of achievement
Suggested observations: 1
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Medical Expert
- Part A: ME 1.3 Apply knowledge of normal and abnormal light microscopic appearance of tissues
- Part A: ME 1.3 Apply knowledge of how a light microscope works
- Part A: ME 3.4 Use a light microscope to examine microscopic slides
- Part A: ME 3.4 Perform basic microscope maintenance
- Part A: ME 2.2 Correlate microscopic features with normal and abnormal gross appearance of tissues
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
Foundations
F-1
Assessing patients with a disorder affecting the neurologic system
Key features and assessment plan
- The purpose of this EPA is to establish and apply the skills and knowledge of clinical medicine that will be used in later stages of training and in practice as a neuropathology consultant. - This EPA includes performing the history and physical exam, selecting and interpreting the results of investigations, developing a differential diagnosis, and summarizing findings for the clinical supervisor. - It also includes communicating with patients and their families to gather clinical information and convey information about the diagnosis and/or management plan. - This EPA will be observed in the clinic or inpatient setting, with adult and pediatric patients in a range of medical and surgical clinical conditions, especially neurological disease.
Direct observation and/or case review with supervisor Use Form 1. Form collects information on: - Setting: neurology; neurosurgery; other - Activity (select all that apply): taking a history; physical exam; developing a treatment plan; documentation; other - Pediatric/perinatal: no; yes Collect 5 observations of achievement - At least 1 of each setting: neurology and neurosurgery - At least 1 pediatric or perinatal - At least 3 different assessors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Setting
- neurology
- neurosurgery
- other
Activity
- taking a history
- physical exam
- developing a treatment plan
- documentation
- other
Pediatric/perinatal
- no
- yes
Medical Expert
- ME 2.2 Elicit an accurate, relevant history
- ME 2.2 Perform a physical examination relevant to the presentation
- ME 2.2 Synthesize and interpret the history and physical examination to localize a neurological problem
- ME 2.2 Select and interpret the results of investigations in the context of the patient’s presentation
- ME 2.2 Develop a differential diagnosis
- ME 2.4 Develop and implement a plan for initial management
- ME 4.1 Determine the need and urgency of referral to other health care professionals
- ME 1.6 Seek assistance in situations that are complex or new
Communicator
- COM 2.1 Seek and synthesize relevant information from other sources (e.g., family, medical record)
- COM 3.1 Communicate the diagnosis, prognosis and plan of care in a clear, compassionate, respectful, and accurate manner to the patient and family
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
F-2
Performing post-mortem gross examinations
Key features and assessment plan
- This EPA focuses on verifying consent, reviewing clinical information, and directing dissection and tissue handling for autopsies. - This EPA includes the technical skills of dissection and blocking, and demonstrating appropriate methods for tissue handling. - It also includes providing appropriate documentation, including photographs. - This EPA may be observed in organ-limited and full autopsies.
Direct observation and case review by supervisor, Anatomical Pathology TTP or Core resident, or pathology assistant (prosector) Use Form 1. Form collects information on: - Type of autopsy: full; partial - Case type: hospital; forensic homicide; forensic trauma; forensic suicide; forensic external-only - Pediatric/perinatal: no; yes Collect 5 observations of achievement - At least 4 full autopsies - A variety of case types
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Type of autopsy
- full
- partial
Case type
- hospital
- forensic homicide
- forensic trauma
- forensic suicide
- forensic external-only
Pediatric/perinatal
- no
- yes
Medical Expert
- ME 5.2 Apply safe practices in the laboratory and autopsy suite to minimize occupational risk
- ME 1.3 Apply knowledge of normal anatomy and gross appearance of tissues
- ME 2.2 Review clinical history, imaging, and other relevant data
- ME 3.4 Perform gross dissection, description, and sampling of autopsy specimens
- ME 3.4 Work efficiently, ensuring appropriate fixation in a timely manner
- ME 3.4 Take high quality photographs of specimens
- ME 3.4 Seek assistance as needed
- ME 1.3 Demonstrate knowledge of relevant laws and regulations in relation to tissue/organ procurement, tissue retention, principles of consent, privacy and confidentiality
Collaborator
- COL 1.1 Receive and appropriately respond to input from others
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
F-3
Performing post-mortem histological assessments
Key features and assessment plan
- This EPA focuses on performing all aspects of the histologic assessment of post- mortem tissue, leading to a final diagnosis and report. - This EPA includes selecting, ordering, and interpreting special stains, immunohistochemical reactions, and other ancillary tests; integrating clinical and other autopsy findings; communicating with clinicians; and preparing a final report. - It also includes recognizing and troubleshooting slide quality and providing feedback to the pathology technologists as well as recognizing post-mortem histological changes of different organs and tissues, including those caused by a post-mortem delay or artifact.
Direct observation and case review by supervisor or Anatomical Pathology TTP resident Use Form 1. Form collects information on: - Pediatric/perinatal: no; yes - Context: hospital; forensic Collect 3 observations of achievement - At least 2 different assessors
Suggested observations: 3
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Pediatric/perinatal
- no
- yes
Context
- hospital
- forensic
Medical Expert
- ME 2.2 Recognize changes caused by post-mortem delay and artifacts
- ME 2.2 Recognize the limits of histological examination for diagnosis
- ME 1.3 Apply knowledge of normal and abnormal light microscopic appearance of tissues
- ME 1.3 Apply knowledge of the principles of and indications for immunohistochemistry and special histochemical stains
- ME 2.2 Synthesize patient information to determine diagnosis
- ME 2.2 Gather and integrate data from health information systems to contextualize the microscopy findings
Communicator
- COM 4.1 Document microscopic assessment accurately
- COM 4.1 Integrate information from ancillary studies and other sources into the pathology report if applicable
- COM 4.1 Prepare a clear, concise, and timely written report
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
F-4
Handling surgical and autopsy specimens in the pre-analytical phase
Key features and assessment plan
- This EPA focuses on common skills required for adequate and safe handling of human body/tissue specimens during the pre-analytical phase in order to optimize pathological analysis. - This includes applying knowledge covered in the orientation to the laboratory in order to match pathology requisition, autopsy consent, container, specimen, and body; systematically verifying the adequacy of patient and clinical information to initiate the laboratory evaluation; selecting the appropriate tissue preservation technique (temperature, fixative type and amount, etc.); and manipulating and harvesting tissue for special techniques. - It also includes resolving uncertainties and discrepancies in patient and clinical data or requested analyses with the surgical team. - This EPA includes special techniques such as the lymphoma protocol, microbiology studies, cytogenetic studies, molecular studies, tissue banking, and electron microscopy. - An important aspect of this EPA is the focus on safety in laboratory practice, including applying knowledge of precautions and protocols regarding handling of tissue from patients with specific infections (e.g., tuberculosis, spongiform encephalopathies, Hepatitis B).
Direct observation and case review by supervisor, Neuropathology TTP or Core resident, Anatomical Pathology TTP or Core resident, medical lab technologist, or pathology assistant (prosector) Use Form 1. Form collects information on: - Context (select all that apply): microbiology studies; lymphoma protocol; tumour banking; cytogenetic studies; electron microscopy; muscle biopsy; other Collect 5 observations of achievement - At least 3 different assessors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Context
- microbiology studies
- lymphoma protocol
- tumour banking
- cytogenetic studies
- electron microscopy
- muscle biopsy
- other
Medical Expert
- ME 5.2 Apply safe practices in the laboratory, intraoperative consultation suite, and autopsy suite to minimize occupational risk
- ME 1.3 Apply knowledge of precautions and protocols regarding handling of infected tissue (e.g., tuberculosis, spongiform encephalopathies, hepatitis B)
- ME 3.2 Identify the features of an appropriate consent
- ME 2.2 Assess specimen adequacy
- ME 1.3 Apply knowledge of the principles of tissue fixation, decalcification, processing, and the proper handling of fresh tissues
- ME 2.2 Manipulate and harvest tissue for special techniques
- ME 3.3 Recognize and discuss the importance of the triaging and timing of specimen collection
- ME 2.2 Gather and integrate data from health information systems to optimize case management
Collaborator
- COL 2.1 Respond to requests and feedback in a respectful and timely manner
- COL 1.3 Communicate effectively with other health care professionals
Leader
- L 1.1 Apply knowledge of the principles of quality assurance pertinent to laboratory medicine
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
F-5
Performing gross examinations of surgical specimens
Key features and assessment plan
- This EPA focuses on handling fresh and fixed specimens, performing gross dissections, selecting tissue sections for histological examination, and preparing a report of the gross findings. - This EPA includes resolving uncertainties and discrepancies (i.e., in specimen type, orientation, differential diagnosis, or clinical indication) with the surgical team. - This EPA also includes adherence to safety and quality assurance protocols, and existing grossing protocols.
Direct observation and case review by supervisor, Anatomical Pathology TTP or Core resident, or pathology assistant (prosector) Use Form 1. Form collects information on: - Body site (write in): - Specimen state: fresh; fixed - Specimen type: biopsy; simple resection; complex resection - Case type: neoplastic; non-neoplastic Collect 10 observations of achievement - A variety of cases - At least 3 direct observations by a pathologist
Suggested observations: 10
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Medical Expert
- ME 5.2 Apply universal precautions to minimize hazardous exposures such as potential infectious and chemical agents
- ME 1.3 Apply knowledge of normal anatomy and gross appearance of tissues
- ME 2.2 Obtain a relevant clinical history
- ME 3.4 Perform gross dissection, description, and sampling of surgical specimens
- ME 3.4 Work efficiently, ensuring appropriate fixation in a timely manner
- ME 1.6 Recognize limits of own expertise and seek assistance
Communicator
- COM 4.1 Prepare a description of the findings of gross examination
Professional
- P 2.2 Demonstrate a commitment to patient safety and quality improvement through adherence to institutional policies and procedures
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
F-6
Performing diagnostic assessments of surgical and cytological specimens
Key features and assessment plan
- This EPA focuses on common neoplastic and non-neoplastic lesions (including meningioma, schwannoma, and glioblastoma), common non-neoplastic entities in the nervous system, and neoplastic entities outside the nervous system that may metastasize to or involve the CNS; including GI, Gyne, GU, and breast, and others such as sarcomas and lymphoma. - It includes providing a general description of the microscopic findings, and, as relevant, identifying features of a metastatic lesion and determining the site of origin. - This EPA includes selecting, ordering, and interpreting special stains, immunohistochemical reactions, and other ancillary tests; integrating clinical findings, communicating with clinicians (as needed), and preparing a final report.
Direct observation and case review by supervisor, Neuropathology or Anatomical Pathology TTP resident Use Form 1. Form collects information on: - Body site: breast; CNS; CSF; GI; GU; gyne; endocrine; head & neck; lung; lymphoma; skin (neoplastic); soft tissue/bone; other - Case type: neoplastic; non-neoplastic Collect 5 observations of achievement - A variety of cases from major organ systems, including neoplastic and non-neoplastic diseases - At least 2 different assessors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Body site
- breast
- CNS
- CSF
- GI
- GU
- gyne
- endocrine
- head & neck
- lung
- lymphoma
- skin (neoplastic)
- soft tissue/bone
- other
Case type
- neoplastic
- non-neoplastic
Medical Expert
- ME 2.2 Perform a pathological examination that is comprehensive and relevant
- ME 2.2 Select and/or interpret investigations
- ME 1.3 Apply knowledge of the principles of and indications for immunohistochemistry and special histochemical stains
- ME 2.2 Synthesize patient information to determine diagnosis
- ME 1.6 Recognize limits of own expertise and seek assistance
- ME 2.2 Gather and integrate data from health information systems to contextualize the microscopy findings
Communicator
- COM 4.1 Integrate information from ancillary studies and other sources into the pathology report if applicable
- COM 4.1 Convey critical or unexpected results in a timely manner
- COM 4.1 Prepare a clear, concise, and timely written report
Collaborator
- COL 1.3 Communicate effectively with other health care professionals
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
F-7
Performing the pre-interpretive steps of intraoperative consultations
Key features and assessment plan
- This EPA focuses on the first elements of an intraoperative consultation, including reviewing clinical information (including imaging), communication with the clinical team, specimen handling, and preparation of slides. - This includes reviewing the clinical history, discussing the purpose and impact of intraoperative consultation diagnosis on patient management with the clinical team, performing gross examination and selecting tissue for processing, preparing intraoperative smears or touch preparations, cutting frozen sections, and coordinating specimen handover to the pathology lab. - This EPA also includes working effectively with an interprofessional team, including medical laboratory technologists, pathologists, nurses, and surgeons. - This EPA does not include diagnostic interpretation and communication of results to the clinical team.
Direct observation by supervisor, or Neuropathology or Anatomical Pathology TTP or Core resident Use Form 1. Form collects information on: - Case type: smear; touch preparation; frozen section - Indication: margins; diagnosis; adequacy Collect 3 observations of achievement - At least 1 supervisor - At least 2 different assessors
Suggested observations: 3
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Case type
- smear
- touch preparation
- frozen section
Indication
- margins
- diagnosis
- adequacy
Medical Expert
- ME 1.3 Apply knowledge of the principles of tissue fixation, decalcification, processing, and the proper handling of fresh tissues
- ME 2.2 Obtain a relevant clinical history
- ME 2.2 Perform gross examination of specimens
- ME 3.4 Select tissue for processing
- ME 3.4 Prepare intraoperative smear, touch preparation and/or cut frozen sections, as relevant
- ME 1.3 Apply knowledge of the principles of and indications for ancillary diagnostic techniques
- ME 5.2 Apply safe practices in the laboratory and intraoperative consultation suite to minimize occupational risk
Collaborator
- COL 1.2 Discuss indications for appropriate use of intraoperative and urgent consultation
- COL 1.2 Work effectively with laboratory staff
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
Core
C-1
Performing gross examinations of the nervous system at the time of autopsy
Key features and assessment plan
- This EPA focuses on autopsy cases (including fetal and pediatric) of clinical nervous system disease and includes applying appropriate precautions and performing organ removal and sampling of fresh and fixed nervous system tissues. - This EPA includes reviewing the consent, clinical history, and imaging, identifying and reporting forensic issues, harvesting tissue, banking tissue, and obtaining photographs. - It also includes generating a draft autopsy report, in a timely manner, that includes the clinical history and gross findings and may include a primary diagnosis.
Direct observation and case review by supervisor, Neuropathology TTP resident, or pathology assistant (prosector) Use Form 2. Form collects information on: - Demographic: fetal; pediatric; adult - Forensic: yes; no - Brain-only: yes; no - Brain-plus: NA; eye; neck vessels; nerve/muscle; spinal cord Collect 5 observations of achievement - At least 1 fetal case - At least 1 pediatric case - At least 3 adult cases - At least 1 adult spinal cord - At least 1 adult case including dissection of neck vessels - At least 1 observed by supervisor - At least 3 different assessors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Demographic
- fetal
- pediatric
- adult
Forensic
- yes
- no
Brain-only
- yes
- no
Brain-plus
- NA
- eye
- neck vessels
- nerve/muscle
- spinal cord
Medical Expert
- ME 1.3 Apply a broad base and depth of knowledge in clinical and biomedical sciences in autopsy pathology
- ME 1.3 Demonstrate knowledge of relevant laws and regulations in relation to tissue/organ procurement, tissue retention, principles of consent, privacy and confidentiality
- ME 3.2 Ensure appropriate consent has been obtained and documented
- ME 5.2 Apply safe practices in the laboratory and autopsy suite to minimize occupational risk
- ME 2.2 Review clinical history, imaging, and other relevant data
- ME 3.4 Perform gross dissection, description, and sampling of autopsy specimens
- ME 1.6 Recognize limits of own expertise and seek assistance
- ME 3.4 Take high quality photographs of specimens
Collaborator
- COL 1.1 Receive and appropriately respond to input from others
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-2
Performing brain dissection
Key features and assessment plan
- This EPA focuses on autopsy cases of clinical nervous system disease including appropriate safety precautions and dissection. - This EPA includes preparation of case materials, photography, brain and spinal cord examination and cutting, implementation of a sampling protocol, and ordering of special stains and immunohistochemistry as appropriate. - It also includes presenting a case to the staff at brain cut, including summarizing the clinical history, displaying the brain properly, highlighting areas of pathology/interest, and suggesting and applying an approach to blocking.
Direct observation of gross exam and case review by supervisor or Neuropathology TTP resident Use Form 2. Form collects information on: - Demographic: fetal; pediatric; adult - Case mix: neurodegenerative; forensic; congenital malformation; other developmental disease; vascular; other (write in) Collect 10 observations of achievement - At least 1 pediatric forensic case - At least 1 adult forensic case - At least 1 congenital malformation - At least 2 different supervisors
Suggested observations: 10
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Demographic
- fetal
- pediatric
- adult
Case mix
- neurodegenerative
- forensic
- congenital malformation
- other developmental disease
- vascular
- other (write in)
Medical Expert
- ME 1.3 Apply knowledge of normal anatomy and gross appearance of tissues
- ME 2.2 Perform a neuropathological examination that is focused and relevant
- ME 2.2 Review clinical history, imaging, and other relevant data
- ME 5.2 Apply universal precautions to minimize hazardous exposures such as potential infectious and chemical agents
- ME 3.4 Perform gross dissection, description, and sampling of autopsy specimens
- ME 2.2 Select special stains and ancillary tests, as relevant
- ME 3.4 Seek assistance as needed
- ME 3.4 Take high quality photographs of specimens
Leader
- L 1.1 Participate in quality management, including minimizing cross contamination and using standardized grossing templates and protocols as appropriate
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-3
Performing post-mortem histological assessments of the nervous system
Key features and assessment plan
- This EPA focuses on performing microscopic examinations of sections in autopsy cases associated with nervous system diseases, including adult, pediatric, and fetal cases. - This EPA includes describing the microscopic findings and may include ordering additional special stains and immunohistochemistry and instigating ancillary studies (e.g., genetic) as appropriate. - It also includes formulation and refinement of a differential diagnosis and preparation of a final report of the histological investigation.
Direct observation and/or case review by supervisor or Neuropathology TTP resident Use Form 1. Form collects information on: - Demographic: fetal; pediatric; adult - Case mix: developmental disease; neurodegenerative; trauma; other Collect 10 observations of achievement - At least 3 pediatric cases - At least 5 adult cases - At least 1 adult neurodegenerative case - At least 2 different supervisors
Suggested observations: 10
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Demographic
- fetal
- pediatric
- adult
Case mix
- developmental disease
- neurodegenerative
- trauma
- other
Medical Expert
- ME 1.3 Apply knowledge of microscopic appearance of tissues in normal and disease states
- ME 1.3 Apply knowledge of the principles of and indications for immunohistochemistry and special histochemical stains
- ME 2.2 Perform a neuropathological examination that is focused and relevant
- ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
- ME 2.2 Integrate information from ancillary studies and other sources into the histologic interpretation
- ME 2.2 Formulate a differential diagnosis based on the histologic examination
Collaborator
- COL 1.2 Consult as needed with other health care professionals, including other physicians
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-4
Integrating neuropathology autopsy findings to provide a report
Key features and assessment plan
- This EPA focuses on clinicopathologic correlation and includes integrating the clinical information with macroscopic and microscopic examination to establish a final opinion and produce an accurate, timely and clinically relevant report of neuropathology findings.
Direct observation and/or case review by supervisor or Neuropathology TTP resident Use Form 1. Form collects information on: - Context (select all that apply): forensic; adult; pediatric; perinatal - Complexity: simple medical non-neurological disease; simple neurological disease; complex neurological disease - Case mix: autoimmune; infectious disease; inflammatory; malformation; metabolic/toxic; neoplastic; neurodegenerative; trauma; vascular; other Collect 10 observations of achievement - At least 5 complex neurological cases - At least 2 different supervisors
Suggested observations: 10
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Context
- forensic
- adult
- pediatric
- perinatal
Complexity
- simple medical non-neurological disease
- simple neurological disease
- complex neurological disease
Case mix
- autoimmune
- infectious disease
- inflammatory
- malformation
- metabolic/toxic
- neoplastic
- neurodegenerative
- trauma
- vascular
- other
Medical Expert
- ME 1.3 Apply a broad base and depth of knowledge in clinical and biomedical sciences in autopsy pathology
- ME 2.2 Interpret post-mortem findings in light of the clinical history and appreciate potential limitations of such interpretations
- ME 2.2 Establish a final diagnosis that takes into account clinical correlations
Communicator
- COM 2.1 Integrate and summarize the information obtained from an autopsy
- COM 4.1 Prepare a clear, concise, comprehensive, and timely written report
Collaborator
- COL 1.1 Receive and appropriately respond to input from others
Professional
- P 1.2 Demonstrate an appreciation of the limitations of findings, personal professional limits and the necessity of seeking appropriate second opinions
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-5
Performing gross assessments of surgical specimens of the central nervous system and associated structures
Key features and assessment plan
- This EPA focuses on gross assessment of tissue, including accurate description, measurement, margins, and sampling of specimens. - This EPA includes selecting ancillary tests and investigations on fresh tissue (including photography). - Quality management is an important aspect of this EPA and includes matching requisition to specimen and adhering to protocols for lab safety and biohazardous/infectious specimens.
Direct observation and case review by supervisor or Neuropathology TTP resident, with input from pathology assistant (prosector) Use Form 1. Form collects information on: - Demographic: fetal; pediatric; adult - Specimen: biopsy; resection; lobectomy - Case-mix: neoplastic; non-neoplastic Collect 5 observations of achievement - At least 1 lobectomy - At least 2 different supervisors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Demographic
- fetal
- pediatric
- adult
Specimen
- biopsy
- resection
- lobectomy
Case-mix
- neoplastic
- non-neoplastic
Medical Expert
- ME 1.3 Apply knowledge of normal anatomy and gross appearance of tissues
- ME 5.2 Apply safe practices in the laboratory and intraoperative consultation suite to minimize occupational risk
- ME 5.2 Adhere to quality management processes throughout the pre-analytic phase
- ME 2.2 Perform a neuropathological examination that is focused and relevant
- ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
- ME 3.4 Take high quality photographs of specimens
Leader
- L 1.1 Participate in quality management, including minimizing cross contamination and using standardized grossing templates and protocols as appropriate
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-6
Performing histological assessments of surgical specimens of the central nervous system and its associated …
Key features and assessment plan
- This EPA focuses on microscopic assessment of tissue from small biopsies (e.g., vasculitis, encephalitis, etc.), resections (including vascular malformations) and lobectomies; it does not include neuromuscular biopsies. - This EPA includes clinical history review, timely formulation of a diagnosis, clinicopathologic correlation of findings, and dissemination of results to clinicians. - It also includes the appropriate use of ancillary tests (immunohistochemistry, molecular tests, EM), and generation of a written report (micro and diagnosis, incorporation of molecular findings).
Direct observation and case review by supervisor or Neuropathology TTP resident Use Form 1. Form collects information on: - Demographic: fetal; pediatric; adult - Specimen: biopsy; resection; lobectomy - Case mix: non-neoplastic; neoplastic-primary; neoplastic-secondary - Site (select all that apply): brain/leptomeninges; dura; pituitary; spine/paraspinal; cauda equina; skull/skull base; cranial/spinal nerves; temporal artery; other - Diagnosis (write in): Collect 10 observations of achievement - A variety of the case mix - At least 1 of each site - At least 3 different assessors
Suggested observations: 10
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Demographic
- fetal
- pediatric
- adult
Specimen
- biopsy
- resection
- lobectomy
Case mix
- non-neoplastic
- neoplastic-primary
- neoplastic-secondary
Site
- brain/leptomeninges
- dura
- pituitary
- spine/paraspinal
- cauda equina
- skull/skull base
- cranial/spinal nerves
- temporal artery
- other
Medical Expert
- ME 1.3 Apply knowledge of the clinical and biomedical sciences relevant to Neuropathology
- ME 1.3 Apply knowledge of microscopic appearance of tissues in normal and disease states
- ME 2.2 Perform a neuropathological examination that is focused and relevant
- ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
- ME 2.2 Establish a diagnosis that takes into account clinical correlations
Communicator
- COM 4.1 Integrate information from ancillary studies and other sources into the pathology report
- COM 4.1 Prepare a clear, concise, comprehensive, and timely written report
Collaborator
- COL 1.2 Consult as needed with other health care professionals, including other physicians
Leader
- L 1.1 Perform routine quality assurance and quality control activities on histologic and ancillary studies
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-7
Performing diagnostic assessments of neuromuscular biopsies
Key features and assessment plan
- This EPA includes clinical history review, timely formulation of a differential diagnosis, clinicopathologic correlation of findings, formulation of comments and dissemination of results to clinicians. - This EPA includes the assessment of cryostat sections, including special stains and enzyme histochemistry; paraffin embedded tissue studies; electron microscopy, including review of plastic sections, ultrastructural assessment and photography; and immunohistochemistry, including cryostat and permanent/FFPE sections. - It also includes correlating and incorporating genetic findings.
Direct observation and case review by supervisor or Neuropathology TTP resident Use Form 1. Form collects information on: - Demographic: pediatric; adult - Site: muscle; nerve - Complexity: simple; complex - Electron microscopy: yes; no - Diagnosis (write in): Collect 10 observations of achievement - At least 1 pediatric - At least 1 adult - At least 2 nerve - At least 3 electron microscopy - At least 5 with diagnosis of disease - At least 2 different assessors
Suggested observations: 10
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Demographic
- pediatric
- adult
Site
- muscle
- nerve
Complexity
- simple
- complex
Electron microscopy
- yes
- no
Medical Expert
- ME 1.3 Apply knowledge of inherited and acquired diseases of skeletal muscle and of the peripheral nerve and neuromuscular junction
- ME 2.2 Review clinical history, imaging, and other relevant data
- ME 1.3 Apply knowledge of the principles of and indications for immunohistochemistry and special histochemical stains
- ME 1.3 Apply knowledge of the principles of and indications for electron microscopy
- ME 2.2 Assess specimen adequacy
- ME 2.2 Select ancillary techniques judiciously in a resource-effective and ethical manner
- ME 3.3 Prioritize routine and ancillary studies when specimen adequacy is limited
- ME 2.2 Integrate histology, histochemical stains, ancillary studies, and relevant clinical history to develop a pathological diagnosis
- ME 5.2 Perform routine quality assurance and quality control activities
Communicator
- COM 4.1 Integrate information to form a comprehensive and clinically meaningful pathology report
- COM 4.1 Convey critical or unexpected results in a timely manner
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-8
Performing intraoperative consultations
Key features and assessment plan
- This EPA focuses on all elements of an intraoperative consultation, from specimen handling to diagnostic interpretation and communication of results to the clinical team. - This EPA includes reviewing the clinical history, including imaging; handling and triaging the tissue, including preparation of smears and frozen sections; working effectively with all members of the clinical team (surgeon, nurse, technologist, staff pathologist); performing gross and microscopic assessment; formulating a differential diagnosis; establishing a final diagnostic interpretation; conveying the findings to the clinical team; and coordinating specimen handover to the laboratory.
Direct observation by supervisor or Neuropathology TTP resident Use Form 1. Form collects information on: - Specimen: biopsy; resection - Case mix: non-neoplastic; neoplastic-primary; neoplastic-secondary Collect 5 observations of achievement - At least 3 biopsies - At least 1 non-neoplastic biopsy - At least 2 different assessors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Specimen
- biopsy
- resection
Case mix
- non-neoplastic
- neoplastic-primary
- neoplastic-secondary
Medical Expert
- ME 2.2 Obtain a relevant clinical history
- ME 1.3 Apply knowledge of sample requirements and handling
- ME 1.3 Apply knowledge of gross and microscopic appearance of tissues in normal and disease states
- ME 2.2 Prepare the appropriate histologic studies for intraoperative consultation
- ME 2.2 Perform a gross and microscopic pathological examination that is focused and relevant
- ME 3.3 Triage investigations, taking into account clinical urgency and available resources
- ME 2.2 Formulate a differential diagnosis based on the neuropathological examination and clinical context
- ME 3.4 Establish and implement a plan for post-procedure handling of tissue
Communicator
- COM 4.1 Communicate findings to the surgical team in a timely and accurate fashion
Collaborator
- COL 1.3 Work effectively with clinical colleagues to assist in the interpretation of laboratory findings in the clinical context
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
C-9
Presenting neuropathology findings at multidisciplinary rounds and meetings
Key features and assessment plan
- This EPA focuses on the presentation of both visual and oral components of neuropathology findings to other health professionals. - This includes formulating a presentation by gathering clinical information and using digital pathology and digital photographs, including editing macroscopic and microscopic photographs, to facilitate presentation of the case and demonstrating oral presentation skills to effectively convey the neuropathology findings. - It also includes understanding the role of rounds as a means of quality assurance in medicine. - This EPA includes formal presentations at rounds, conferences, and meetings, and/or preparation of findings for use in court as appropriate.
Direct observation by supervisor or Neuropathology TTP resident, with input from audience (e.g., review of evaluations of rounds (i.e., MOCOMP)) Use Form 1. Form collects information on: - Setting: rounds; meetings; conference; other - Topic: surgical pathology; autopsy; research - Complexity: simple; complex Collect 5 observations of achievement - At least 2 different assessors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Setting
- rounds
- meetings
- conference
- other
Topic
- surgical pathology
- autopsy
- research
Complexity
- simple
- complex
Medical Expert
- ME 1.4 Synthesize relevant information in the preparation of a case for discussion at multidisciplinary rounds
- ME 2.2 Obtain and interpret whole slide scanned images
- ME 2.3 Provide diagnostic interpretation and prognostic information to help clinicians establish goals of care and guide management decisions
Collaborator
- COL 1.3 Convey information from the pathology assessment to clinicians in a clear, concise, and understandable manner
- COL 1.3 Participate in discussion, questions, and interaction relevant to the case
Health Advocate
- HA 1.1 Respond to individual patient needs and issues as part of patient care
Scholar
- S 3.3 Critically evaluate the literature
- S 3.4 Integrate best evidence and clinical expertise
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
Transition to Practice
TTP-1
Managing the caseload of a neuropathologist
Key features and assessment plan
- This EPA focuses on a full diagnostic case load as appropriate to the junior faculty member, including performing diagnostic investigations, autopsies, and intraoperative consultations. - This includes attaining concordance with peer review, complying with institutional turnaround time (TAT), and adhering to institutional performance indicators. - It also includes working effectively with the interprofessional team, acting as a liaison with clinicians, providing on-call services, and participating in the routine QA/QC activities related to their caseload. - The observation of this EPA is based on a day’s work; supervisor documentation of this EPA must include narrative feedback.
Direct observation and case review by supervisor, with input from other healthcare professionals Use Form 1. Collect 5 observations of achievement - At least 2 different supervisors
Suggested observations: 5
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Medical Expert
- ME 1.5 Set priorities, triage, and manage the workload within accepted turnaround times
- ME 5.1 Recognize and respond to related to a breach in quality or safety of laboratory practices
- ME 1.4 Perform timely, accurate diagnostic assessments
- ME 1.6 Demonstrate insight into one’s own limits of expertise and seek consultation as necessary
Communicator
- COM 4.1 Formulate comprehensive and clinically meaningful reports
Collaborator
- COL 1.2 Work effectively with other health professionals
Leader
- L 4.2 Describe the principles of workload measurement within the laboratory
- L 2.1 Allocate health care resources for optimal patient care
- L 3.1 Demonstrate knowledge of the principles of laboratory management, including resource allocation, collaboration with technical managers, and hospital and laboratory administration
Scholar
- S 3.4 Integrate best evidence and clinical expertise into decision-making
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
TTP-2
Representing Neuropathology in multidisciplinary rounds
Key features and assessment plan
- This EPA focuses on the role of the neuropathologist in contributing expertise to shared clinical decision making for individual patients. - 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, including seeking peer review and consensus on diagnosis as necessary.
Direct observation and case review by supervisor Use Form 1. Form collects information on: - Settings: tumour board; other Collect 3 observations of achievement - At least 2 different settings - At least 2 different assessors
Suggested observations: 3
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Settings
- tumour board
- other
Medical Expert
- ME 1.4 Present and discuss neuropathology cases effectively at clinical rounds, including the use of high-quality images, in the role of a consultant in Neuropathology
- ME 1.6 Convey diagnostic uncertainty and recommend additional studies when needed
- ME 1.6 Demonstrate insight into one’s own limits of expertise
Collaborator
- COL 1.3 Convey information from the neuropathology assessment to clinicians in a manner that enhances patient management
- COL 2.2 Seek consensus in recommendations provided by other health care professionals
Scholar
- S 3.4 Integrate best evidence and clinical expertise
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
TTP-3
Supervising, teaching, and assessing junior learners
Key features and assessment plan
- This EPA focuses on the informal teaching that occurs as part of usual laboratory activities, and includes teaching, providing support and feedback, and ensuring the quality of laboratory practices and reports. - This EPA may be observed in daily laboratory activities such as grossing, performing an autopsy, intraoperative consultation, or case sign-out.
Direct and/or indirect observation by supervisor, with input from junior learners Use Form 1. Collect 4 observations of achievement
Suggested observations: 4
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Scholar
- S 2.1 Recognize the influence of role-modelling and the impact of the formal, informal, and hidden curriculum on learners
- S 2.2 Create a positive learning environment for all members of the team
- S 2.3 Supervise learners to ensure they work within their limits, seeking guidance and supervision when needed
- S 2.4 Provide teaching and/or other informal learning activities
- S 2.5 Provide feedback to enhance learning and performance
Professional
- P 3.3 Participate in the assessment of junior learners
- P 1.1 Intervene when behaviours toward learners undermine a respectful environment
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.
TTP-4
Participating in laboratory management activities in the role of junior staff
Key features and assessment plan
- This EPA focuses on the role of the neuropathologist in laboratory quality management. - This includes managing critical incidents, such as breaches in laboratory safety or mislabeling of specimens, and leading quality management activities, including chairing quality assurance rounds, such as case consensus rounds, or other pathology quality related rounds; leading a process improvement initiative; leading the validation of a new test or methodology; participating as a member of a hospital committee responsible for the oversight of multiple quality assurance activities; participating in laboratory accreditation activities. - The observation of this EPA is divided into two parts: leading quality management activities; and managing a critical incident. - The critical incident may be real or simulated.
Part A: Leadership in quality management activities Direct and indirect observation by supervisor Use Form 1. Form collects information on: - Activity (write in): Collect 1 observation of achievement Part B: Management of critical incident(s) Direct observation and/or incident review by supervisor Use Form 1. Form collects information on: - Type of critical incident (write in): - Nature of critical incident: real; simulation Collect 1 observation of achievement
Suggested observations: 1
Entrustment (how much supervision did this activity need?)
- I had to do
- I had to talk them through
- I needed to prompt
- I needed to be there just in case
- I didn’t need to be there
Medical Expert
- Part A: ME 2.1 Identify and explore clinical issues to be addressed in the pre-analytical, analytical, and post-analytical handling of a case
- Part A: ME 5.1 Identify potential improvement opportunities arising from harmful patient safety incidents and near misses
- Part B: ME 5.1 Recognize and respond to a breach in quality or safety of laboratory practices
Communicator
- Part A: COM 3.2 Plan and document follow-up to a harmful patient safety incident
- Part B: COM 3.2 Document actions taken to address a breach in quality or safety
Leader
- Part A: L 1.2 Contribute to a culture that promotes patient safety
- Part A: L 1.4 Use health informatics to improve the quality of patient care and optimize patient safety
- Part A: L 3.1 Demonstrate knowledge of the principles of laboratory management, including resource allocation, collaboration with technical managers, and hospital and laboratory administration
Health Advocate
- Part A: HA 2.2 Improve clinical practice by applying a process of continuous quality improvement to disease prevention, health promotion, and health surveillance activities
Professional
- Part A: P 2.2 Demonstrate a commitment to patient safety and quality improvement initiatives within their own practice environment
- Part A: P 3.1 Fulfil and adhere to the professional and ethical codes, standards of practice, and laws governing practice
- Part A: P 3.3 Explain the role of intra- and extra-departmental review of diagnostic material
Case description
Feedback provided
Next steps
Copyright © 2021 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission.