Continuing Undergraduate Pathology Medical Education in the Coronavirus Disease 2019 (COVID-19) Global Pandemic: The Johns Hopkins Virtual Surgical Pathology Clinical Elective.

CONTEXT.­: In the early months of the response to the coronavirus disease 2019 (COVID-19) pandemic, the Johns Hopkins University School of Medicine (JHUSOM) (Baltimore, Maryland) leadership reached out to faculty to develop and implement virtual clinical clerkships after all in-person medical student clinical experiences were suspended. OBJECTIVE.­: To develop and implement a digital slide-based virtual surgical pathology (VSP) clinical elective to meet the demand for meaningful and robust virtual clinical electives in response to the temporary suspension of in-person clinical rotations at JHUSOM. DESIGN.­: The VSP elective was modeled after the in-person surgical pathology elective to include virtual previewing and sign-out with standardized cases supplemented by synchronous and asynchronous pathology educational content. RESULTS.­: Validation of existing Web communications technology and slide-scanning systems was performed by feasibility testing. Curriculum development included drafting of course objectives and syllabus, Blackboard course site design, electronic-lecture creation, communications with JHUSOM leadership, scheduling, and slide curation. Subjectively, the weekly schedule averaged 35 to 40 hours of asynchronous, synchronous, and independent content, approximately 10 to 11 hours of which were synchronous. As of February 2021, VSP has hosted 35 JHUSOM and 8 non-JHUSOM students, who have provided positive subjective and objective course feedback. CONCLUSIONS.­: The Johns Hopkins VSP elective provided meaningful clinical experience to 43 students in a time of immense online education need. Added benefits of implementing VSP included increased medical student exposure to pathology as a medical specialty and demonstration of how digital slides have the potential to improve standardization of the pathology clerkship curriculum.

Practice of Academic Surgical Pathology During the COVID-19 Pandemic.

OBJECTIVES: To determine the impact of the coronavirus disease 2019 (COVID-19) pandemic on our service, pre-, and postgraduate education and discuss the measures taken to ensure continued provision of quality service as well as education during the mandatory lockdown. METHODS: Measures taken to protect staff from infection and minimize virus transmission within the department as well as measures taken to allow smooth provision of quality service and uninterrupted pre- and postgraduate education were analyzed. Data were collected regarding case volumes (histology, cytology, and frozen sections) and case complexity during the lockdown and analyzed. RESULTS: Staggered rota was introduced for all staff. Strict social distancing measures were implemented. Staff was extensively counseled regarding the importance of protective measures. Pre- and postgraduate education, which was temporarily suspended, was quickly resumed using online teaching ensuring continuation of academic activities. The volume of cases decreased during the lockdown but complexity increased even more. CONCLUSIONS: Immediate and effective measures were taken to protect staff from infection and ensure smooth provision of quality services. Measures were quickly taken to ensure resumption of pre- and postgraduate academic activities. The volume of cases decreased but complexity increased. There is fear among faculty and staff regarding the future.

Evaluation of an online training tool for scoring programmed cell death ligand-1 (PD-L1) diagnostic tests for lung cancer.

BACKGROUND: Numerous studies indicate that higher tumour programmed cell death ligand-1 (PD-L1) expression is associated with greater response to anti-programmed cell death-1 (PD-1)/PD-L1 immunotherapy in non-small cell lung cancer (NSCLC). In the era of precision medicine, there is a need to provide reliable, standardised training for pathologists to improve their accuracy of interpretation and scoring, as the results are used directly to inform clinical decisions. Here we present findings regarding reader reproducibility of PD-L1 tumour cell (TC) staining scoring for NSCLC using a PD-L1 e-trainer tool as part of a PD-L1 immunohistochemistry reader training course. METHODS: The PD-L1 training course was developed based on the use of VENTANA PD-L1 (SP263) and Dako PD-L1 IHC PharmDx 22C3 stained NSCLC samples in combination with a PD-L1 e-trainer tool. Five-hundred formalin-fixed, paraffin-embedded archival samples were obtained from commercial sources and stained for PD-L1. Slides were scored by two expert pathologists, then scanned to produce digital images and re-scored. Thirty-three cases were selected and sorted into three sets: a training set and two self-assessment tests (pre-test and 'competence' test). Participants (all selected board-certified pathologists) received face-to-face training including use of an e-trainer tool. Statistical analyses were performed using the competence test set. Overall percentage agreement (OPA) was assessed between the participant pathologists' registered scores and the reference scores assigned by expert pathologists at clinically relevant PD-L1 cut-offs (≥1%, ≥25% and ≥ 50%). RESULTS: Seven sessions were held and 69 participant pathologists completed the training. Inter-reader concordance indicated high OPA (85-95%) for PD-L1 TC scoring at clinically relevant cut-offs, with Fleiss' Kappa > 0.5. CONCLUSIONS: Use of this web-based training tool incorporated into classroom-style training was associated with an overall moderately good level of inter-reader reproducibility at key cut-offs for TC PD-L1 expression testing in NSCLC. Overall, the online training tool offers a means of standardised training for practising pathologists in a clinical setting.

Grossing Technology Today and Tomorrow.

OBJECTIVE: To describe the perspective of grossing technology and highlight the prospective of its development in histology laboratory. METHODS: Analysis of different components of grossing technology. RESULTS: Increased requirements for a specimen's turnaround time and the advancements in modern processing equipment make the triage of workflow a significant part of a grossing person's responsibilities. The implementation of digital pathology in morphology studies practice requires standardization of fixation, the thickness of gross section, and optimal embedding orientation. To meet tomorrow's challenges, grossing technology should work on embedding automation and gross digital pathology to record gross sections corresponding the microscope slide. Specialization of grossing stations might be beneficial to the quality of processing and smooth workflow productivity. The emerging grossing technologist subspecialty requires development of a special training program. CONCLUSION: Grossing technology can contribute to new challenges in modern histology laboratory, assuring high-quality microscope slides for the pathologist's diagnosis and research evaluation.

Surgical Pathology "Boot Camp": A Military Experience.

CONTEXT.­: A common concern in pathology residency training is the variability with which incoming trainees have attained basic pathology competencies during undergraduate medical education. While multifactorial deficiencies are likely due to recent de-emphasis of dedicated pathology courses during preclinical training, accelerating the transition from medical student to pathology resident is critical-particularly in military practice where a greater degree of autonomy is required of recent graduates. OBJECTIVE.­: To describe the implementation and results of a 4-week surgical pathology "boot camp" in the largest military pathology residency program in the United States. DESIGN.­: Interns were administered an assessment on basic pathology knowledge, slide practicals, and a skills self-assessment. All specimens were grossed by interns with constant direct supervision. A daily microscopic didactic session was given by an upper level resident and a daily gross conference was led by the interns. Subsequent academic performance was evaluated via monthly slide practicals and diagnostic agreement with faculty. RESULTS.­: Following boot camp, average scores on the knowledge assessment increased from 36.0% ± 16.2% (standard deviation [SD]) to 80.0% ± 12.6% (SD) (P < .001). Slide practical scores showed an increase from 32% ± 12.0% (SD) to 74.0% ± 16.2% (SD) (P < .001). Skills self-assessment showed a global increase across all measures. Throughout the following academic year, postgraduate year 1 (PGY1) residents performed at the same level of current PGY2 residents, based on surgical pathology faculty diagnostic agreement and slide practical performance. CONCLUSIONS.­: An intense 4-week surgical pathology rotation specifically tailored to incoming interns was successful in transitioning medical students to pathology residents within a relatively short time.

The Implementation of an Introductory Surgical Pathology Didactic Series to Transition First Year Residents and Facilitate Upper Level Resident Teaching.

The increasing complexity of the practice of pathology and health care in general requires that pathology residents acquire a vast number of skills during their training. This has been reflected by the broad range of skills addressed in the Accreditation Council for Graduate Medical Education (ACGME) milestones. In order to address some of these milestones, our residency program instituted an introductory didactic series in surgical pathology that focused on 2 objectives. First, the didactics provided basic grossing and histology training to first year residents transitioning from medical school. Second, the sessions allowed upper level residents to refine their teaching and communication skills at the microscope and therefore served as an important career development tool. Surveys of both first year residents and the upper level residents that led these sessions confirm the utility of these didactics and the use of upper level residents to teach junior trainees. In addition, these sessions led to a dramatic increase in RISE scores among first year trainees. An introductory series with upper level residents leading slide sessions could easily be replicated at other institutions and provide similar benefits.

Interesting Gross Case Workshop to Remedy Disconnect in Surgical Pathology Curriculum.

Introduction: This workshop was created by pathologists' assistants (PAs) who undertake specialized training programs heavily focused on grossing, which is the macroscopic inspection, evaluation, and sampling of pathology specimens for histologic evaluation by a surgical pathologist. Typically, pathologists or their trainees, during training, focus upon microscopic features, with less emphasis on the macroscopic appearance of disease. Methods: We developed monthly hour-long "interesting gross case workshops" (IGCWs) led by PAs to aid in the process of educating and refining pathology residents' grossing skills and abilities to diagnose at a macroscopic level. Our workshops include gross photography, grossing vocabulary, reference to standardized sampling manuals, and viewing of a specimen library to reinforce subject matter. This workshop was designed to train multilevel pathology providers including PA students, residents, fellows, and medical students, in addition to actively practicing PAs. This resource offers the audience preparation materials to host a workshop in any medical training facility. Results: Our use of the IGCWs has been evaluated positively over a 3-year period, with 78 of 150 participants stating they have increased confidence and capabilities to accurately assess and diagnose at the macroscopic level. Discussion: Utilizing this workshop can be valuable to teach the importance of a thorough gross description and tissue sampling for the diagnostic process. Future work includes expansion to additional pathology learners, improving photography database quantity and quality, and incorporating microscopic correlation when necessary.

Sustainable Development of Pathology in Sub-Saharan Africa: An Example From Ghana.

CONTEXT: - Pathology services are poorly developed in Sub-Saharan Africa. Komfo Anokye Teaching Hospital in Kumasi, Ghana, asked for help from the pathology department of the University Hospital of North Norway, Tromsø. OBJECTIVE: - To reestablish surgical pathology and cytology in an African pathology department in which these functions had ceased completely, and to develop the department into a self-supporting unit of good international standard and with the capacity to train new pathologists. DESIGN: - Medical technologists from Kumasi were trained in histotechnology in Norway, they were returned to Kumasi, and they produced histologic slides that were temporarily sent to Norway for diagnosis. Two Ghanaian doctors received pathology training for 4 years in Norway. Mutual visits by pathologists and technologists from the 2 hospitals were arranged for the introduction of immunohistochemistry and cytology. Pathologists from Norway visited Kumasi for 1 month each year during 2007-2010. Microscopes and immunohistochemistry equipment were provided from Norway. Other laboratory equipment and a new building were provided by the Ghanaian hospital. RESULTS: - The Ghanaian hospital had a surgical pathology service from the first project year. At 11 years after the start of the project, the services included autopsy, surgical pathology, cytopathology, frozen sections, and limited use of immunohistochemistry, and the department had 10 residents at different levels of training. CONCLUSIONS: - A Ghanaian pathology department that performed autopsies only was developed into a self-supported department with surgical pathology, cytology, immunohistochemistry, and frozen section service, with an active residency program and the capacity for further development that is independent from assistance abroad.

Ready, steady, go! What do histopathology trainees think they need from training to enable them to develop autonomy in surgical pathology reporting?

AIMS: This is a qualitative study of the perceived learning needs of trainees for graded responsibility in histopathological training in the UK. METHODS: A focus group with trainees and interviews with consultants was carried out. Participants were asked 'What do you perceive are the learning needs of histopathology trainees to develop skills for safe and confident independent reporting in surgical histopathology?' Data was analysed using open coding content analysis for items relating to training content and structure. RESULTS: Trainees and consultants perceived a need for a case load of around 100 specimens per week with a continuously variable case mix. It was thought necessary to be the principal presenter of cases at multidisciplinary team meetings. There was a perceived need for adequate amounts of supervision by consultants using double-headed microscopes and sufficient time to develop skills in microscopic visual perception through detailed feature discussion, not necessarily related to specific diagnoses. Being able to write clear histopathology reports, developing the ability to recognise normal histology and to be aware of diagnostic pitfalls were also thought to be important. CONCLUSIONS: Our findings may inform efficacious implementation of graded responsibility in histopathology departments and be used as a sound basis for further research.

Training in Informatics: Teaching Informatics in Surgical Pathology.

This article presents an overview of the curriculum deemed essential for trainees in pathology, with mapping to the Milestones competency statements. The means by which these competencies desired for pathology graduates, and ultimately practitioners, can best be achieved is discussed. The value of case (problem)-based learning in this realm, in particular the kind of integrative experience associated with hands-on projects, to both cement knowledge gained in the lecture hall or online and to expand competency is emphasized.

Interinstitutional whole slide imaging teleconsultation service development: assessment using internal training and clinical consultation cases.

CONTEXT: Assessment of accuracy and feasibility of whole slide imaging (WSI) for interinstitutional consultation in surgical pathology. OBJECTIVES: To train technical and pathologist staff in WSI technology, establish and evaluate a WSI workflow using training cases and second-opinion consultations, and assess diagnostic accuracy. DESIGN: First, WSI training and evaluation using selected subspecialty service cases were performed and compared with the clinical glass slide (GS) diagnosis. Second, WSI and GS diagnoses of consecutive, second-opinion consultation cases were compared. Discrepancies underwent adjudication to determine a reference diagnosis. Participant observations on WSI initiation to practice were gathered. RESULTS: There were 130 cases evaluated, with 123 correlations (94.6%) and 6 minor (4.6%) and 1 major (0.8%) discrepancies. The 74 consultation cases interpreted had 52 correlations (70.3%), and 18 minor (24.3%) and 4 major (5.4%) discrepancies. The WSI and GS adjusted major discrepancy rates in second-opinion consultations were 2.7% (2 of 74) and 4.1% (3 of 74), respectively. Statistical analysis showed that WSI was not inferior to GS interpretation. Pathologists agreed the software was easy to use and the images were adequate, but more time was spent rendering WSI interpretations. CONCLUSIONS: A significant learning curve was observed in the transition from the training set to clinical consultation cases associated both with WSI interpretation and adjustments to the digital analogs of routine GS workflow. Results from second-opinion consultations indicated that WSI interpretation was as accurate as GS interpretation among properly trained and experienced users. Overall, WSI-based practice appears feasible for second-opinion consultations.

[Clinical--anatomic ground of caudal approach in newborns with surgical pathology].

Anatomic research have been done on 20 dead bodies of newborns for updating of caudal block level. For definition of caudal block level it was proved, that injection of coloring agent in volume of 0.5 ml/kg, 1 ml/kg and 1.2 ml/kg promotes reaching middle thoracic, high thoracic and highest level of epidural block. Analysis of hemodynamic and serum cortisol level in 25 newborns with surgical pathology showed the best analgesic effect in 15 newborns, who have got caudal-epidural anesthesia comparably with 10 newborns, who have got traditional multicomponent general anesthesia.

Anatomic and clinical pathology boot camps: filling pathology-specific gaps in undergraduate medical education.

CONTEXT: The Liaison Committee on Medical Education began an initiative to change medical education across the United States in the early 2000s. With the explosion in medical science knowledge, the need arose to teach selected fundamental information both in a contextual and in an active learning manner. OBJECTIVE: To identify ways to address gaps in training and knowledge that became apparent following implementation of learner-centered teaching methods, with devotion of more time to Internet-based learning and less emphasis on face-to-face lecture time. There was a dramatic departure from or de-emphasis of many traditional courses, such as embryology, gross anatomy, microscopic anatomy, and pathology, to the integration of these sciences into system-based active learning courses. This change in medical school curricula produces a medical graduate who hopefully thinks differently but certainly lacks subject-specific knowledge for a variety of medical specialties. DATA SOURCES: Pathology residency programs have developed "boot camps" for the initial months of residency training both to provide the necessary foundation of pathology-specific medical science and to introduce basic skills and processes required for practice of anatomic pathology and laboratory medicine. The College of American Pathologists Graduate Medical Education Committee sent a questionnaire out on the Program Directors Section Listserv; the results are discussed and 3 boot camp programs are described. CONCLUSIONS: Boot camps have 2 purposes: (1) to teach or strengthen knowledge required to practice pathology and (2) to introduce basic skills and processes that will be used during the practitioner's career.

Consolidation of the North Shore-LIJ Health System anatomic pathology services: the challenge of subspecialization, operations, quality management, staffing, and education.

OBJECTIVES: To describe our experience, both in meeting challenges and in reporting outcomes, of the consolidation of anatomic pathology services in the North Shore-LIJ Health System in February 2011. METHODS: We addressed issues of governance, personnel, physical plant, quality programming, connectivity, and education. CONCLUSIONS: The highly regulated nature of the laboratory industry and the fact that patient care necessarily never pauses require that such a consolidation take place without a break in service or degradation in turnaround time and quality while engaging personnel at all levels in the extra duties related to consolidation. Subspecialization has allowed us to better meet the needs of our in-system health care community while increasing our access to the competitive outreach marketplace.