RESIDENCY TRAINING PROGRAM IN GENERAL PATHOLOGY
DEPARTMENT OF LABORATORY MEDICINE AND PATHOLOGY
UNIVERSITY OF ALBERTA
Program Director: L. Puttagunta, MD
Associate Professor of Pathology
Revised September 2008
1
INTRODUCTION
The training manual is designed to provide residents in the General Pathology Residency Training
Program with an outline of the general and specific objectives of the program and of the rotations
available. The manual is also intended to provide an overview of the facilities available to you. The
manual serves secondarily as a guide for faculty teaching in the program.
The training program is structured to ensure that residents obtain the experience necessary to fulfil
the requirements of the Royal College for certification. However, we also attempt to provide for the
special interests or needs of individual residents. The program is based at a number of institutions
which include the University of Alberta Hospital, DynaLIFE DX Diagnostic Laboratory Services, the
Royal Alexandra Hospital, the Misericordia Community Hospital, the Grey Nuns Hospital, the Cross
Cancer Institute and the Medical Examiner’s Office. There are program coordinators at all of these
institutions.
The program has both didactic and apprenticeship components and residents are expected to make
full use of both. Lists of available didactic teaching sessions, rounds and seminars are included in the
manual and you are encouraged to attend, where possible. There are ample library facilities within
the Department and in the hospital and university. However, please remember that, while the
program provides the learning opportunities, experience, and facilities, the resident remains
responsible for utilizing these to their fullest.
Enclosed are the Royal College requirements for training and our own objectives for the program.
Evaluation will be based on these objectives and on your performance on rotations; you will be
provided with regular feedback on your progress.
The teaching faculty hopes that you enjoy and profit from your training and the program welcomes
your feedback at all times. You are entering an exciting new phase of your career, and we are eager
to help you in every way possible in your training.
Director
General Pathology Training Program
2
ORGANIZATION OF PROGRAM
The training program is led by the Program Director with the assistance of the Program Administrator
and the General Pathology Residency Program Committee. The General Pathology Program
Committee meets regularly (four times during the academic year) and major problems may be
brought to the committee’s attention by contacting the resident representatives, or any of its
members.
GENERAL PATHOLOGY RESIDENCY PROGRAM COMMITTEE
TERMS OF REFERENCE
The Residency Program Committee (RPC) in General Pathology is responsible to the Chair of the
academic Department of Laboratory Medicine and Pathology and to the Associate Dean responsible
for Postgraduate Medical Education. The RPC is responsible for policy and operation of the
Residency Training Program. The Committee is made up of the Program Director as Chair, faculty
representing the principal areas of training and practice in General Pathology, and the Program
Administrator. At least one faculty member from each participating institution will sit on the
Committee. A resident representative sits on this committee; however, all residents are welcome to
attend the regular Committee meetings.
It is the function of the Committee:
1.
to recommend policies regarding all aspects of education for the training program,
2.
to formulate the procedures whereby the Royal College of Physicians and Surgeons of
Canada, Faculty and Departmental policies are met,
3.
to survey the overall quality of the Residency Program by regular review and to make
recommendations as may be appropriate,
4.
to maintain liaison and communication with the Royal College of Physicians and Surgeons of
Canada regarding the organization and conduct of the Residency Training Program,
5.
to maintain liaison and communication with the Director of Postgraduate Medical Education
and the Postgraduate Medical Education Committee of the Faculty of Medicine.
6.
to maintain liaison and communication with other residency programs in Canada,
7.
to ensure that there is a regular evaluation of resident performance according to
Departmental and Faculty policy and to review, twice annually, the progress of each resident
in the program,
8.
to make recommendations to the Program Director for acceptance of candidates into the
program .
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RESIDENCY PROGRAM COMMITTEE IN GENERAL PATHOLOGY
2008 - 2009
Dr. Fiona Bamforth (UAH)
Dr. Stuart Brown (DynaLIFE)
Dr. Greg Charrois (Chief Resident)
Dr. Gwen Clarke (UAH)
Dr. John Danyluk (MCH)
Dr. Kinga Kowalewska (UAH)
Dr. Carolyn O’Hara (DynaLIFE)
Dr. Lakshmi Puttagunta (Chair) (UAH)
Mrs. Susan Baert (UAH)
Ex Officio:
Associate Dean for Postgraduate Medical Education.
4
SELECTION OF RESIDENTS
The program only recruits residents through a national match organized by the Canadian Resident
Matching Service (CaRMS) or through the Alberta International Medical Graduate Program. The first
iteration of the CaRMS match is restricted to Canadian citizens or landed immigrants. Applicants
must be graduates of medical schools accredited by the Liaison Committee on Medical Education
(LCME) and must have no previous post-MD clinical training.
Residents are selected/ranked on the basis of academic qualifications, previous performances, letters
of reference and on-site interviews.
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RCPSC Specific Standards of Accreditation for
Residency Programs in General Pathology
Adopted by Council in April 1998
INTRODUCTION
The purpose of this document is to provide program directors and surveyors with an
interpretation of the general standards of accreditation as they relate to the
accreditation of programs in general pathology. This document should be read in
conjunction with the booklet General Standards of Accreditation and the document
Objectives of Training and Specialty Training Requirements in General Pathology.
STANDARD I: ADMINISTRATIVE STRUCTURE
There must be an appropriate administrative structure for each residency
program.
Please refer to Standard B.I in the booklet General Standards of Accreditation for
the interpretation of this standard.
STANDARD II: GOALS AND OBJECTIVES
There must be a clearly worded statement outlining the goals of the residency
program and the educational objectives of the residents.
The general goals and objectives for general pathology are outlined in the document
Objectives of Training and Specialty Training Requirements in General Pathology.
Based upon these general objectives each program is expected to develop rotation
specific objectives suitable for that particular program, as noted in Standard B.II of
the booklet General Standards of Accreditation.
Contents
STANDARD III: CONTENT AND ORGANIZATION OF THE RESIDENCY
PROGRAM
There must be an organized program of rotations and other educational
experiences, both mandatory and elective, designed to provide each resident
with the opportunity to fulfill the educational requirements and achieve
competence in the specialty.
The content and organization of each accredited program in general pathology must
be consistent with the specialty training requirements as outlined in the document
Objectives of Training and Specialty Training Requirements in General Pathology.
In addition to offering the components noted in the specialty training requirements all
accredited programs in general pathology must offer community-based learning
experiences.
The resident must be provided with a graduated increase in individual professional
responsibility, under appropriate supervision, appropriate to the level of competence
and experience.
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STANDARD IV: RESOURCES
There must be sufficient resources including teaching faculty, the number and
variety of patients, physical and technical resources, as well as the supporting
facilities and services necessary to provide the opportunity for all residents in
the program to achieve the educational objectives and receive full training as
defined by the specialty training requirements in general pathology.
In those cases where a university has sufficient resources to provide most of the
training in general pathology but lacks one or more essential elements, the program
may still be accredited provided that formal arrangements have been made to send
residents to another accredited residency program for periods of appropriate
prescribed training.
Learning environments must include experiences that facilitate the acquisition of
knowledge, skills, and attitudes relating to aspects of age, gender, culture, and
ethnicity appropriate to general pathology.
1. Teaching Faculty
There must be a sufficient number of qualified teaching staff to supervise
residents and provide teaching in the basic and clinical sciences related to
laboratory medicine.
There should be ongoing exposure to general pathologists, initiated at the
commencement of training, who can serve as role models during the
formative years of the general pathologist's training. Professional staffing
(pathologists, pathology assistants, technologists and other personnel),
should be sufficient that service work and academic endeavors and roles of
the department can be achieved whether or not residents are present in the
department.
2. Volume and Variety of Pathological Material
While there are no specified minimum numbers of autopsies,
surgical/cytology specimens, or forensic work, the volume and diversity of
work available for teaching must be adequate to attain the educational
objectives of the program. Material provided in the clinical disciplines must
also be of sufficient variety to fulfill the stated training objectives.
The program must provide an opportunity for the resident to acquire a level of
competence in the practice of laboratory medicine appropriate to direct
laboratories in community hospital or free-standing laboratories with the
capability of recognizing those instances where material and/or cases should
be referred.
3. Laboratory Components of the Program
The laboratory program must provide adequate resources to ensure
satisfaction of the training objectives in individual domains encompassed by
7
laboratory medicine. It is important for the general pathology resident to
understand the statistical and analytical bases of laboratory testing, test
interpretation, and effective laboratory.
Training in general pathology must include:
a. Anatomic Pathology
i.
Autopsy Pathology
There must be adequate numbers of autopsies available to
provide full training in gross autopsy techniques,
histotechniques, photographic, and postmortem microbiological
techniques. Instruction in postmortem prosection must be
provided under the direction of staff pathologists.
Departments of Pathology must ensure prompt resident
interpretation and reporting of autopsy findings including clinicopathological correlation. Completed autopsy protocols should be
in the patient's medical record within three months after the date
of autopsy.
ii.
Surgical Pathology
There must be an adequate volume and range of surgically
excised tissues to provide training in the gross examination,
dissection, and selection of appropriate tissue blocks for
histological study. Experience in biopsy and frozen section
interpretation is essential. Experience in the range of
histological diagnoses within the range of tissues sent for study
in community hospital or free-standing laboratories is essential.
iii.
Cytopathology
There must be an adequate volume and mix of cytologic
specimens and facilities available for training in cytology,
including aspiration cytology and exfoliative cytology.
iv.
Forensic Pathology
Residents must obtain experience in the special procedures
which may be associated with medicolegal autopsies. If
necessary to provide such experience, rotations or other
arrangements must be available to residents at an appropriate
forensic centre or laboratory. A well structured program, one
month at least, must be implemented.
v.
Technical and Special Methods
In addition to adequate facilities and equipment for routine
fixation and staining of tissues, there must be adequate
8
opportunity to develop knowledge of the applications of special
staining procedures. Competence in the operation of the light
microscope must be assured, including the applications of
polarizing optics and fluorescent microscopy.
Residents must acquire a basic knowledge of the principles and
techniques of morphometry, molecular pathology, and flow
cytometry, and their interpretation.
b. Hematopathology
There must be adequate experience in the following areas of
hematopathology: morphology, immunohematology, blood banking,
hemostasis and anticoagulation. Emphasis should be placed on the
interpretation of laboratory results.
c. Medical Biochemistry
There must be adequate experience in the following areas of medical
biochemistry: test ordering and patient preparation, methodology,
quality control, interpretation of biochemical findings.
d. Medical Microbiology
There must be adequate experience in the following areas of medical
microbiology: bacteriology, antimicrobial sensitivity testing,
parasitology, mycology, virology, and infection control.
e. Additional areas common to more than one of the above domains
include the following:
i.
Immunology and immunopathology.
ii.
Medical genetics and principles of cytogenetic analysis.
iii.
Pediatric pathology which must be supported by an adequate
volume and variety of teaching material and appropriate faculty.
iv.
Laboratory administration; instruction and experience in
managing of laboratories of secondary care facilities must be
available.
v.
Information management and data processing applicable to
laboratories.
4. Consultation
The resident must have ongoing opportunity to act as a consultant to clinical
colleagues on the interpretation and clinical relevance of laboratory findings.
5. Community Learning Experiences
Community experiences must be available which provide a learning
environment with appropriate supervision based on rotation specific
objectives. This assumes administrative support and linkages with the
9
program.
Exposure to laboratories in smaller community hospitals and free-standing
laboratories should be an integral part of the program. The program must
include training in facilities with laboratory physicians practising general
pathology.
6. Supporting Services — Clinical, Diagnostic, Technical
Accredited programs in other disciplines of laboratory medicine are beneficial
but not essential for an adequate general pathology program. The integration
of general pathology residency with other active teaching services in general
surgery, internal medicine, pediatrics, obstetrics and gynecology and
psychiatry, through the attendance at rounds and interaction with residents
and staff in these other disciplines is to be encouraged. Integration of the
general pathology program with the family medicine program is also
advantageous.
STANDARD V: ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM
The academic and scholarly aspects of the program must be commensurate
with the concept of a university postgraduate education. The quality of
scholarship in the program will in part, be demonstrated by a spirit of enquiry
during clinical discussions, rounds, and conferences. Scholarship implies an
in-depth understanding of basic mechanisms of normal and abnormal states
and the application of current knowledge to practice.
1. Organized Scholarly Activities
Organized scholarly activities such as journal clubs, research conferences
and seminars must be a regular part of the program. Provision of rounds in
each of the specialty areas on a regular basis should be an integral part of the
program and residents should be encouraged to attend clinical conferences
provided by clinical departments, and if possible, participate in presenting the
laboratory component.
2. Basic and Clinical Sciences Relevant to General Pathology
The academic program must include organized teaching in the basic and
clinical sciences relevant to the specialty.
3. Biomedical Ethics
The academic program must ensure that residents gain an understanding of
the basic principles and practice of biomedical ethics as it relates to general
pathology.
4. Communication Skills
The program must ensure that residents learn effective communication skills
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for interacting with colleagues, co-workers from other disciplines and
students. Clearly defined educational objectives for teaching these skills and
mechanisms of formal assessment should be in place.
5. Patient Care Team
Residents must be given opportunities to develop effective skills in
collaborating with all members of the patient care team.
6. Teaching Skills
Residents must be given opportunities to develop effective teaching skills by
teaching junior colleagues and students, as well as through conference
presentations, clinical and scientific reports, and patient education.
7. Management Skills
Residents must be given opportunities to develop skills in management as
applied to general pathology. Residents should also be prepared for their role
as a health care advocate.
8. Quality Assurance/Improvement
The program must provide residents with opportunities to gain an
understanding of the principles and practice of quality assurance monitoring
as it applies to the appropriate utilization of the laboratory and specifically
quality control programs applicable to each area of the laboratory. General
pathology residents must participate in quality assurance programs in both
the laboratory and in the hospital setting.
9. Research Opportunities for Residents
There must be a faculty member with the responsibility to facilitate the
involvement of residents in research and other scholarly work. The academic
program must provide the opportunity for residents to learn biostatistics and
the critical appraisal of research methodology and medical literature. Such
teaching must include issues related to age, gender, culture, and ethnicity in
research protocols and data presentation and discussion. The resident should
be encouraged to participate in research programs in the departments to
which he or she is assigned. Participation in a research program with the
publication of papers or presentation or research findings at medical meetings
is to be encouraged.
10. Faculty Research
A satisfactory level of research and scholarly activity must be maintained
among the faculty identified with the program.
11. Life-Long Learning
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All programs must promote development of skills in self-assessment and selfdirected life-long learning. To promote this end, the program should provide
opportunities for residents to attend conferences outside their own university.
STANDARD VI: EVALUATION OF RESIDENT PERFORMANCE
There must be mechanisms in place to ensure the systematic collection and
interpretation of evaluation data on each resident enrolled in the program.
Please refer to Standard B.VI in the booklet General Standards of Accreditation for
the interpretation of this standard.
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RCPSC Objectives of Training and
Specialty Training Requirements in General Pathology
Approved by Education Committee, 2000
(Please also see Policies and Procedures for Certification and Fellowship)
Contents
Objectives of Training



Definition
General objectives
Specific objectives
Specialty training requirements
Objectives of Training
DEFINITION
General Pathology is that branch of medicine concerned with all aspects of
laboratory investigation in health and disease. The discipline incorporates both
morphological and non-morphological diagnostic techniques in the areas of
Anatomic Pathology, Medical Biochemistry, Medical Microbiology, Hematopathology,
and Transfusion Medicine.
Contents
GENERAL OBJECTIVES
On completion of the education program, the residents will be competent to function
as consultants in General Pathology and medical laboratory directors. This will
require acquisition of a sufficient level of skill in the separate disciplines of Anatomic
Pathology, Medical Biochemistry, Medical Microbiology, Hematopathology and
Transfusion Medicine to serve as a consultant within the context of a regional or
community hospital.
Contents
SPECIFIC OBJECTIVES
(Revised into CanMEDS format — May 2000)
At the completion of training, the residents will have acquired the following
competencies and will function effectively as:
Medical expert
General Requirements
o
o
o
Demonstrate diagnostic and therapeutic skills for ethical and effective
patient care.
Access and apply relevant information to clinical practice.
Demonstrate effective consultation services with respect to patient
care, education and legal opinions.
At the completion of training, the residents will demonstrate the diagnostic
skills required for ethical and effective patient care and will demonstrate
effective consultation skills with respect to patient care, education and legal
opinions. The level of knowledge in all areas will reflect the needs of
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community or regional laboratories. It is not expected that the residents will
have the same depth or breadth of knowledge in the laboratory medicine
specialties as residents trained in a single discipline. From a functional
standpoint the General Pathology residents must be able to recognize and
diagnose common morphological and clinical entities. "Common" may be
defined as likely to occur one or more times in the course of a year in a
laboratory medicine population base of 50,000. The residents must
appreciate those clinical situations, cases or specimen types which will
require referral to a laboratory medicine specialist working in a tertiary
hospital setting.
Specific Requirements
D. Anatomic Pathology
While the general pathology residents must be familiar with and able to
characterize disease processes in a wide range of tissues they must
develop particular skills in diagnosing common entities in the realms of
dermatopathology, gynecological pathology, breast pathology, male
genitourinary pathology, lower urinary tract pathology, gastrointestinal
(including hepatobiliary and pancreatic) pathology, thyroid and
parathyroid pathology, respiratory tract pathology, autopsy pathology,
morphologic hematology (peripheral blood, lymph nodes, bone marrow
biopsies and spleen), and cytopathology (both fine needle and
exfoliative). The residents will recognize the type of case which,
because of tissue type, rarity, complexity, or therapeutic implications
will require referral to a tertiary centre. The residents will also
appreciate those cases where consultation with General Pathology
colleagues would be advisable.
The expected knowledge base will include:
i.
ii.
iii.
iv.
v.
vi.
vii.
viii.
Normal anatomy and its common variants with a basic
understanding of embryological development.
The normal gross and light microscopic appearance of tissues
both as intact organs and biopsy material.
The principles of tissue fixation and preparation of specimens
for microscopic examination.
The normal appearance of tissue cells in common fixatives,
exfoliated or obtained by needle aspiration.
The principles of cell biology, immunology, medical genetics and
pathogenic mechanisms with an understanding of changes seen
in disease states.
The principles of light microscopy including polarization, dark
field and fluorescence microscopy.
The principles of specialized histology techniques including
histochemical, immunocytochemical, flow cytometry,
morphometry, and hybridization techniques and their application
in diagnosis.
The rules regarding retention of specimens and processed
surgical material as well as the retention of records.
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ix.
x.
xi.
xii.
xiii.
xiv.
The rules governing consent for postmortem examination and
the types of cases which must be reported to the coroner or
medical examiner.
The definitions of cause, mechanism and manner of death.
The sampling of tissues and fluids for the toxicological
examination and the legal requirements for the handling of
these samples.
The recognized standards of workplace safety and the rules
governing transportation of dangerous goods.
The utilization of ancillary techniques such as biochemical,
microbiological, photographic, and radiological studies in
surgical and forensic pathology.
The principles of quality assurance pertinent to surgical and
autopsy pathology.
The residents will develop and be able to demonstrate the following
skills by the conclusion of the residency program:
xv.
To recognize and accurately diagnose a broad range of
common inflammatory and neoplastic conditions on both
histological and cytological material.
xvi.
To provide appropriate strategies for biopsy (histological and
cytological), tissue handling, and reporting to include the
features of prognostic and therapeutic importance.
xvii.
To describe appropriate handling, dissection, and sampling of
those tissues normally received for examination by regional or
community hospital laboratories.
xviii.
To be capable of offering a competent intraoperative
consultation (frozen section/ imprint/ cytological) with an
understanding of the appropriate use and limitations of these
procedures.
xix.
To obtain satisfactory photomicrographs and photographs of
gross specimens.
xx.
To perform a complete postmortem examination with
appropriate descriptions at the gross and microscopic levels and
incorporating all clinical information.
xxi.
To be capable of undertaking a complete forensic autopsy in all
common situations excluding homicide. This will require
knowledge of relevant autopsy techniques and expected
findings as well as of the practical aspects of establishing time
of death and identifying remains.
E. Medical Biochemistry
Medical Biochemistry is the study and measurement of biochemical
abnormalities in human disease and forms a core component of the
training program in general pathology.
In all specialties, but especially those that are technologically driven,
there is a rapid evolution to be expected in diagnostic test
methodology. In addition, as understanding of biochemical
15
abnormalities increases, there is a constant need to update and
expand test menus in order to provide rational and efficient strategies
to confirm or exclude disease. The increasing availability of new
technologies is also expected to blur the distinction between traditional
clinical disciplines, enhance the capabilities of community or regional
hospital laboratories, and increase the consultative role of the General
Pathologist.
The discipline of Medical Biochemistry as it pertains to General
Pathology involves the following major areas of activity:


The supervision and direction of the clinical biochemistry
laboratory at the level of a community or regional hospital.
The provision of consultation services to clinical colleagues with
respect to appropriate and effective biochemical testing
strategies and their interpretation.
At completion of training, the residents will have a broad knowledge of
biochemical testing and laboratory instrumentation pertinent to
supervising a community or regional hospital laboratory and offering
consultative services to clinical colleagues. The residents must
understand the common disorders of, and test strategies pertinent to
diagnosis of:














Body water and electrolytes
Acid-base control
Renal function
Liver function
Lipid disorders
Bone disease
Pancreatic function and digestive disease
Cardiac disease and hypertension
Blood sugar control
Iron, porphyrin and bilirubin metabolism
Endocrine function (especially thyroid, parathyroid, gonadal,
pituitary, adrenal)
Uric acid metabolism
Protein metabolism
Common genetic disorders of metabolism
A more basic knowledge of pediatric and prenatal clinical biochemistry,
nutrition, cancer-associated biochemical abnormalities, therapeutic
drug monitoring, pharmacokinetics, and toxicology is required with
special emphasis on testing available in community or regional hospital
laboratories.
The residents will demonstrate the following skills by the conclusion of
the residency program:
xvii.
Given a clinical scenario, will provide appropriate advice
16
regarding biochemical test selection with a view to optimizing
laboratory utilization.
xviii.
Will have a practical knowledge of statistics pertinent to clinical
biochemistry. This will include the concepts of sensitivity,
specificity, efficacy, precision, accuracy, incidence, prevalence,
predictive value, reference ranges, means, standard deviation,
variance, parametric and non-parametric distribution, and the
control of pre-analytical variables.
xix.
Will demonstrate knowledge of common analytical techniques
and instrumentation in the biochemical laboratory.
xx.
Will demonstrate an understanding of laboratory equipment
selection.
xxi.
Will define the components of a quality assurance program and
describe the methods of quality control and their application.
xxii.
Will demonstrate an understanding of the principles of
laboratory safety and the regulations as they apply to workplace
hazards and transportation of dangerous goods.
xxiii.
Will define the basic components of a Laboratory information
system and its application to the modern biochemical laboratory.
F. Medical Microbiology
Medical Microbiology as applicable to General Pathology includes the
following major areas of activity:



The supervision and direction of the clinical microbiological
laboratory at the level of the community or regional hospital.
The direction of a hospital infection control program as it
pertains to the role and utilization of the hospital laboratory.
The provision of consultative services to clinical colleagues
regarding appropriate microbiological investigations and their
interpretation.
The General Pathologist may be expected to assume some of the
responsibilities of an infectious disease consultant depending on the
availability of such resources and an understanding of common
antimicrobial agents and their appropriate use if required.
The organisms for which a working knowledge is required are those
that are normally isolated or otherwise identified in a regional hospital
laboratory.
Bacteria: staphylococci, streptococci, Corynebacteriae (including other
aerobic and facultative gram-positive rods), Clostridia, Neisseriae
(including moraxella), Enterobacteriaceae, Campylobacter,
Pseudomonas (and other common gram negative opportunistic bacilli),
Hemophilus, Bordatellae, Legionellae, Chlamydiae, Mycoplasmae, and
common pathogenic mycobacteria.
Fungi: Candida, Aspergillus, Histoplasma, Coccidioides, Blastomyces,
17
Cryptococcus, Mucor, and Pneumocystis.
Parasites: Malaria, ehrlichia, common helminthic infections (cestodes,
Enterobius, Strongyloides, Ascaris), Giardia, Schistosomes,
Cryptosporidia, Microsporidia, Entamoeba, Dientamoeba, blastocystis,
echinococcus, Trichinella.
For less common bacterial, fungal, and parasitic organisms there
should be a general understanding of testing strategies, specimen
collection and handling, laboratory safety, and interpretation of
diagnostic reports.
A basic knowledge of viral classification and identification techniques is
required with particular emphasis on public health and hospital
infection control implications.
The residents must know the common bacterial toxins, associated
disease implications, and toxin identification techniques.
Hospital infection control must be understood in some depth including
prevention and control of infection and epidemics, disinfection and
sterilization procedures, appropriate handling and disposal of infectious
materials, employee health and laboratory safety issues, and pertinent
public health regulations.
The residents must know the common quality control procedures
applicable to microbiology.
The residents at end of training must be able to demonstrate the
following skills:
iii.
iv.
v.
vi.
vii.
viii.
ix.
x.
xi.
A practical knowledge of all common bench-level test methods
including manual, semi-automated and automated systems.
The ability to prepare and interpret Gram, Ziehl-Neelsen and
special stains for fungi and parasites.
The ability to interpret fluorescence microscopy.
The ability to recognize the diagnostic features of common
bacterial species on differential media, including common
fermentation patterns.
The ability to interpret culture data from non-sterile body sites,
presuming knowledge of the common components of normal
flora.
The ability to describe the common etiological pathogens of
infectious disease by disease process and body site.
The ability to recognize common fungal and parasitic organisms
in human tissue and to utilize serologic and culture
investigations for diagnosis.
The ability to utilize and interpret serological investigations for
the diagnosis of bacterial and viral diseases.
A working knowledge of the newer molecular diagnostic
18
methodologies and their use in microbiological diagnosis and
outbreak investigation.
xii.
The ability to analyze and interpret antimicrobial sensitivity data
and to describe specific techniques for assessing antimicrobial
sensitivity.
xiii.
The ability to interpret quality control data applicable to Medical
Microbiology.
G. Hematopathology and Transfusion Medicine
The level of expertise in hematology must reflect the knowledge base
required in a regional or community hospital. The discipline as
applicable to General Pathology includes the following major areas of
activity:
.
i.
ii.
iii.
iv.
The supervision and clinical direction of a hematopathology
laboratory as organized at the level of a regional or community
hospital.
The supervision and clinical direction of a transfusion service in
association with provincial and national blood agencies.
The morphological assessment and diagnosis of blood, bone
marrow and lymph node based disorders with utilization of
newer technologies as appropriate.
The provision of consultation services with regard to appropriate
and effective hematological investigation.
The provision of consultation services regarding appropriate use
of, and possible alternatives to, blood component therapy.
The General Pathology residents must have a basic knowledge of the
following:
v.
vi.
vii.
viii.
ix.
x.
Normal hematopoiesis and cell biology as it pertains to the
structure and function of all hematopoietic elements.
The structure and functional relationships of all components of
the reticulo-endothelial system.
The components of humoral and cellular immunity, the role of
complement and its pathways of activation.
The components and functional relationship of the hemostatic
and fibrinolytic systems including control mechanisms.
Immunohematology including major blood group systems and
the role of the human leukocyte antigen (HLA) system.
Genetics as applicable to blood disorders.
This knowledge base is required as a framework for understanding
disorders of hematopoiesis and coagulation and to successfully
resolve problems of blood component therapy.
The knowledge base of hematopathological disorders must include the
following:
xi.
Common anemias including diagnostic strategies,
19
xii.
xiii.
xiv.
xv.
xvi.
xvii.
xviii.
morphological findings at the peripheral blood and bone marrow
level, clinical associations, complications, and basic principles of
management.
Major causes of polycythemia including diagnostic strategies,
morphological features, clinical associations, complications, and
basic principles of management.
Common non-neoplastic disorders of leukocytes including
reactive, congenital and drug-related abnormalities.
Common neoplastic disorders of leukocytes including diagnostic
strategies, common classification schemes and the role of
cytogenetics, stem cell studies, and flow cytometry.
Major categories of lymphoma including common diagnostic
strategies, morphological features, ancillary investigations, and
prognostic features.
Common disorders of thrombocytes including diagnostic
strategies, clinical associations and principles of management.
Major disorders of coagulation, congenital and acquired,
including strategies for investigation, clinical associations and
principles of management.
Common problems of blood banking including incompatible
cross-match, auto- and alloimmune antibodies and their
differentiation, neonatal blood banking issues, types and
investigation of adverse reactions to blood component therapy
and the appropriate use of blood components in the treatment of
hematological and coagulation disorders.
At the end of training, the residents will have developed skills in the
following:
xix.
xx.
xxi.
xxii.
xxiii.
xxiv.
xxv.
xxvi.
Bench level tests available in a community or regional hospital
hematology laboratory. This will include manual, semiautomated, and automated tests in addition to the basic
principles of test methodology and instrumentation.
Peripheral blood film and bone marrow/lymph node biopsy
interpretation. This must include all abnormalities likely to be
encountered in a community/regional hospital laboratory
practice.
Decision-making regarding appropriate use of newer diagnostic
methodologies for hematological diagnosis.
Constructing test strategies to diagnose common disorders of
hematopoesis and coagulation.
Bench level testing in the blood bank and recognition of
standards as they apply to the testing and release of blood
products.
Assessing transfusion orders in relation to appropriateness,
risks of blood product transfusion, and alternatives to
transfusion.
Transfusion reaction investigation.
Hematology Quality Assurance (QA) and Quality Control (QC)
issues and laboratory safety practices.
20
xxvii.
Skill in bone marrow aspiration and biopsy technique should be
acquired.
Communicator
General Requirements
o
o
o
o
Establish therapeutic relationships with patients/families.
Obtain and synthesize relevant history from
patients/families/communities.
Listen effectively.
Discuss appropriate information with patients/families and the health
care team.
Specific Requirements
Laboratory physicians, as active members of the health delivery team, will
establish appropriate relationships with consulting physicians and surgeons.
From time to time, especially in the clinical disciplines, the pathologist may
find it helpful, in the best interests of patient care, to communicate directly
with patients, families, and other health care providers. In this regard the
residents must demonstrate skills in communicating, both in verbal and
written form, in a manner appropriate to the intended recipient.
The residents must understand effective clinical history taking and must have
a broad knowledge of the laboratory basis of diagnosis in order to
appropriately advise regarding test strategies and interpretation. Effective
communication with clinical colleagues is essential in order to interpret
surgical and autopsy pathology findings in the clinical context. The residents
must be able to formulate comprehensive and clinically meaningful surgical
pathology reports and organize diagnostic summaries to prioritize the features
of importance. Diagnostic uncertainty must be clearly expressed with
appropriate differential diagnoses and suggestions regarding further studies
or ancillary investigations. There must be an awareness of ethical and
medico-legal issues regarding the release and dissemination of confidential
patient information. The residents must demonstrate awareness of the
importance of timeliness, clarity and accuracy in all verbal and written
communications.
Collaborator
General Requirements
o
o
Consult effectively with other physicians and health care professionals.
Contribute effectively to other interdisciplinary team activities.
Specific Requirements
The residents must be aware of the strong interface between the laboratory
and clinical disciplines. The residents must also develop skills in supporting
educational and/or research endeavours of clinical and laboratory colleagues
through individual opportunities or group learning experiences.
In the realm of surgical pathology the residents must be aware of, and
respond appropriately to, situations in which the laboratory will significantly
affect critical patient management decisions. Such situations will include
intraoperative consultations, assessment of surgical margins, staging
21
procedures, situations where deferral of diagnosis is recommended, and
situations where ancillary investigations or consultation is required for optimal
case management. In the clinical disciplines the residents will be able to
assist in optimal laboratory utilization appreciating the diagnostic limitations of
laboratory tests and the importance of control of pre-analytic variables. The
residents will understand the clinical requirements for turnaround time in
specimen reporting, the range of testing which should be continuously
available in the community/regional hospital and the appropriate laboratory
response to critical values.
The residents must understand the value of interdisciplinary and
intradisciplinary collaboration in patient management decisions. This includes
the need for case review including review by external institutions and
agencies. The residents must demonstrate a willingness to seek consultation
opinions if so requested by clinical colleagues with modification of subsequent
diagnostic impressions if appropriate.
Manager
General Requirements
o
o
o
o
Utilize resources effectively to balance patient care, learning needs,
and outside activities.
Allocate finite health care resources wisely.
Work effectively and efficiently in a health care organization.
Utilize information technology to optimize patient care, life-long
learning and other activities.
Specific Requirements
At the end of training, the residents will understand the basic principles of
laboratory management.
Specifically the residents will have some knowledge of:
o
o
o
o
o
o
o
o
o
o
o
o
o
Staffing and personnel management.
Budgeting (personnel, materials, capital equipment)
Workload measurements.
Funding structures for laboratories.
Hospital medical staff organization and roles.
Quality control, quality assurance and continuous quality improvement.
Laboratory safety and the transportation of dangerous goods.
Management styles.
Principles of optimal laboratory utilization.
Equipment purchasing and selection.
Relevant legislation and/or regulations governing the operation of
laboratories, including issues of informed consent.
Relevant legislation and/or regulations governing laboratory operation
and informed consent
Laboratory information systems and components (hardware and
software).
It is expected that management issues pertinent to the laboratory will be
taught as part of the academic activities of the residency-training program and
may be supplemented with specific research activities.
22
Health Advocate
General Requirements
o
o
o
Identify the important determinants of health affecting patients.
Contribute effectively to improved health of patients and communities.
Recognize and respond to those issues where advocacy is
appropriate.
Specific Requirements
As part of an interdisciplinary team of professionals responsible for patient
and community health care, the residents will understand those components
of the laboratory and its services that are required to:
iv.
Respond adequately to community, and hospital service demands
including the need for population screening.
Respond to hospital, community and regional public health needs to
detect and control infectious disease.
Provide sufficient and safe blood bank resources.
v.
vi.
The residents will demonstrate the ability to recognize and respond to
situations where health advocacy and application of health care resources is
required. This will include the introduction of improved instrumentation and
methodologies to augment community health care.
Scholar
General Requirements
o
o
o
o
Develop, implement and monitor a personal continuing education
strategy.
Critically appraise sources of medical information.
Facilitate learning of patients, housestaff/students and other health
professionals.
Contribute to development of new knowledge.
Specific Requirements
During the training period, the residents will demonstrate an ability to develop
and implement a strategy for learning including a program of continuing
education following completion of the residency. There must be a working
knowledge of statistics applicable to all aspects of laboratory medicine and
the capability of appraising sources of medical information. An important
aspect of the role of the general pathologist is the continuing education of
laboratory technologists and clinical medicine colleagues. An ability to
perform this educational role must be developed by the senior residency
years.
Contribution towards new knowledge is a major role of academic laboratory
medicine specialists and the General Pathology residents must also be
familiar with research methodology. In this regard the residents should have
undertaken at least one research project during the 5-year program and must
be familiar with the principles of critical appraisal.
Professional
General Requirements
23
o
o
o
Deliver highest quality care with integrity, honesty and compassion.
Exhibit appropriate personal and interpersonal professional
behaviours.
Practise medicine ethically consistent with obligations of a physician.
Specific Requirements
The residents must develop a broad understanding of the role of the
physician within the community and hospital structure. The residents must
establish a high standard of laboratory medical practice, appreciating
personal limitations in diagnostic skill which will require referral of particular
types of case in the best interests of patient care. The residents will
demonstrate integrity, honesty and compassion in all aspects of the practice
of laboratory medicine as well as personal and interpersonal professional
behaviours of a high ethical standard. These behaviours will include those
relating to confidentiality, respect for others, conflict of interest, codes of
conduct, personal and professional boundaries, consent, and the role of
professional self-regulation and continuing education.
Specialty Training Requirements
Editorial revision — November 2002
(These specialty training requirements apply to those who began training on or after 1 June 2000.
Please see also the 1994 training requirements pertaining to those who began training on or before
31 May 2000.)
Five years of approved residency. This period must include:
1. One year of basic clinical training.
2. a. Two years of approved training in anatomical pathology; these two years must
include:
i.
ii.
iii.
at least one year of surgical pathology;
at least 2 months of training in a formal, structured medico-legal
autopsy program, which must provide exposure to an appropriate mix of
medico-legal autopsy cases in sufficient numbers to meet training
objectives;
3 months training in cytopathology.
b. Six months of approved training in each of the following:
i.
ii.
iii.
medical biochemistry;
hematological pathology, incorporating morphological hematology,
coagulation, and transfusion medicine;
microbiology, including bacteriology, immunology, mycology,
parasitology and virology.
c. One of the following options. These should include experience in laboratories
in smaller community hospitals and to freestanding clinical laboratories. It must
include training in facilities with laboratory physicians practicing general
pathology.
24
i.
ii.
iii.
Up to six months of approved residency training in a university affiliated
hospital, preferably community based, integrating the skills required of a
general pathologist in a practice setting.
Six months of further approved training in one or more of the following:
anatomical pathology, medical biochemistry, hematological pathology,
or microbiology.
Six months of other approved residency or research, relevant to the
objectives of general pathology and acceptable to the director of the
training program, at a hospital or university centre in Canada.
25
Further to the RCPSC objectives are the program’s general objectives:
GENERAL OBJECTIVES
1.
Medical Expert
 A thorough knowledge of cellular, tissue and organ structure, function, and pathophysiology
as they apply to human disease.
 An adequate knowledge of practical clinical problems to enable the graduate to identify and
fulfill clinical service needs and to make useful clinicopathological correlations.
 A knowledge of laboratory safety precautions within the department (e.g. handling of
infectious cases).
 A "safe" level of skills in surgical pathology and biopsy diagnosis, combined with an
understanding of your own limitations and when and how to obtain assistance from more
experienced colleagues.
 A full range of skills in general and special autopsy techniques, including medico-legal
autopsies.
 A full range of skills in surgical pathological techniques, including rapid diagnosis on frozen
sections, immunohistopathology, and molecular pathology.
 A full range of skills in exfoliative cytology and aspiration cytology diagnosis, and screening
cytology.
 Special skills in selected subspecialty areas.
 A full range of skills in Hematopathology including blood banking, coagulation,
instrumentation, and peripheral smears and bone marrows. The resident will learn how to
obtain bone marrow aspirates and trephine biopsies.
 A full range of skills in medical biochemistry including electrophoresis, screening and
toxicology.
 A full range of skills in medical microbiology including virology, mycology, bacteriology,
parasitology and molecular technology.
 An ability to take photographs of gross and microscopic specimens.
2.
Communicator
 A knowledge of the roles of the Anatomical Pathologist in medical audit and the generation,
communication and storage of data.
 The ability to generate clear, concise, comprehensive and accurate written pathology reports.
3.
Collaborator
 An understanding of the role of the Anatomical Pathologist as a member of a health care
team, including understanding of the ways in which the roles of the Anatomical Pathologist
differ from, as well as complement, those of other members of the team.
26
4.
Manager
 A sound knowledge of the technical basis of Anatomical Pathology as a medical specialty, so
that you can effectively organize and direct a laboratory.
 A sound knowledge of the principles and practices of quality assurance and quality control in
Anatomical Pathology.
 Acquire the ability to manage the day-to-day work of an anatomical pathologist in order to
deliver high quality laboratory/pathology results in a timely manner to optimize patient care.
5.
Scholar
 Recognition of the essential nature of accurate professional self-assessment and of continuing
education and honing of skills. Responsibility to keep abreast of recent advances in
Anatomical Pathology on an ongoing basis, through a diligent coverage of journals,
monographs, symposia, and attendance at meetings and workshops.
 An ability to make presentations at educational/teaching rounds (departmental and
interdepartmental).
 A knowledge of the role of the Anatomical Pathologist in medical education.
 A commitment to participate in undergraduate, graduate and post-graduate medical
education.
 Contribute to the development of new knowledge through research.
6.
Professional
 Deliver the highest quality of care with integrity, honesty, and compassion.
 Exhibit appropriate professional behavior and perform duties in a dependable and
responsible manner.
 Practice medicine in an ethical manner and with sensitivity to diverse patient and co-worker
populations.
 Recognition that every Anatomical Pathologist, no matter how competent, needs the
assistance of his colleagues to help him keep his errors to a minimum and recognition that he
owes his help to his colleagues in turn.
 Understanding that the practice of Anatomical Pathology is a profession and not a business.
7.
Health Advocate
 Recognition that the responsibility of an Anatomical Pathologist in hospital practice is
primarily for the welfare of the patient.
 Recognition that all Anatomical Pathologists make some errors and that these must never be
glossed over or covered up, but must be brought out and corrected and studied in order not
to be repeated.
 Learn how to effectively educate and advise clinical/surgical practitioners/colleagues on the
appropriateness and quality of diagnostic tests to optimize patient care.
27
CONTENT AND ORGANIZATION OF THE PROGRAM
Content and Sequence of Training
PGY1:
(weeks) 4 - ER; 8 - Elective; 4 - Psychiatry; 4 - Pediatrics;
4 - Radiation Oncology; 4 - General Surgery; 8 - Internal
Medicine; 4 - CCU; 4 - Diagnostic Radiology; 4 – Family Medicine
PGY2:
8 weeks AP @ UAH
2 weeks autopsy path @ MEO
1 week histo lab UAH
13 weeks AP @ UAH
24 weeks @ 2 clinical rotations
PGY3:
12 weeks @ 1 clinical rotation
6 weeks AP @ DynaLIFE
6 weeks cytology 1 @ UAH/DynaLIFE
4 weeks breast/GU @ MIs (to be taken before surg path rotation)
4 weeks lymphoma @ CCI (to be taken before molecular path rotation)
4 weeks neuropathology (Oct – Dec only)
4 weeks AP @ GNH
8 weeks elective
PGY4:
2 weeks dermpath @ UAH
24 weeks @ 2 clinical rotations
8 weeks @ MEO
12 weeks surg path/gyne path @ RAH
2 weeks diagnostic molecular path
PGY5:
2 weeks diagnostic molecular path
4 weeks surg path @ MIS
12 weeks @ 1 clinical rotation
6 weeks cytology 2 @ UAH/DynaLIFE
20 weeks GP @ DynaLIFE
4 weeks study/exam leave
28
ACADEMIC AND SCHOLARLY ASPECTS OF THE PROGRAM
Half-day Teaching Schedule
Current schedule available on Webeval site (https://www.webeval.med.ualberta.ca/webeval/index.php).
Other regular teaching sessions/clinical rounds
Other regular teaching sessions/clinical rounds
CME Rounds at DynaLIFE (weekly)
Department of Laboratory Medicine and Pathology Grand Rounds (weekly)
Department of Medicine Grand Rounds (weekly).
Dermatopathology Rounds (bi-monthly).
G.I. Pathology Rounds (weekly).
General AP teaching session (includes Cytology) (weekly)
General Pathology Journal Club (monthly).
GI Clinical Conference (weekly).
Neuropathology Rounds (weekly).
Pulmonary Cytology Rounds (weekly).
Radiology/Pathology Rounds (monthly).
Renal Pathology Rounds (bi-monthly).
Soft Tissue teaching session (bi-monthly).
Occasional teaching sessions/clinical rounds
Head & Neck Pathology Rounds
Surgery A Pathology Rounds
Surgery B Pathology Rounds
29
RESEARCH IN THE GENERAL PATHOLOGY RESIDENCY PROGRAM
The Royal College of Physicians and Surgeons of Canada have established the following terminal
objectives in the Scholar domain of their Objectives of Training and Specialty Training requirements
in General Pathology document:
“During the training period, the residents will demonstrate an ability to develop and implement a
strategy for learning including a program of continuing education following completion of the
residency. There must be a working knowledge of statistics applicable to all aspects of laboratory
medicine and the capability of appraising sources of medical information. An important aspect of the
role of the general pathologist is the continuing education of laboratory technologists and clinical
medicine colleagues. An ability to perform this educational role must be developed by the senior
residency years.
Contribution towards new knowledge is a major role of academic laboratory medicine specialists and
the General Pathology residents must also be familiar with research methodology. In this regard the
residents should have undertaken at least one research project during the 5-year program and must
be familiar with the principles of critical appraisal.”
Residents in General Pathology are expected to identify a research project either during their PGY1
year or early in their PGY2 year. The faculty member responsible for coordinating resident research
(Dr. Victor Tron) is available to assist residents in the selection and implementation of a reasonable
research project. The projects may be either basic or clinical in nature. It is expected that residents
will make one presentation at the Resident Research Day during their residency.
The Department of Laboratory Medicine and Pathology holds an annual Resident and Graduate
Student Research Day in conjunction with the annual Macgregor Memorial Lecture usually held each
fall. The external judge is the John W. Macgregor Lecturer for the year and a prize is awarded for the
best resident research presentation.
Approved November 2001
30
RESIDENT GRADED RESPONSIBILITY IN GENERAL PATHOLOGY
Anatomical Pathology: Graded responsibility is addressed from the point of view of clinical service
and education. Both program organization and the level of expectation by staff, of a resident’s
performance at different levels of training are the principal mechanisms by which graded
responsibility is implemented. For example, during the PGY2 year (first year of pathology training)
the resident is exposed to a broad spectrum of basic gross and microscopic surgical and autopsy
pathology. In contrast, during the final year of training, senior residents participate in a variety of
elective rotations which concentrate on more sophisticated levels of histopathological evaluation in
subspecialized areas of anatomical pathology. They also have an opportunity to review substantial
volumes of consultation material from the various staff members with a variety of subspecialty
interests.
During the first two years of training, the expectation of residents is that they should comprehend
basic gross and microscopic pathology, gain expertise in dissection, become familiar with laboratory
techniques in general and appreciate the significance of clinico-pathologic correlation. At this level of
training, they are not expected to report surgical cases routinely (but may be assigned simple cases
for signout) and their participation in frozen section pathology is primarily as observers. As training
proceeds, residents will be given increased responsibility in preparing surgical reports and to
participate more actively in handling frozen section cases.
During the last two years of training, residents are expected to have a comprehensive approach to
the interpretation of complicated cases, be adept at communication with clinicians and to participate
actively in educational activities directed at junior residents and medical students. In addition, they are
required to generate comprehensive pathology reports of high quality on a routine basis and are
expected to document their diagnoses at the time of frozen section prior to reporting by a staff
member.
Hematological Pathology: At the beginning of his/her Hematopathology (HP) rotation at the UAH
site, the General Pathology (GP) resident is taught to approach morphology systematically and
throroughly. Initially, his/her primary focus in morphology is on the review of abnormal blood smears
referred in by the senior technologists (with senior Hematopathology staff back-up whenever
required), and on reading of peripheral smears and bone marrows alongside the hematopthologists
signing out the cases for the day. As the GP resident gains more experience in HP morphology,
he/she is encouraged and expected to dictate his/her own morphology reports, starting with
peripheral smears and progressing on to bone marrows and cell marker reports. These reports are
always reviewed and co-signed by a hematopathologist.
During his/her HP rotation, the GP resident is also taught to perform bone marrow aspirations and
biopsies. Initially (usually for the first 2 - 3 weeks), the staff hematopathologists supervise the
procedures very closely, but as the resident gains experience and confidence, he/she will graduate to
performing the procedure on his/her own. Senior staff back-up is always available.
A similar process if assuming more responsibility with time and experience is in place for other areas
of HP, and the resident handles problems from these areas on call with senior staff back-up. The rate
at which a resident gains increasing autonomy obviously depends on the individual concerned, but
the expectation is for the GP resident to be able to handle with competence most of the common
hematology issues seen in general hospital laboratories at the end of 6 months of HP training.
31
In all areas, as the GP resident becomes more experiences, he/she also undertakes a supervisory
role with respect to more junior residents and elective medical students.
Medical Biochemistry: General Pathology residents spend a total fo 24 weeks in Medical
Biochemistry, 12 weeks during the second and third years and 12 weeks during the fourth and fifth
years. The first rotation focuses on introduction to clinical chemistry with emphasis on blood
collection, sample handling, analytical techniques, general biochemistry and quality assurance. The
resident is on-call after the first two weeks of the rotation and with the help of a staff person is
expected to handle calls regarding appropriate test requests, and interpretation of results.
During the second rotation more emphasis is placed on specialist areas although the resident does
receive revision of the areas covered in the first rotation. The resident is expected to have a greater
depth and breadth of knowledge in laboratory medicine and is encouraged to have a greater
consultative role. The specialist areas provide more opportunity for interaction with physicians and
the resident is encouraged to call physicians with request for further patient information e.g. with
reference to toxicological testing and examine patient charts if necessary. The resident is also
expected to have sufficient knowledge eto discuss more esoteric test results and suggest further
appropriate further testing.
Medical Microbiology: General Pathology residents-in-training spend two twelve-week blocks in
Medical Microbiology. Most of that time is spent in the Medical Microbiology Laboratory at University
of Alberta Hospital. Additional time is spent at DynaLIFE during the last 24 weeks of their program
when they may also have responsibilities in medical microbiology as well as other disciplines.
During the first 4 weeks of the first 12-week rotation in Medical Microbiology at UAH, the resident is
not on call. This permits them time to familiarize themselves with the day-to-day functions of the
laboratory and to re-acquaint themselves with the fundamentals of medical microbiology. The last 8
weeks they are inserted into the regular resident call rotation along with medical microbiology
residents in the department. The microbiologist on call is always available for backup, and decisions
made by the resident are discussed with the microbiologist on call as a continuing learning exercise.
The resident is encouraged during this period to make regular daily decisions on interpretation at the
bench level during daily rounds and to interact with the microbiologist on call on interpretation of
significant results.
During the second 12-week rotation, the resident is included in the full rotation of on call schedules for
residents. They take first call for the laboratory, but still always have a microbiologist on call as
backup. Once again the resident interactions with clinicians are discussed with the microbiologist,
and they are involved in the routine sign-out of significant reports from the laboratory.
In this way, graded responsibility is developed so that by the end of their training the resident can
function actively and confidently with clinicians in the clinical interpretation of microbiology results.
32
ROTATION SPECIFIC OBJECTIVES
MANDATORY ROTATIONS
33
ROTATION SPECIFIC OBJECTIVES:
AUTOPSY PATHOLOGY TECHNIQUE
Selection:
Site:
Preceptor:
Length of Rotation:
Prerequisites:
Specific Objectives:
Mandatory
Medical Examiner’s Office
Chief and Assistant Chief Medical Examiner
Two weeks
PGY-1
MEDICAL EXPERT










Learn the technical aspects of performing an autopsy and perform an autopsy from the
opening incision to the closing suture for both adult and paediatric cases.
Learn variations of autopsy technique (i.e. block versus organ-by-organ) and special autopsy
procedures (eg. neck dissection, leg vein dissection, eye removal, collection of appropriate
blocks for cardiac conduction system examination, collection of blood cultures).
Acquire skills in gross examination of organs and interpretation of gross organ pathology at a
level appropriate to this early stage of training.
Perform a complete and appropriate assessment of a patient.
Become familiar with the difference in consent procedures required for conducting a hospitalbased family-consented autopsy versus a medicolegal autopsy.
Begin learning the types of questions an autopsy cannot answer.
Become familiar with normal postmortem histology.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR





Summarize the medical history and scene findings for the staff pathologist, summarize the
questions that must be answered by an examination of the body, decide whether an autopsy is
required in order to answer those questions, and justify the reasoning for the choice of
examination type.
Provide the staff pathologist with a differential for the expected autopsy findings/cause of death
and explain how that differential impacts the choice of autopsy technique and/or the use of
special autopsy procedures.
Present gross anatomic findings to the staff pathologist at the completion of every autopsy.
Become familiar with the contents of an autopsy report in preparation for dictating these reports
independently.
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
34


Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
35
COLLABORATOR


Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
MANAGER




Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE





Respond to the individual health needs of the patient and their family and issues as part of patient
care, including specific needs centered on the end of life issues.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR





Develop an individualized case-by-case approach to the conduct of an autopsy, based upon
answering relevant questions that the clinical history and circumstances of the death raise.
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL








Show respect for the deceased at all times.
Know and follow all safety precautions in the autopsy facility, and understand the role a
pathologist must play in ensuring the safety of all morgue staff and any observers at an autopsy.
Develop an understanding of varying religious, ethnic, and cultural beliefs about the autopsy and
the preparation of a body for ultimate disposal.
Develop an understanding of how the autopsy technique can impact a funeral home’s preparation
of the body for viewing.
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
36
Outline of Rotation:









The resident will review the charts of all cases requiring examination, first thing every morning
of the rotation.
The resident will summarize the cases to the staff pathologist, explain which cases require an
autopsy, and why an autopsy is required.
For those cases requiring an autopsy, the resident will provide a differential of the most likely
causes of death, will explain whether any cause of death in the differential requires
modifications of the basic autopsy technique, and whether any special autopsy procedures will
be needed.
The resident will perform all technical aspects of the autopsy on both adult and paediatric nonhomicide cases, to a maximum of two autopsies per day, including: opening incision; removal
of chest plate with rib cutters; collection of toxicology specimens; evisceration of the neck,
thoracic, abdominal, and pelvic organs; removal of the brain, including use of an oscillating
bone saw and dura stripper; examination of all organs with collection of appropriate tissue
blocks; return of viscera to body; and closure of body.
The resident will stop the autopsy immediately upon coming across an unexpected finding, will
present the finding to the staff pathologist, will discuss how the autopsy technique should be
modified in order to best demonstrate and document the finding, and will then proceed to
modify the technique in accordance with the outcome of that discussion.
The resident will demonstrate to and discuss the gross anatomic findings with the staff
pathologist at the completion of each autopsy.
At the conclusion of every autopsy, the resident will outline and discuss what additional tests
(eg. histology, neuropathology, toxicology, etc.) they would conduct in order to answer relevant
outstanding autopsy questions.
The resident will participate in performing special autopsy procedures as cases permit.
The resident will learn and observe all safety rules while conducting postmortem examinations.
Educational Materials:
1.
2.
3.
Ludwig J. Handbook of Autopsy Practice 3rd Edition. Humana Press, Totowa: 2002.
Boglioli LR and Taff ML. Religious Objection to Autopsy: An Ethical Dilemma for Medical
Examiners. Am J Forensic Med Pathol 11: 1-8, 1990.
Sternberg S. Histology for Pathologists 2nd Edition. Lippincott-Raven Publishers, Philadelphia:
1997.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
37
ROTATION SPECIFIC OBJECTIVES
AUTOPSY AND SURGICAL PATHOLOGY
1.
Medical Expert/Clinical Decision-Maker
 Ability to conduct appropriate gross examination and dissection of surgically excised
tissues including:
- examination of arterial supply and venous drainage
- examination of regional lymph nodes
- selection of appropriate tissue blocks for histological study
- preparation and examination of quick frozen sections, when indicated
 Knowledge of the Fatality Inquiries Act and laws or other statutes governing death, organ
donation, burial and the performance of autopsies.
 Ability to perform a complete autopsy on an adult patient, including the evisceration,
dissection and blocking of organs.
 Skill in interpretation of microscopic pathology to enable identification of common disease
processes and formulation of a reasonable differential diagnosis for less common conditions.
 Ability to satisfactorily create a full autopsy report including an accurate clinical summary,
description of gross and microscopic findings, clinico-pathologic correlation, final diagnosis(es)
and cause of death (if possible).
 Ability to describe and recognize grossly and microscopically the common lesions
examined in the routine surgical service of a medium-sized hospital and to use the
appropriate consultant options.
 Ability to effectively supervise the routine technical procedures of the histology laboratory and
troubleshoot any QA/QC issues that arise..
 Familiarity with the principles of tissue fixation and processing, common special staining
procedures i.e. neutral fat, glycogen, elastin etc., and immunohistochemistry with selection of
appropriate stains and panels.
 Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
 Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
 Integrate clinical, radiological and other laboratory data to provide the best diagnosis and
direct further investigations and therapeutic strategies.
 Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
2.
Communicator
 Assist in the continuing education of physicians and other members of the hospital staff by
participating in conferences and case presentations.
 Act as consultant to clinical colleagues on the interpretation and relevance of pathological
findings, with particular regard to their significance in the management of the patient and to
assist in further diagnostic studies if samples are insufficient for diagnosis.
 Develop rapport, trust and professional relationships with other physicians and allied health
care workers and patients and families (as needed).
 Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
 Accurately convey relevant information and explanations to colleagues and other
professionals.
38


Develop a common understanding on issues and problems with colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
3.
Collaborator
 Demonstrate the ability to advise on the appropriateness of obtaining histological and
cytological specimens for diagnostic, teaching and research purposes and to advise on further
appropriate investigations.
 Contribute effectively to interdisciplinary team activities by participating in interdisciplinary
rounds or research activities.
 Participate effectively and appropriately in an interprofessional healthcare team.
 Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
 Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
4.
Manager
 Utilize time and resources effectively to balance patient care, budget restrictions,
professional expectations and personal life.
 Allocate finite health care and health education resources effectively to optimize patient
care and life-long learning.
 Work effectively and efficiently in a medical laboratory organization.
 Familiarity with quality control procedures in histology.
 Familiarity with methods of tissue collection for receptor studies and staining by
immunological methods.
 Participate in activities that contribute to the effectiveness of their healthcare organizations
and systems.
 Manage their practice and career effectively.
 Allocate finite healthcare resources appropriately.
 Serve in administration and leadership roles, as appropriate.
5.
Health Advocate
 Identify the important determinants of health affecting patients pertaining to disease
processes.
 As a member of an interdisciplinary team of professionals responsible for patient health,
the resident will assist in regularly evaluating laboratory practices and test selections to
determine that they meet community needs.
 Recognize and reinforce to the public and to the medical profession the essential
contribution of laboratory medicine to health.
 Respond to individual patient health needs and issues as part of patient care.
 Respond to the health needs of the communities that they serve.
 Identify the determinants of health of the populations that they serve.
 Promote the health of individual patients, communities and populations.
 Acquire appropriate QA/QC knowledge and become aware of one’s own diagnostic
limitations/thresholds to ensure patient safety, and accuracy of medical/pathology reports.
39
6.
Scholar
 Develop and implement a personal continuing educational strategy.
 Apply the principles of critical appraisal to sources of medical information.
 Contribute to the development of new knowledge through research.
 Participate in rounds, conferences and teaching sessions.
 Maintain and enhance professional activities through ongoing learning.
 Critically evaluate information and its sources, and apply this appropriately to practice
decisions.
 Facilitate the learning of patients, families, students, residents, other health professionals,
the public, and others, as appropriate.
 Contribute to the creation, dissemination, application, and translation of new medical
knowledge and practices.
7.
Professional
 Deliver the highest quality of care with integrity, honesty and compassion.
 Practice medicine in an ethical manner and with a sensitivity to diverse patient and coworker populations.
 Exhibit appropriate professional behavior and perform duties in a dependable, consistent
and responsible manner.
 Demonstrate commitment to excellence and ongoing professional development.
 Demonstrate a commitment to their patients, profession, and society through ethical
practice.
 Demonstrate a commitment to their patients, profession, and society through participation
in profession-led regulation.
 Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
In the early phase of training, the trainee learns the basic techniques and skills required for the
performance of autopsies in all categories of cases. He must learn the discipline of completeness and
thoroughness; he must learn to make accurate and meaningful observations and to accurately and
completely record his findings. This requires example, supervision and practice.
The resident is on the autopsy service on a rota basis and does a minimum of every third autopsy. The
resident is to check with Admitting and/or the Autopsy Assistant to determine if there is an autopsy for
that day. If there is, the resident must ensure that all documentation is appropriate, notably that the
consent for the autopsy is appropriate and determine if the case needs review by the MEO. The
resident needs to inform the responsible staff about the autopsy. The resident must review the chart and
present a thorough summary of the case to the staff pathologist. The resident will discuss the best
approach to the case with the staff and will only proceed with the autopsy with the approval of the staff
involved.
After the resident has completed the two week autopsy rotation at the MEO office, he/she is expected to
produce a completed protocol for each of his autopsy cases based upon his gross and microscopic
observations and the details of the clinical record. His protocol includes a summary which outlines the
major clinical and pathological findings, details of the clinicopathological correlations and identifies any
unresolved problems. The compiled protocol includes drawings, photographs, descriptive material and
microbiological reports in addition to weights and measures, clinical summary (including therapy),
40
pathological diagnosis and final summary with clinicopathological correlations. The resident must
formulate a preliminary pathological diagnosis and present it to the staff. The resident must finalize the
case in a timely fashion. This is particularly important if the resident is to leave the service.
The resident will cover a subspecialty area one week at a time. During this week, they are to
macroscopically and microscopically examine all specimens pertaining to the subspecialty area covered.
To ensure adequate grossing experience, the rota will cover high volume subspecialty areas (head &
neck, large GI, GU) more frequently with lower volume subspecialty areas covered less frequently. The
resident will also cover frozen sections on every fourth day. Call coverage will be one week at a time,
from home, shared with all other PGY2-5 residents.
The resident will be expected to preview cases that they have examined macroscopically, formulate a
differential diagnosis, order ancillary tests and issue microscopic reports according to the skill level of the
resident. The resident should strive to acquire accuracy, efficiency, breadth and speed in handling the
surgical routines.
The resident is required to read around cases and perform literature searches. The resident is also
encouraged to maintain a regular schedule of standard textbooks to ensure that all topics are covered
thoroughly.
Educational Materials:
Suggested reading:
 Robbins Pathologic Basis of Disease, 6th edition, W.B. Saunders Company, 1999.
 Ackerman’s or Sternberg.
 Ludwig’s Handbook of Autopsy Practice, 3rd edition.
Clinical material:
 Current cases
 Archival material (Resident Teaching File)
 Wheater’s Basic Histopathology, 4th edition.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
May 2007
41
ROTATION SPECIFIC OBJECTIVES FOR BREAST/
MALE GENITAL AND URINARY PATHOLOGY
Selection:
Site:
Preceptor:
Length of Rotation:
Specific Objectives:
Mandatory
Misericordia Hospital
Dr. J. Danyluk
Four weeks
MEDICAL EXPERT


















To develop expertise in optimal intraoperative and gross examination of breast specimens,
utilizing specimen x-ray for maximum diagnostic information.
To have knowledge of and be able to diagnose and report most benign and malignant
abnormalities in the breast and to have knowledge of the pitfalls.
To have knowledge of and be able to diagnose and report most benign and malignant
abnormalities in the urinary bladder and prostate as they present in transurethral resection,
endoscopic and needle biopsies, and to have knowledge of the pitfalls.
To have knowledge of and be able to diagnose and report most of the neoplasms and
pseudotumors in the testis, scrotum and spermatic cord, and to have knowledge of the pitfalls.
To examine ethical and quality assurance issues that might arise as case material is examined.
To expand an appreciation of the role of the pathologist as a clinical consultant in the
multidisciplinary setting.
function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care
establish and maintain clinical knowledge, skills and attitudes appropriate to their practice
perform a complete and appropriate assessment of a patient
use preventative and therapeutic interventions effectively
demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic
seek appropriate consultation from other health professionals, recognizing the limits of their
expertise
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR



Assist in the continuing education of physicians and other members of the staff by participating in
conferences and case presentations.
Act as consultant to clinical colleagues on the interpretation and relevance of pathological
findings, with particular regard to their significance in the management of the patient.
develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed)
42









accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals
accurately convey relevant information and explanations to colleagues and other professionals
develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families
convey effective oral and written information about a medical encounter
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR





Demonstrate the ability to advise on the appropriateness of obtaining histological and cytological
specimens and to advise on further appropriate investigations.
participate effectively and appropriately in an interprofessional healthcare team
effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict
Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
MANAGER










Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life.
Allocate finite health care and health education resources effectively to optimize patient care
and life-long learning.
participate in activities that contribute to the effectiveness of their healthcare organizations and
systems
manage their practice and career effectively
allocate finite healthcare resources appropriately
serve in administration and leadership roles, as appropriate
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE


Identify the important determinants of health affecting patients pertaining to pathological
processes.
As a member of an interdisciplinary team of professionals responsible for patient health, the
resident will assist in regularly evaluating laboratory practices and test selections to determine
that they meet community needs.
43











Recognize and reinforce to the public and to the medical profession the essential contribution
of laboratory medicine to health.
respond to individual patient health needs and issues as part of patient care
respond to the health needs of the communities that they serve
identify the determinants of health of the populations that they serve
promote the health of individual patients, communities and populations
acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR












Develop and implement a personal continuing educational strategy.
Apply the principles of critical appraisal to sources of medical information.
Contribute to the development of new knowledge through research.
Participate in rounds, conferences and teaching sessions.
maintain and enhance professional activities through ongoing learning
critically evaluate information and its sources, and apply this appropriately to practice decisions
facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate
contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL











Deliver the highest quality of care with integrity, honesty and compassion.
Practice medicine in an ethnical manner and with a sensitivity to diverse patient and co-worker
populations.
Exhibit appropriate professional behavior and perform duties in a dependable and responsible
manner.
Demonstrate commitment to excellence and ongoing professional development.
demonstrate commitment to excellence and ongoing professional development
demonstrate a commitment to their patients, profession, and society through ethical practice
demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation
demonstrate a commitment to physician health and sustainable practice
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
44

Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
The resident shall be able:
 To participate in the intraoperative assessment of breast carcinomas.
 To perform the gross examination of breast resections for carcinoma and to effectively utilize
specimen x-ray.
 To perform a microscopic examination and prepare surgical pathology reports relating to
breast and small specimen urologic pathology specimens.
 To attend group meetings at the Misericordia Hospital.
 As time permits, examine case material referred by other pathologists and archived case
material.
 Attend multidisciplinary breast rounds at the Cross Cancer Institute
Educational Materials:
Suggested reading:
- Surgical pathology and specialty textbooks.
- Collection of recent articles and literature.
- The resident is expected to develop and follow a reading schedule, eg.
Week 1 - Breast Examination, Benign and DCIS.
Week 2 - Prostate
Week 3 - Breast - Other Malignancies
Week 4 - Urinary Bladder, Testis, Scrotal Contents and Spermatic Cord
Conferences:
1. Surgical rounds at the Misericordia Hospital - to attend and present the pathology cases.
2. To attend and present at the Misericordia Breast Interest Group meeting.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
45
ROTATION SPECIFIC OBJECTIVES IN CYTOPATHOLOGY 1 @ UAH
Selection: Mandatory.
Site: University of Alberta Hospital.
Preceptors: Dr. P. Makarla.
Length of Rotation: Four weeks.
Prerequisites: Twelve months autopsy pathology and general surgical pathology.
MEDICAL EXPERT
 To become familiar with the organization and administration of a cytology laboratory,
including quality assurance.
 To know how to handle different types of specimens from various body sites and the
preparation method most suitable for the test required as well as fixation and staining
techniques.
 To be able to recognize the cytological appearance of normal (exfoliated, scraped or
aspirated) cells and the morphological differences between various cell types.
 To become familiar with cytological diagnostic criteria, limitations of cytology, and criteria of
adequacy.
 Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
 Eestablish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
 Perform a complete and appropriate assessment of a case.
 Use preventative and therapeutic interventions effectively.
 Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
 Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.





COMMUNICATOR
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans with colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter and direct/advise further
testing as the need arises.
46
COLLABORATOR
 Participate effectively and appropriately in an interprofessional healthcare team.
 Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.




















MANAGER
Manage time to maximize educational resources and opportunities.
Manage workload appropriately to ensure timely completion of case work.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE
Acquire appropriate QA/QC knowledge and regulations specific to cytology to ensure patient
safety and accuracy of medical reports.
Become fully cognizant of limitations in cytopathology to direct/advise clinicians on the further
testing/management for a patient.
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
SCHOLAR
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
47
Outline of Rotation:
 The resident must meet with the preceptor at the beginning of the rotation.
 The resident should tour the UAH Cytology Department and familiarize himself with
general process and relevant personnel.
 The resident will spend a minimum of two days in the laboratory area to understand, in
depth, the principles and practices of specimen collection and preparation and the
principles and rationales for use of various staining procedures.
 The resident should by reading and discussion develop an understanding of the
appropriate role for cytologic investigations.
 On a daily basis, the resident will spend a minimum of one hour with Ms. Gray to become
familiar with the cytological appearance of normal cells and to determine specimen
adequacy determination for different specimen types.
 The resident will attend and assist at the weekly FNAB clinic run by faculty
cytopathologists.
 The resident will thoroughly screen ten specimens to gain an appreciation for normal
cellular components and to develop appropriate screening habits.
 The resident will actively participate on a daily basis with case sign-out to as great an
extent as possible.
 The resident will become familiar with the range of Quality Assurance activities
incorporated into the practice of cytology.
Educational Materials:
Required reading 1. Cibas, E.S. and Ducatman, B.S. Cytology: Diagnostic Principles and Clinical Correlates,
W.B. Saunders Company, Philadelphia, 1996.
2. Orell, S.R., Sterrett, G.F., Walters, M.N-I., and Whitaker, D. Manual and Atlas of Fine Needle
Aspiration Cytology, 2nd edition, Churchill Livingstone, Edinburgh, 1992.
3. Kurman, R.J. and Solomon, D. The Bethesda System for Reporting Cervical/Vaginal
Cytologic Diagnoses. Springer-Verlag, New York, 1994.
Suggested supplemental reading –
1. DeMay RM. The Art and Science of Cytopathology, ASCP, Chicago, 1996.
2. Koss, L.G. Diagnostic Cytology and Its Histopathologic Bases, 4th edition, J.B. Lippincott
Company, Philadelphia, 1992.
3. Bibbo, M. Comprehensive Cytopathology, 2nd edition, W.B. Saunders Company,
Philadelphia, 1997
Conferences –
Pulmonary Rounds.
Clinical material –
1. Current cases.
2. Archival material (Please consult with cytopathologists re: personal collections and Ms Gray
re: Cytotechnology Student Teaching files.
3. FNA clinic.
48
Evaluation:
1.
On completion of both this rotation and the 2-week rotation at DynaLIFE, the resident will
be evaluated on his/her ability to adequately screen, in a timely fashion, 20 cases from different
sites. The assessment will be done by Ms. Gray.
2.
Overall assessment based on standard resident evaluation form provided by Program
Director’s Office.
3.
Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
Sept 2008
49
ROTATION SPECIFIC OBJECTIVES IN CYTOPATHOLOGY 1 @ DynaLIFE
Selection: Mandatory.
Site: DynaLIFE DX Diagnostic Laboratory Services Core Laboratory.
Preceptor: Dr. G. Johnson.
Length of Rotation: Two weeks.
Prerequisites: Cytopathology 1 @ UAH
MEDICAL EXPERT
 To be able to recognize common pathologic conditions in both gynecological and nongynecological cytology.
 To recognize common pitfalls in cytopathology.
 Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
 Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
 Perform a complete and appropriate assessment of a patient’s medical history relevant to
diagnostic pathology.
 Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.




COMMUNICATOR
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals
verbally and in the form of written cytopathology reports.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
COLLABORATOR
 Demonstrate the ability to advise on the appropriateness of obtaining histological and cytological
specimens and to advise on further appropriate investigations.
 Collaborate with colleagues at all levels in the pathology laboratory particularly with respect to
consultation, peer review and continuing professional development.
 Participate effectively and appropriately in an interprofessional healthcare team.
 Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.






MANAGER
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage time to maximize educational resources and opportunities.
Manage workload appropriately to ensure timely completion of case work.
Develop skills in the management of technical and support staff in the laboratory.
Manage their practice and career effectively.
Allocate finite healthcare resources and health education resources effectively to optimize patient
care and life-long learning.
50




















Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE
Identify the important determinants of health affecting patients pertaining to pathological
processes.
Acquire appropriate QA/QC knowledge specific to cytopathology to ensure patient safety and
accuracy of medical reports.
Recognize and reinforce to the public and to the medical profession the essential contribution of
laboratory medicine to health.
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
SCHOLAR
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices by participating in research, rounds, conferences and teaching sessions.
Develop and implement a personal continuing education strategy.
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
PROFESSIONAL
Develop the highest quality of care with integrity, honesty and compassion.
Practice medicine in an ethical manner and a sensitivity to diverse patients and co-worker
populations.
Exhibit appropriate professional behaviour and perform duties in a dependable and
responsible manner.
Demonstrate commitment to evidence-based medicine, excellence, and on-going professional
development.
Demonstrate a commitment to their patients, profession, and society through ethical practice/
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
51
Outline of Rotation:
1.
Tour DynaLIFE Cytology Department and familiarize yourself with general process and
relevant personnel.
2.
One-hour session with Dr. Johnson or delegate to familiarize resident with reporting
formats and protocols in place at DynaLIFE, including synoptic reports in use.
3,
Understand, in depth, principles and practices of specimen collection and preparation.
4.
Understand principles and rationales for use of various staining procedures.
5.
Develop understanding of appropriate role for cytologic investigations.
6.
Develop theoretical knowledge of fine needle aspiration techniques in various organ sites.
7.
Understand specimen adequacy determination for both gyne and non-gyne specimens.
8.
Thoroughly screen five of each specimen type to gain appreciation for normal cellular
components.
9.
Develop appropriate screening habits.
10. Actively participate on a daily basis with case sign-out to as great an extent as possible.
11. Understand and apply management recommendation for gyne cytology cases as outlined
in “Alberta Standardized Management Recommendation” report.
12. Prepare for a 30-45 minute tutorial on non-gyne cytology each week during the
rotation.
13. Prepare 30 minute CME session for presentation at biweekly cytopathology department
conference.
Educational Materials:
Required reading 1. Cibas, E.S. and Ducatman, B.S. Cytology: Diagnostic Principles and Clinical
Correlates, W.B. Saunders Company, Philadelphia, 1996.
2. Orell, S.R., Sterrett, G.F., Walters, M.N-I., and Whitaker, D. Manual and
Atlas of Fine Needle Aspiration Cytology, 2nd edition, Churchill Livingstone,
Edinburgh, 1992.
3. Kurman, R.J. and Solomon, D. The Bethesda System for Reporting
Cervical/Vaginal Cytologic Diagnoses. Springer-Verlag, New York, 1994.
Suggested reading –
1. Koss, L.G. Diagnostic Cytology and Its Histopathologic Bases, 4th edition, J.B.
Lippincott Company, Philadelphia, 1992.
2. Bibbo, M. Comprehensive Cytopathology, 2nd edition, W.B. Saunders Company,
Philadelphia, 1997
52
Clinical material –
1. Current cases.
2. Archival material (Please consult with Dr. Johnson).
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
Sept 2008
53
ROTATION SPECIFIC OBJECTIVES IN CYTOPATHOLOGY 2 @ UAH
Selection: Mandatory.
Site: University of Alberta Hospital.
Preceptors: Dr. P. Makarla.
Length of Rotation: Four weeks.
Prerequisites: Cytopathology 1 @ UAH; Cytopathology 1 @ DynaLIFE.
MEDICAL EXPERT
 To become familiar with and apply cytological diagnostic criteria including limitations of
cytology and criteria for specimen adequacy.
 To be able to write a concise cytology report with appropriate clinical pathologic
correlations and advice re: further evaluation and/or follow-up.
 To be able to handle most non-gynecological and gynaecological cytologic preparations.
 To become familiar with fine needle aspiration techniques.
 To function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
 Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
 Perform a complete and appropriate assessment of a case.
 Use preventative and therapeutic interventions effectively.
 Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
 Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.





COMMUNICATOR
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR
 Participate effectively and appropriately in an interprofessional healthcare team.
 Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.





MANAGER
Manage time to maximize educational resources and opportunities.
Manage workload appropriately to ensure timely completion of case work.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
54
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

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
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Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
Become fully cognizant of limitations in cytopathology to direct/advise clinicians on the further
testing/management for a patient.
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
SCHOLAR
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
 Review with Dr. Makarla the reporting format and protocols in place at UAH.
 Review specimen adequacy determination.
 Participate on a daily basis with case sign-out to as great an extent as possible, balancing
both non-gyne and gyn cytology. Due to the breadth of non-gyn, greater emphasis is
placed on non-gyn cytology at the UAH site.
 As this is a more senior rotation residents are expected to complete and dictate reports for
review and sign-out with preceptor.
 Participate with cyto-histologic correlation assessment with responsible pathologist.
 Attend special diagnostic procedures and FNA clinic.
 Prepare and present Pulmonary rounds each week.
Educational Materials:
Required reading 1. Cibas, E.S. and Ducatman, B.S. Cytology: Diagnostic Principles and Clinical Correlates,
W.B. Saunders Company, Philadelphia, 1996.
2. Orell, S.R., Sterrett, G.F., Walters, M.N-I., and Whitaker, D. Manual and Atlas of Fine Needle
Aspiration Cytology, 2nd edition, Churchill Livingstone, Edinburgh, 1992.
3. Kurman, R.J. and Solomon, D. The Bethesda System for Reporting Cervical/Vaginal
Cytologic Diagnoses. Springer-Verlag, New York, 1994.
55
Suggested supplemental reading –
1. DeMay RM. The Art and Science of Cytopathology, ASCP, Chicago, 1996.
2. Koss, L.G. Diagnostic Cytology and Its Histopathologic Bases, 4th edition, J.B. Lippincott
Company, Philadelphia, 1992.
3. Bibbo, M. Comprehensive Cytopathology, 2nd edition, W.B. Saunders Company,
Philadelphia, 1997
Conferences –
Pulmonary Rounds.
Clinical material –
1. Current cases.
2. Archival material (Please consult with cytopathologists re: personal collections and Ms Gray
re: Cytotechnology Student Teaching files.
3. FNA clinic.
Evaluation:
 Each of the weekly presentations at Pulmonary Rounds will be graded.
 Practical examination at end of rotation administered by Ms. Gray. Ten cases from
different sites. A mark of 70% will be considered a pass mark on this examination.
 Overall evaluation based on standard resident evaluation form provided by Program
Director’s Office.
 Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
Sept 2008
56
ROTATION SPECIFIC OBJECTIVES IN CYTOPATHOLOGY 2 @ DynaLIFE
Selection: Mandatory.
Site: DynaLIFE DX Diagnostic Laboratory Services Core Laboratory.
Preceptor: Dr. Gordon Johnson.
Length of Rotation: Two weeks
Prerequisites: Cytopathology 1 & @ @ UAH, Cytopathology 1 @ DynaLIFE
MEDICAL EXPERT
 To be able to handle most gynecological and non-gynecological cytologic preparations.
 To be able to write a concise cytology report with appropriate clinical pathologic
correlations and advise re further evaluation and/or follow-up.
 Gunction effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
 Rstablish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
 Perform a complete and appropriate assessment of a patient.
 Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
 Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.





COMMUNICATOR
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR


Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.





MANAGER
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage time to maximize educational resources and opportunities.
Manage workload appropriately to ensure timely completion of case work.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.


HEALTH ADVOCATE
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.

57
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









Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
1.
Review with Dr. Johnson reporting format and protocols in place at DynaLIFE.
2.
Review specimen adequacy determination.
3.
Review management recommendation for gyne cytology specimens.
4.
Actively participate on a daily basis with case gyne sign-out to as great an extent as
possible.
5.
Complete and dictate non-gyne reports for review and sign-out with preceptor.
6.
Participate with cyto-histologic correlation assessment with responsible
pathologist.
7.
Prepare for 30-45 minute tutorial on non-gyne cytology topic with Dr. Johnson
each
week.
8.
Prepare 30 minute CME session for presentation at biweekly cytopathology department
conference.
9.
Become familiar with the range of Quality Assurance activities incorporated into
the
practice of cytology.
Educational Materials:
Required reading 1. Cibas, E.S. and Ducatman, B.S. Cytology: Diagnostic Principles and Clinical
Correlates, W.B. Saunders Company, Philadelphia, 1996.
2. Orell, S.R., Sterrett, G.F., Walters, M.N-I., and Whitaker, D. Manual and
Atlas of Fine Needle Aspiration Cytology, 2nd edition, Churchill Livingstone,
Edinburgh, 1992.
3. Kurman, R.J. and Solomon, D. The Bethesda System for Reporting
Cervical/Vaginal Cytologic Diagnoses. Springer-Verlag, New York, 1994.
Suggested reading –
58
1. Koss, L.G. Diagnostic Cytology and Its Histopathologic Bases, 4th edition, J.B.
Lippincott Company, Philadelphia, 1992.
2. Bibbo, M. Comprehensive Cytopathology, 2nd edition, W.B. Saunders Company,
Philadelphia, 1997
Clinical material –
2. Current cases.
2. Archival material (Please consult with Dr. Johnson).
Evaluation:
1.
Each of the weekly tutorials will be graded.
2.
Practical examination at end of rotation. A mark of 70% will be considered a pass mark
on this examination.
3.
Overall evaluation based on standard resident evaluation form provided by Program
Director’s office.
4.
Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
Sept 2008
59
ROTATION SPECIFIC OBJECTIVES IN DERMATOPATHOLOGY
General Pathology Residents
Selection: Mandatory.
Site: University of Alberta Hospital
Preceptor: Dr. Ken Alanen
Prerequisites: PGY2
Length of Rotation: Two weeks
MEDICAL EXPERT
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To have a good understanding of normal cutaneous histology.
To understand the stains and indications used in the diagnosis of dermatological conditions.
To have a good understanding of the various techniques used to biopsy cutaneous conditions.
To develop a diagnostic approach to inflammatory dermatoses.
To understand the necessary information required in reporting melanoma.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR






Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
60
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


Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR




Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
MANAGER








Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE









respond to individual patient health needs and issues as part of patient care
respond to the health needs of the communities that they serve
identify the determinants of health of the populations that they serve
promote the health of individual patients, communities and populations
acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
 Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical
reports.
SCHOLAR



maintain and enhance professional activities through ongoing learning
critically evaluate information and its sources, and apply this appropriately to practice decisions
facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate
61





contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL








demonstrate commitment to excellence and ongoing professional development
demonstrate a commitment to their patients, profession, and society through ethical practice
demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation
demonstrate a commitment to physician health and sustainable practice
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
Residents will spend two weeks working with Dr. Victor Tron and other UAH faculty signing out
dermatopathology cases. This will involve reviewing slides before sign-out, going over slides with Dr.
Tron and dictating cases. Residents will also be given teaching slides to go over. Residents will also
be encouraged to write up a case report.
Educational Materials:
Residents will be provided with teaching slide sets and text books will be recommended.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
62
ROTATION SPECIFIC OBJECTIVES
DIAGNOSTIC MOLECULAR PATHOLOGY
Selection: Mandatory
Site: UAH
Preceptor: Dr. Imran Mirza
Length of Rotation: Four weeks
Prerequisites: PGY-3
Specific Objectives:

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
MEDICAL EXPERT
Understand the principles, advantages and limitations of polymerase chain reaction (PCR)
assays
Be able to run simple PCR assays
Be familiar with the common clinical applications of PCR based assays
Be familiar with the latest technologies in detecting and/or quantifying PCR products, and their
clinical applications
Be familiar with other non-PCR based molecular techniques (such as Southern blots and
fluorescence in situ hybridization) that are commonly used in molecular diagnostic laboratory
Understand the issues of contamination in a molecular diagnostic laboratory, and measures
taken to minimize contamination
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice
Perform a complete and appropriate assessment of a patient
Use preventative and therapeutic interventions effectively
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise
COMMUNICATOR
Communicate effectively and demonstrate caring and respectful behavior when interacting with
medical colleagues, nursing and technical staff
Obtain and discuss appropriate information with staff pathologists and clinicians in difficult
cases
Generate written reports of excellent quality that incorporate all necessary information in a
clear and concise manner
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed)
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals
Accurately convey relevant information and explanations to colleagues and other professionals
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families
Convey effective oral and written information about a medical encounter
63
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








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
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


COLLABORATOR
Work as a part of a multidisciplinary team in the management and treatment of patients
Ensure that reports are generated in a timely and accurate fashion for optimal patient
management/treatment
Participate in relevant committees
Demonstrate the ability to advise on the appropriateness of obtaining samples for molecular
studies
Participate effectively and appropriately in an interprofessional healthcare team
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict
MANAGER
Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life
Allocate finite health care and health education resources effectively to optimize patient care
and life-long learning
Demonstrate knowledge of the methods of quality control in a molecular pathology lab
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems
Manage their practice and career effectively
Allocate finite healthcare resources appropriately
Serve in administration and leadership roles, as appropriate
HEALTH ADVOCATE
Recognize how technological advances in molecular biology may apply to improvement in
diagnostic pathology
Respond to individual patient health needs and issues as part of patient care
Respond to the health needs of the communities that they serve
Identify the determinants of health of the populations that they serve
Promote the health of individual patients, communities and populations
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports
SCHOLAR
Develop and implement a personal continuing educational strategy
Apply the principles of critical appraisal to sources of medical information
Contribute to the development of new knowledge through research
Participate in rounds, conferences and teaching sessions when applicableaintain and enhance
professional activities through ongoing learning
Critically evaluate information and its sources, and apply this appropriately to practice decisions
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices
PROFESSIONAL
Deliver the highest quality of care with integrity, honesty and compassion
Practice medicine in an ethical manner and with a sensitivity to diverse patient populations
Exhibit appropriate professional behavior and perform duties in a dependable and responsible
manner
Demonstrate commitment to excellence and ongoing professional development
64
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


Demonstrate commitment to excellence and ongoing professional development
Demonstrate a commitment to their patients, profession, and society through ethical practice
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation
Demonstrate a commitment to physician health and sustainable practice
Outline of Rotation:
The molecular diagnostics block will take place at the Section of Molecular Pathology, the University
of Alberta Hospital, over a 4-week period. An extended elective rotation with more in-depth training
will be available to those are interested.
The resident will learn the indications and principles of some of most widely used diagnostic
molecular tests including T-cell and B-cell gene rearrangement studies for the diagnosis of
lymphoproliferative disorders, detection of aberrant fusion genes in both solid and hematologic
malignancies, and mutational analysis of coagulation factors. The residents will be familiar with a
variety of different techniques in performing these studies, and understand their advantages and
limitations. The resident will review all the results generated daily from the laboratory. He/she will
obtain hand-on experience in performing some of the polymerase chain reaction (PCR) assays. The
resident also will learn the principles and techniques used to prevent contamination within a
diangostic molecular laboratory.
The Molecular Pathology Section has been receiving an average of 200 samples per month, and it is
expected that this number will grow by 20-40% over the next two years. The section is equipped with
some of most up-to-dated machines including a gene sequencer and a quantitative PCR
thermocycler. In addition to three full-time technologists, a full-time scientist in the Section will take up
teaching responsibility.
At the completion of training, the resident will have acquired the following competencies and will function
effectively in the following CanMEDS roles:
1. Understand the basic principles, advantages, and limitations of various molecular diagnostic
techniques commonly used in diagnostic molecular pathology laboratory
 Polymerase chain reaction (PCR)-based assay
 Southern blot hybridization
 In situ hybridization including FISH and CISH
2. Perform simple PCR assays and analyze data from gene sequencer and quantitative PCR
thermocycler
3. Be familiar with the common clinical applications of these techniques:
 Diagnosis (Establishment of clonality in lymphoid cells, sub-classification of Lymphoma and
leukemia, classification of soft tissue tumors, factor VLeiden, Human identity testing)
 Prognosis (i.e. quantitation of t(9;22))
4. Familiar with the biology of some of the clinically important oncogenes, tumor suppressor genes
and transcription factor genes
 lymphoma: c-myc, bcl-2, bcl-6, cyclin D1, retinoblastoma gene, p53
 Precursor B-cell acute leukemia: AML1, CBF, E2A, MLL
 Precursor T-cell acute leukemia: tal-1, p16, p15
 Acute myelogeneous leukemia: AML1, PML, MLL
 Chronic myelogeneous leukemia: c-abl
5. Quality control/assurance in molecular pathology
65
6. Participate in a short-term project that requires the use of some of the molecular techniques (e.g.
Western blots, molecular cloning, gene transfection, FISH, gene sequencing, and genotyping)
Educational Materials:
1)
2)
3)
4)
5)
Educational Materials (all of these books are available in Dr. Lai’s office)
Gene cloning and DNA analysis by T.A. Brown, Blackwell Publishing. 2002
PCR primer by C.W. Dieffenbach, CSHL press, 1995
Essentials of molecular biology by G.M. Malacinski, Jones and Bartlett publishers, 2003
Neoplastic hematopathology by D. Knowles, LW & W, 2002
PCR mutation detection protocols by B.Theophilus, humana press, 2002
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
66
ROTATION SPECIFIC OBJECTIVES FOR FORENSIC PATHOLOGY
General Pathology Residents
Selection:
Mandatory
Site:
Office of the Chief Medical Examiner, 7007 – 116 Street
Preceptors:
Chief and Assistant Chief Medical Examiner
Length of Rotation:
8 weeks
Prerequisites:
PGY 3
MEDICAL EXPERT
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To familiarize the resident with the role and operation of the Medical Examiner’s Office in sudden
death investigation.
To teach the resident similarities and differences between hospital and forensic autopsies,
including preparation of reports.
To familiarize the resident with autopsy findings in a variety of sudden natural and violent
deaths.
To teach the resident how to properly certify cause and manner of death including knowledge
of the working definitions for “cause of death”, “manner of death”, and “mechanism of death”.
To introduce the resident to the external examination as an investigative procedure in Forensic
Pathology.
To teach the resident proper techniques for collection and handling of toxicology specimens.
To teach the resident proper techniques for handling of evidence during the course of a
homicide autopsy.
To teach the resident the importance of photographic documentation of autopsy findings, with
particular reference to homicides.
To introduce the resident to the procedures used for the positive identification of human
remains, with particular reference to the use of consultants in fingerprintings, odontology,
radiology, and anthropology.
To teach the resident the value of scene investigation in Forensic Pathology.
To introduce the resident to courtroom proceedings and the presentation of evidence in court
by a Pathologist.
To ensure that the resident is adequately prepared for questions about Forensic Pathology on
Canadian or other pathology examinations.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR

Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
67




Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR


Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.




Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.





Respond to individual patient health needs and issues as part of patient care.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
MANAGER
HEALTH ADVOCATE
68
SCHOLAR




Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL




Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:














Tour the Medical Examiner’s facility, with the Chief or Assistant Chief Medical Examiner, and
receive an introductory explanation of the methods employed by the Office to investigate sudden
death.
View the film, “Investigating Sudden Death: A Team Approach”.
Read the Fatality Inquiries Act.
Perform a minimum of 20 autopsies, under the supervision of the Chief or Assistant Chief Medical
Examiner, and prepare autopsy reports in accordance with the format recommended by the
preceptor.
Observe a minimum of 15 external examinations, performed by the Chief or Assistant Chief
Medical Examiner, and participate in the proper collection of toxicology specimens.
Prepare a neuropathology report for all autopsies performed by the resident wherein the brain is
kept for detailed examination.
Read Petty CS: “Autopsy Records in Trauma Situations” in Curran WJ, McGarry AL and Petty CS
(editors). Modern Legal Medicine, Psychiatry, and Forensic Science. FA Davis Co.,
Philadelphia, 1980: pp. 479-488.
Read Spitz WU and Fisher RD (editors). Medicolegal Investigation of Death, Third Edition.
Charles C. Thomas, Springfield, 1993.
Attend all homicide scenes and homicide autopsies as an observer.
Take an active role in the positive identification of tentatively identified or unidentified cases
through the use of x-rays and dental records.
Spend at least 1 hour with the Chief Toxicologist discussing the role of and methods used for the
analysis and interpretation of postmortem toxicology pertaining to sudden death investigation.
Attend a minimum of 5 non-homicidal death scenes with a Medical Investigator.
Spend 1 hour with the Chief or Assistant Chief Medical Examiner learning the proper method of
completing a death certificate.
Attend, as a spectator, all court cases in which the Chief or Assistant Chief Medical Examiner is
giving expert testimony.
Evaluation:
1.
On-going day-to-day evaluation.
69
2.
Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
Sept 2008
70
THE FATALITY INQUIRIES ACT
REPORTING AND INVESTIGATION OF DEATHS
DEATHS THAT REQUIRE NOTIFICATION
10.
(1) Any person having knowledge or reason to believe that a person has died under any of the
circumstances referred to in subsection (2) or section 11, 12 or 13 shall immediately notify a
medical examiner or an investigator,
(2) Deaths that occur under any of the following circumstances require notification under
subsection (1):
(a) deaths that occur unexplainedly;
(b) deaths that occur unexpectedly when the deceased was in apparent good
health;
(c) deaths that occur as the result of violence, accident or suicide;
(d) maternal deaths that occur during or following pregnancy and that might
reasonably be related to pregnancy;
(e) deaths that may have occurred as the result of improper or negligent treatment
by any
person;
(f) deaths that occur
(i) during an operative procedure,
(ii) within 10 days of an operative procedure,
(iii) while under anesthesia, or
(iv) repealed 1991 c21 s9;
(v) any time after anesthesia and that may reasonably be attributed to that anesthesia;
(g) deaths that are the result of poisoning;
(h) deaths that occur while the deceased person was not under the care of a physician;
(i) deaths that occur while the deceased person was in the custody of a peace officer or as a
result of the use of force by a peace officer while on duty; (NOTE: The words "or as a
result of the use of force by a peace officer while on duty" in clause (i) were added by
SA 1999 c26 s9. The amending formula in that section did not specify where in the
clause the words were to be added.)
(j) deaths that are due to
(i) any disease or ill-health contracted or incurred by the deceased,
(ii) any injury sustained by the deceased, or
(iii) any toxic substance introduced into the deceased, as a direct result of the
deceased's employment or occupation or in the course of one or more of his
former employments or occupations.
INVESTIGATION OR AUTOPSY
21.
The Chief Medical Examiner may at any time
(a) direct a medical examiner to make an investigation into any death at any place in Alberta,
or
(b) authorize an autopsy of the body of any person who died under the circumstances
described in section 10, 11, 12 or 13.
CONDUCT OF AUTOPSY
26.
(1) A medical examiner may authorize the autopsy of the body of any person who died under
the circumstances described in section 10, 11, 12 or 13.
71
(2) Where a medical examiner authorizes an autopsy
(a) the autopsy shall only be carried out by a pathologist;
(b) the person who performs the autopsy may excise, remove and retain any part of the body
or any object found in the body for the purpose of establishing the cause of death and the
manner of death.
REMOVAL OF TISSUE
27.
Notwithstanding section 26(2)(b), a medical examiner may remove or allow the removal of
tissue in accordance with the Human Tissue Gift Act, if the removal of the tissue does not
interfere with any investigation or proceeding under any law in force in Alberta.
RELEASE OF INFORMATION
31.
(1) Except for reports, certificates and other records made in the course of a public fatality
inquiry, all reports, certificates and other records made by any person under this Act are the
property of the Government and shall not be released without the permission of the Chief
Medical Examiner.
(2) On the completion of
(a) the investigation, and
(b) the public fatality inquiry, if one is held,
and on the receipt of a request from any of the adult next of kin or the personal representative of the
deceased, the Chief Medical Examiner shall complete and send a report to the person making the
request.
WITNESSES
38.
(1) A judge who holds an inquiry under this Act has all the powers of
a commissioner appointed under the Public Inquiries Act.
(2) The judge may issue or direct a clerk to issue a summons to any person who in the opinion
of the judge may be able to give evidence that relates to the death under investigation.
(3) Persons called as witnesses shall be examined on oath.
(4) A judge has the same powers
(a) to compel the attendance of witnesses, and
(b) to punish a witness for
(i) disobeying a summons to appear,
(ii) refusing to be sworn, or
(iii) refusing to give evidence,
as are conferred upon a provincial judge by the Criminal Code (Canada).
72
EVIDENCE AT PUBLIC FATALITY INQUIRY
40.
(1) Subject to subsection (2), a judge may admit in evidence at a public fatality inquiry,
whether or not it is admissible as evidence in a judicial proceeding,
(a) any oral testimony, or
(b) any document or other thing,
that is relevant to the purposes of the public fatality inquiry but shall refuse to admit in evidence
all or part of any oral testimony or any document or other thing if he is satisfied that the oral
testimony, document or other thing or part of it is vexatious, unimportant or unnecessary for
the purposes of the public fatality inquiry.
(1.1) Notwithstanding any other Act, regulation or other law, a judge may admit in evidence all
or any relevant part of a diagnosis, record or information referred to in section 22(3) to enable
him to make findings and recommendations and to report in respect of any or all of the matters
set out in section 47.
(2) Nothing is admissible in evidence at a public fatality inquiry that would be inadmissible in a
judicial proceeding by reason of any privilege under the law of evidence.
(3) If the judge is satisfied as to its authenticity, a copy of a document or other thing may be
admitted in evidence at a public fatality inquiry.
(4) When a document has been admitted in evidence at a public fatality inquiry, the judge
may, or the person producing it or entitled to it may, with the leave of the judge, cause the
document to be photocopied and the judge may
(a) authorize the photocopy to be admitted in evidence in the place of the document admitted
and release the document admitted, or
(b) furnish to the person producing it or the person entitled to it a photocopy of the document
admitted that has been certified by the judge.
73
ROTATION SPECIFIC OBJECTIVES
GENERAL PATHOLOGY REVIEW
Selection: Mandatory
Site: - DynaLIFE DX Diagnostic Laboratory Services, Core Lab
- Royal Alexandra Hospital
- Misericordia Hospital
- Grey Nuns Hospital
Preceptor: Dr. C. O’hara/Dr. S. Brown supported by divisional directors at DynaLIFE and
site leaders at the hospitals.
Length of Rotation: 16 - 24 weeks.
Prerequisites: Completion of PGY4 year.
Specific Objectives:
MEDICAL EXPERT








Integrate the knowledge and training into becoming a practicing pathologist with appropriate
supervision.
Utilize relevant literature/resources on a case-by-case basis.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR







Effectively express ideas and opinions regarding the principles of pathology practice.
Present current/relevant pathologic principles in a rounds format.
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR





Share difficult/challenging cases with medical staff.
Possibly participate in small research projects.
Appropriately delegate when necessary.
Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
74
MANAGER






Demonstrate knowledge of and practice quality assurance principles.
Demonstrate effective time management skills.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE






Communicate effectively with clinicians regarding appropriate use of laboratory tests and
resources.
Advocate on behalf of individual patients by ensuring appropriate and essential laboratory tests
are performedRespond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR






Identify strengths and weaknesses, with focus on preparation for Royal College examinations.
Participate in departmental rounds.
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL







Foster good working relationships with medical, technical and support staff.
Produce timely and accurate reports.
Demonstrate awareness of personal limitations and address areas of weakness.
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
The resident is expected to:
 Review the content of the different disciplines.
 Identify and correct weaknesses.
 Function as a "practicing" pathologist with appropriate supervision.
 Participate in informal quizzing and more formal practice examinations at any site.
 Establish with the preceptor rotations in the following disciplines with approximate times:
75
- Anatomic pathology, especially cytopathology, surgical pathology and
sections - four weeks.
- Hematopathology - four weeks.
- Clinical chemistry - four weeks.
- Medical Microbiology - four weeks.
- Electives and attendance at Royal College examination - eight weeks.
frozen
Educational Materials:





Daily case material
Library resources - PIP, Check Path
Standard textbooks
Internet resources
Interesting case files
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
76
ROTATION SPECIFIC OBJECTIVES
GYNECOLOGICAL PATHOLOGY
Selection:
Mandatory
Site:
Royal Alexandra Hospital
Preceptor:
RAH Staff
Length of Rotation:
Six weeks
Prerequisites:
PGY3
Specific Objectives:
MEDICAL EXPERT
 Develop basic competence at examination of cervical and biopsy material.
 Review selected cases of routine gynecologic pathology.
 Achieve diagnostic competence in oncologic gynecological pathology.
 Achieve diagnostic competence in perinatal pathology, including:
a) the ability to perform a perinatal autopsy,
b) an understanding of placental pathology
 function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical and
patient-centered medical care
 establish and maintain clinical knowledge, skills and attitudes appropriate to their practice
 demonstrate proficient and appropriate use of procedural skills, both diagnostic and therapeutic
 seek appropriate consultation from other health professionals, recognizing the limits of their expertise
COMMUNICATOR
 Formulate written reports based upon macroscopic and microscopic observations for perinatal autopsies
and gynecological specimens with suitable clinicopathological correlations
 Assist in the continuing education of physicians and other members of the hospital staff by participating in
conferences and case presentations
 Act as consultant to clinical colleagues on the interpretation and relevance of pathological findings, with
particular regard to their significance in the management of the patient
 develop rapport, trust and professional relationships with other physicians and allied health care workers
and patients and families (as needed)
 accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues
and other professionals
 accurately convey relevant information and explanations to colleagues and other professionals
 develop a common understanding on issues, problems and plans colleagues and other professionals to
develop a shared plan of care in the best interests of patients and families
 convey effective oral and written information about a medical encounter
COLLABORATOR
 To demonstrate the ability to advise on the appropriateness of obtaining histological, cytological and
autopsy specimens and to advise on further appropriate investigations including infection control and
safety
 participate effectively and appropriately in an interprofessional healthcare team
 effectively work with other health professionals to prevent, negotiate, and resolve interprofessional conflict
MANAGER
 Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life
 Allocate finite health care and health education resources effectively to optimize patient care and lifelong learning
 participate in activities that contribute to the effectiveness of their healthcare organizations and systems
 manage their practice and career effectively
77


allocate finite healthcare resources appropriately
serve in administration and leadership roles, as appropriate
HEALTH ADVOCATE
 Identify the important determinants of health affecting patients pertaining to gynecological processes
 As a member of an interdisciplinary team of professionals responsible for patient health, the resident
will assist in regularly evaluating laboratory practices and test selections to determine that they meet
community needs
 Recognize and reinforce to the public and to the medical profession the essential contribution of
laboratory medicine to health
 respond to individual patient health needs and issues as part of patient care
 respond to the health needs of the communities that they serve
 identify the determinants of health of the populations that they serve
 promote the health of individual patients, communities and populations
 acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports
SCHOLAR
 Develop and implement a personal continuing educational strategy
 Apply the principles of critical appraisal to sources of medical information
 Contribute to the development of new knowledge through research
 Participate in rounds, conferences and teaching sessions
 maintain and enhance professional activities through ongoing learning
 critically evaluate information and its sources, and apply this appropriately to practice decisions
 facilitate the learning of patients, families, students, residents, other health professionals, the public, and
others, as appropriate
 contribute to the creation, dissemination, application, and translation of new medical knowledge and
practices
PROFESSIONAL
 Deliver the highest quality of care with integrity, honesty and compassion
 Practice medicine in an ethnical manner and with a sensitivity to diverse patient and co-worker
populations
 Exhibit appropriate professional behavior and perform duties in a dependable and responsible manner
 Demonstrate commitment to excellence and ongoing professional development
 demonstrate commitment to excellence and ongoing professional development
 demonstrate a commitment to their patients, profession, and society through ethical practice
 demonstrate a commitment to their patients, profession, and society through participation in professionled regulation
 demonstrate a commitment to physician health and sustainable practice
Outline of Rotation:






Cervical pathology, colposcopic biopsies, LLETZ and Cones will be available at the Royal Alexandra
Hospital.
A moderate amount of routine gynecologic pathology originating at the RAH will be assigned to the
resident on a daily basis.
A minimum of three complex gynecologic oncology cases will be assigned per week to the resident for
grossing and microscopic reporting.
The resident will participate in intraoperative consultations, both gynecologic and non-gynecologic, with
follow-through including grossing and microscopic reporting, as arranged with the responsible pathologist,
three mornings per week.
The rotation should allow residents to attend 1 - 2 perinatal autopsies a week with Dr. N. Lilic.
Examination of placentas in the surgical pathology division will be done on a regular basis.
78

Gynecologic consultation cases received at the Royal Alexandra Hospital will be reviewed by the resident
as time permits.
Educational Materials:
Suggested reading –
Blaustein’s Pathology of the Female Genital Tract ed. 5 (R.J. Kurman), Springer-Verlag, 2002.
or, Pathology of the Female reproductive Tract ed 4 (S. Robboy), Churchill Livingstone, 2001.
or, Haines and Taylor Obstetrical and Gynaecological Pathology ed. 5 (H. Fox), WB Saunders, 2002.
Diagnosis of Endometrial Biopsies and Curettings: A Practical Approach ed. 2 (Robinson), Springer-Verlag,
2001.
Color Atlas of Gross Placental Pathology (Cynthia Kaplan), Igaku-Shoin, 1994.
The Malformed Fetus and Stillbirth: A Diagnostic Approach (R.M. Winter), John Wiley & Sons, 1988.
Conferences –
Multidisciplinary Gynecologic Oncology Rounds at the Cross Cancer Institute.
Clinical Material –
Active current cases and review of archival material.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
February 2007
79
ROTATION SPECIFIC OBJECTIVES IN HEMATOLOGICAL PATHOLOGY
Selection:
Site
Preceptor:
Length of Rotation:
Mandatory.
1. University of Alberta Hospital.
2. Canadian Blood Services
Dr. Gwen Clarke.
Hematopathology 1A – twelve weeks.
Hematopathology 1B – twelve weeks.
Specific Objectives:
MEDICAL EXPERT













Have knowledge of peripheral blood and bone marrow morphology in health and in diseased
states.
Have knowledge of the basic principles underlying general hematology laboratory tests.
Have knowledge of the physiology of blood clotting, the pathology of hemostatic and
thrombotic disorders, and the principles of laboratory tests for the diagnosis of these disorders.
Have knowledge of the techniques in blood cross matching and antibody investigation, the
risks and complications associated with transfusion, the indications of blood component
therapy, preparation of blood products, blood donor management and testing, and alternatives
to blood products.
Have an awareness of the regulations and standards that govern the field of transfusion
medicine in Canada.
Understand the basic principles and techniques of conventional cytogenetic analysis in
hematological disorders.
Function as a consultant to colleagues in appropriate laboratory test utilization and
interpretation.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR







Communicate effectively with medical colleagues, nursing and technical staff verbally and in
written reports about all aspects of laboratory hematology and transfusion medicine.
Communicate effectively with patients.
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
80
COLLABORATOR




Work as part of a multidisciplinary team in the management and treatment of patients.
Ensure that reports are generated in a timely fashion for optimal patient
management/treatment.
Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
MANAGER








Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life.
Allocate finite health care and health education resources effectively.
Have in-depth knowledge of quality assurance and improvement.
Understand the value of utilization reviews, transfusion audits, and continual monitoring of
laboratory functioning to improve practice.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE







Recognize how technologic advances may apply to improvement in hematologic diagnosis,
and advocate to introduce those technologies locally.
Recognize alternatives to transfusion that may be appropriate recommendations to clinical
colleagues and patients.
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR








Develop and implement a personal continuing educational strategy.
Apply the principles of critical appraisal to sources of medical information.
Facilitate the learning of patients, students, residents and other health care professionals.
Contribute to the development of new knowledge through research.
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL

Deliver the highest quality of care with integrity, honesty and compassion.
81







Practice medicine in an ethical manner.
Exhibit appropriate professional behavior.
Be cognizant of one’s limitations of professional competence.
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:



Review general objectives with preceptor at beginning of Hematopathology 1A and 1B.
At the beginning of each training period, the trainee will be provided with a list of his/her
rotations for that twelve week period and of the specific objectives to be achieved.
For a more detailed description of the outline, refer to the on-line Residents’ Training Manual at
http://www.lmp.ualberta.ca/Education/Postgraduate/Anatomical_General/GP%20Manual.doc
Evaluation:
 Written, oral and practical examination will be conducted every 6 months as part of the GP
semi-annual assessment of resident performance. A mark of 70% will be considered a pass
mark on this examination.
 Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
Jan 2007
82
GENERAL OBJECTIVES
HEMATOLOGICAL PATHOLOGY
Introduction
General Pathology residents are required to undertake twenty four weeks training in Hematological
Pathology. This is divided into two twelve week blocks, the first of which generally occurs in the PGY-2
or PGY-3 year and the second in the PGY-4 or early in the PGY-5 year.
Objectives are provided below for each rotation in the two blocks. These objectives are meant to serve
as guidelines so that the resident is aware of the topics/assays/procedures that should be covered in
each rotation. Some of them are written in a format that also allows them to be used as a checklist as a
further aid to ensure that all areas are covered. The assigned preceptor for each block has the
responsibility to facilitate the resident’s learning and to make sure that the resident’s knowledge is
adequate by the end of the rotation. The preceptor’s signature is required at the end of each block to
indicate that the curriculum for that rotation has been covered and that the resident has demonstrated
the expected level of knowledge/competency.
HEMATOPATHOLOGY 1A
FIRST TWELVE WEEK BLOCK
The first training block starts off with a fairly intensive course in Blood Banking and Transfusion
Medicine, followed by a rotation through the main areas of the hematological laboratory, during which
they learn basic hematological techniques and peripheral blood and bone marrow interpretation.
During this rotation, the resident is also taught to perform bone marrow aspiration and biopsy. Later in
the block the resident rotates through areas for specialized testing, including the special coagulation
bench.
BLOOD BANK AND TRANSFUSION MEDICINE
The blood bank and transfusion medicine block will take place at the UAH blood transfusion
laboratory over a four to six week period at the start of the residency program. The resident will gain
proficiency in pretransfusion testing and will become familiar with blood components and blood
component therapy, transfusion-related complications and quality assurance. Ongoing blood bank
training will occur throughout the remainder of the rotation in that the resident will be the first in line to
deal with blood bank problems on a daily basis (with senior staff back-up when required).
83
Methods and Procedures
For each of the following methods/procedures the resident will demonstrate knowledge of the:
a)
principle
b)
test requirements including special precautions/handling
c)
limitations, false positives and false negatives
d)
interpretation
e)
quality control
f)
common alternative methods
Methods/procedures:-
Red cell typing
Antibody screening
Compatibility testing
Pre warm technique
Saline replacement
Direct antiglobulin test
Antibody investigation
Elution
Autoadsorption
Donath Landsteiner test
Drug-induced antibodies
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Blood Product/Components
For each of the listed blood products or components the resident will demonstrate knowledge of:
a)
method of preparation
b)
indications for transfusion
c)
pretransfusion testing requirements
d)
volume and dosage
e)
potential complications
f)
storage requirements
g)
administration requirements
h)
special product manipulations (where applicable)
i)
leukodepletion
ii)
irradiation
iii)
freezing and deglycerolization
iv)
warming
v)
pooling
vi)
aliquoting
vii)
further concentrating
viii)
washing
84
Blood Products/components:
1.
2.
3.
4.
5.
6.
7.
i)
ii)
iii)
8.
Red blood cells
Platelets
Granulocytes
Plasma
Cryoprecipitate
IVIG
Other immunoglobulin fractions
HBIg
CMV Ig
RhIg
Coagulation factor concentrates
including
i) Factor VIII
ii) Factor IX
iii) Other concentrates
9. Albumin
10. Plasma anticoagulant
concentrates
i)
Antithrombin III
ii) Protein C
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Transfusion Practice
The resident will demonstrate knowledge in the following areas of transfusion practice:
I Transfusion alternatives
For each of the listed alternatives the resident will demonstrate knowledge of the:
a)
indications
b)
preparation (including special manipulations)
c)
administration
d)
dose
e)
limitations
f)
contraindications
g)
potential complications
h)
efficacy/benefit
i)
relative cost
85
Transfusion alternatives:
1) pre operative autologous
blood collection
2) perioperative hemodilution
3) perioperative cell salvage
4) pharmacologic agents
i) DDAVP
ii) antifibrinolytic agents
iii) erythropoietin
5. pentaspan
6. hemoglobin solutions
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II Perinatal complications
For each of the listed perinatal complications the resident will demonstrate knowledge of:
a)
presentation
b)
pathophysiology
c)
laboratory monitoring
d)
therapeutic interventions
e)
special product manipulations
f)
prevention
Perinatal Complications:
1) Hemolytic Disease of the Newborn
2) Neonatal Alloimmune thrombocytopenia
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III Neonatal and Pediatric Transfusion Practice
For each of the following aspects of pediatric transfusion practice the resident will demonstrate
knowledge of the applicable:
a) blood products
b) special precautions/product manipulations
c) laboratory testing requirements
Neonatal/pediatric transfusion issues:
(a)
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1) CMV infection
2) Neonatal (< 4 months) transfusion
3) Exchange transfusion
86
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IV Transfusion Complications
For each of the following transfusion complications the resident will demonstrate knowledge of:
a)
incidence
b)
etiology
c)
diagnosis
d)
pathophysiology
e)
signs and symptoms
f)
time of onset (relative to transfusion)
g)
therapy
h)
prevention
Transfusion Complications:
1) acute hemolytic transfusion
reaction
2) delayed hemolytic transfusion
reaction
3) febrile non hemolytic transfusion
reaction
4) allergic transfusion reaction
5) anaphylactic transfusion
reaction
6) transfusion related acute lung
injury
7) transfusion-transmitted infection
i) bacterial
ii) HIV
iii) HBV
iv) HCV
v) HTLV
vi) CMV
vii) CJD
viii)Other infectious agents
potentially transmitted by blood
transfusion
8) Graft versus host disease
9) Post-transfusion purpura
10) Transfusion-related
immunosuppression
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87
V
Special Transfusion Situations
For each of the following special transfusion situations the resident will demonstrate knowledge of:
a)
blood products
b)
blood product dose
c)
special precautions
Special transfusion situations:
1)
2)
3)
4)
massive transfusion
bone marrow transplantation
solid organ transplantation
chronic transfusion therapy
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Dr.
has demonstrated knowledge of the above topics.
Preceptor for Blood Bank and Transfusion Medicine rotation:
____________________________________
Signature
________________________
Date
88
GENERAL LABORATORY HEMATOLOGY
This block occurs early in the resident’s training, usually immediately following the Blood Bank and
Transfusion Medicine rotation, and takes place at the University of Alberta Hospital laboratory. At the
start of the rotation the resident is introduced to morphology and common hematological
techniques/equipment. During this rotation, the resident will learn about hematological disorders,
relevant morphological abnormalities and tests (routine and special) which may be required for their
diagnosis. The basic science topics related to these areas will be addressed. The general principles of
quality control and quality assurance will be taught, as well as quality control issues specific to each
assay.
A. General Hematology
The following objectives in this section deal specifically with assays in hematological practice.
Morphology and the diseases that these tests relate to are covered in subsection B entitled
“Morphology”.
At the end of this rotation, for each of the following assays/procedures, the Hematological Pathology
resident will understand:(a) The principle of the assay
(b) Indications for the assay
(c) Test requirements, including special precautions/specimen handling
(d) Interpretation of results
(e) Limitations of the assay (including interferences, false positives and false negatives)
(f) Quality control
(g) Common alternative methods of performing the assay/procedure
Automated complete blood count:1. Hemoglobin
2. Red cell indices
(RBC, MCV, MCH, MCHC)
3. Automated white cell count
4. Automated white cell differential
5. Automated platelet count
6. Fluid cell counts/differentials
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Special Tests:1. Manual white cell count
2. Manual white cell differential
3. Manual platelet count
4. Automated reticulocyte count
5. Manual reticulocyte count
6. Fluid cell counts/differentials
7. Erythrocyte sedimentation rate
8. CSF cytospins
9. Cytochemical stains
10. Erythrocyte osmotic fragility
11. Sucrose hemolysis
12. Ham test
13. G-6-PD screen
14. G-6-PD assay
15. Pyruvate kinase assay
16. Fetal cell stain
17. Hemoglobin H stain
18. Unstable hemoglobin (heat stability)
19. Unstable hemoglobin (isopropanol)
20. Hemoglobin S solubility
21. Heinz body stain
22. Plasma/whole blood viscosity
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Additional topics to be addressed in this rotation include:

bone marrow aspiration and biopsy - techniques, indications, risks and potential
complications. The resident will be taught to perform the procedure at the start of this
rotation.

principles of operation of automated cell counters, standardization and quality control
materials

Romanowsky and other stains used in hematology

slide making and slide stainers

counting chambers for manual cell counts

safety issues that relate to working in a hematology laboratory. These include:(a)
The resident will be taught basic concepts of laboratory safety, including the use of gloves,
masks, eye protection, protective garments, waste disposal, aerosol containment and use of
biological safety cabinets
(b)
The need for universal precautions when handling blood, body fluidsand tissue will be
emphasized.
(c)
The trainee will be taught how to clean up spills of blood and body fluids.
90
(d)
Specific safety rules are available for specific areas/equipment. The resident is required to refer
to the laboratory safety manual at the start of his/her rotation to take specific note of any
specific guidelines for the hematology area. (As hematology is not the first rotation for the
General Pathology resident, it is assumed that he/she has already been shown the laboratory
safety manual and is aware of general safety guidelines. Similarly, it is assumed that the
General Pathology resident is by this stage familiar with the principles of workplace hazardous
material information systems (WHMIS) regulations, material safety data sheets (MSDS), fire
safety, electrical safety, disposal of hazardous materials, the terms of reference of a laboratory
safety committee, and accident reporting to Occupational Health and Safety and to Workers
Compensation Board.)
Dr. _______________________________ has demonstrated knowledge of the above topics.
Preceptor for General Hematology rotation:
Signature
Date
91
B. Morphology (Peripheral Blood and Bone Marrow)
The interpretation of peripheral blood smears and bone marrow aspiration/biopsy specimens is taught
at an early stage of the residency, immediately after the resident’s basic training in transfusion
medicine. During the rotation through the UAH laboratory, the trainee will be expected to participate in
signing-out cases daily. The learning involves making accurate observations, interpretation of findings
in a logical manner, and preparing concise and valid reports in a timely fashion. In addition to
morphology recognition, the resident will learn the pathogenic mechanisms of each disorder,
presentation, diagnosis, management and prognosis.
At the end of the rotation, the trainee will have gained considerable experience and will be able to
recognize the following:
(A) the morphologic features of normal constituents in peripheral blood and bone marrow aspirates,
as well as the histologic features of normal bone marrow trephine biopsy.
(B) the key morphologic features of the following disease processes:
I.
1.
2.
3.
4.
5.
6.
1.
2.
3.
4.
5.
6.
7.
Processes involving red cells
iron deficiency
anemia of chronic disease
anemias seen in alcoholism, chronic renal failure, endocrine disorders
aplastic anemia and pure red cell aplasia
thalassemia
structural hemoglobin abnormalities:
 HbS
 HbC
 HbE
 others
hereditary membranopathies:
 spherocytosis
 elliptocytosis
 stomatocytosis
enzyme deficiencies: G6PD, pyruvate kinase
megaloblastic anemias
hemolytic anemias
 microangiopathic
 immune-mediated
 burns
 clostridium perfringes sepsis
 malaria
hyposplenism/asplenism
sideroblastic anemia / myelodysplastic syndromes
congenital dyserythropoietic anemias
92
II.
Processes involving white cells
1. reactive lymphocytosis
2. benign lymphoid aggregates and reactive plasmacytosis in bone marrow
3. hematogone-like cells in bone marrow
4. acute lymphoblastic leukemia
5. chronic lymphocytic leukemia
6. prolymphocytic leukemia
7. hairy cell leukemia
8. splenic lymphoma with villous lymphocytes
9. Hodgkin’s lymphoma
10. non-Hodgkin’s lymphoma
 low grade lymphomas
 intermediate grade lymphomas
 high grade lymphomas
11. peripheralization of lymphomas
12. large granular lymphocytosis and leukemia
13. sezary syndrome
14. adult T-cell leukemia
15. plasma cell dyscrasias including multiple myeloma, plasma cell leukemia, MGUS, amyloidosis
16. cryoglobinemia
17. toxic changes in neutrophilic granulocytes
18. myelodysplastic syndromes
 refractory anemia
 refractory anemia with ringed sideroblasts
 refractory anemia with excess blasts
 refractory anemia with excess blasts in transformation
 chronic myelomoncytic leukemia
 myelodysplastic syndromes in children
19. acute myelogeneous leukemia
 M0
 M1
 M2
 M3
 M4
 M5
 M6
 M7
20. chronic myeloproliferative disorders
 chronic myelogeneous leukemia
 idiopathic myelofibrosis
 essential thrombocythemia
 polycythemia rubra vera
21. hereditary storage disorders:
 Gaucher disease
 Niemann-Pick
22. qualitative neutrophil disorders
 Chediak Higashi syndrome
 Pelger-Huet anomalies
23. mast cell disease
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24. bone marrow involvement by histiocytosis X
25. hypereosinophilic syndrome
III.
Processes primarily involving platelets
1. increased peripheral platelet consumption
 idiopathic thrombocytopenia purpura
2. decreased platelet production
 megakaryocytic aplasia/hypoplasia
IV.
Miscellaneous
1. leukoerythroblastic anemia
2. hemophagocytic syndrome
3. granuloma
4. parasitic infestation of peripheral blood and bone marrow
5. metastatic malignancies
 carcinoma
 melanoma
 neuroblastoma
 small blue cell tumors in childhood
6. HIV infection and its hematologic complications
7. Know the role of special techniques in establishing diagnosis
 cytochemistry (myeloperoxidase, TRAP, sudan black, NSE, PAS)
 amyloid stain, reticulin stain, collagen stain
 commonly used immunohistochemical markers for trephine biopsy
 flow cytometry
 electron microscopy
Dr.
Preceptor for this rotation:
Signature
has demonstrated knowledge in the above topics.
Date
94
C. Coagulation
The resident rotates through both the routine and the special coagulation areas. During the early part of
the rotation, emphasis is placed on learning the fundamentals of coagulation, understanding the
disease processes that give rise to abnormal hemostasis and the screening tests for their detection.
More specialized coagulation assays and indications for their utilization are covered in the latter part of
the rotation, as well as in the second hematology block.
Topics/disorders/disease processes to be covered in this section include:1. Basic concepts of hemostasis and thrombosis, including
 Role of vessel wall, platelets and humoral coagulation factors
 Pathways of coagulation
 Natural inhibitors of coagulation
 Platelet function
 Role of fibrinolytic system
3. Pathophysiology and classification of thrombocytopenic disorders
4. Diagnostic approach to bleeding disorders
5. Hereditary coagulation disorders, including treatment and complications
6. Acquired bleeding disorders, including liver disease, disseminated intravascular coagulation,
renal failure, and primary fibrinolysis
7. Circulating anticoagulants, including acquired Factor VIII inhibitors in non-hemophilic patients,
lupus anticoagulants and antiphospholipid antibodies
8. Congenital and acquired disorders of platelet function
9. Bleeding caused by vascular abnormalities
10. Basic principles of coagulation assays and instrumentation
11. Quality control
12. Point-of-care coagulation testing
At the end of his/her coagulation training, for each of the following assays, the resident will understand:(a) The principle of the assay
(b) Indications for the assay
(c) Test requirements, including special precautions/specimen handling
(d) Interpretation of results
(e) Limitations of the assay (including interferences, false positives and false negatives)
(f) Quality control
(g) Common alternative methods of performing the assay
95
Assays:1. Partial thromboplastin time
2. Prothrombin time
3. Fibrinogen
4. D-Dimer (plasma)
5. D-Dimer (whole blood)
6. Thrombin time
7. Bleeding time
8. Factor XIII screen
9. Euglobulin lysis time
10. PTT inhibitor screen
11. PT inhibitor screen
12. PTT-based factor assays
13. PT-based factor assays
14. von Willebrand factor antigen
15. Ristocetin cofactor assay
16. Factor VIII inhibitor titre
17. Reptilase time
18. Platelet aggregation studies
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(f)
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(g)
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Dr.
has demonstrated knowledge of the above topics.
Preceptor for Coagulation rotation:
Signature
Date
96
D. Quality Control and Proficiency Testing
Quality control (QC) issues specific to each assay are taught at the bench, but in addition, the general
principles of quality control and quality assurance are addressed during this rotation. These include:1. Basic QC principles and tools, eg. Westgard rules
2. Basic principles of quality assurance and quality improvement, including quality requirements and
indicators
3. Mandate and operation of a quality council
4. Specific QC measures pertaining to each assay and piece of equipment
5. Interlaboratory benchmarking
6. Proficiency testing programs
7. Hospital and laboratory accreditation process
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HEMATOPATHOLOGY 1B
SECOND TWELVE WEEK BLOCK
At the start of the second hematology block, the General Pathology resident is provided with a short
refresher course through Blood Bank and the main hematology lab areas. This is required as there is
usually a two-year gap between the two rotations. It also allows the resident the opportunity to go over
any areas that may not have been adequately covered during the first rotation.
Following the refresher course, the resident rotates through more sophisticated areas of hematology
testing, such as flow cytometry, and also undertakes short rotations through the Canadian Blood
Services, and the cytogenetics and HLA typing laboratories.
During this second hematology block, emphasis is placed on the resident assuming greater
responsibility in the laboratory, especially in handling consultations from technical staff and clinicians and
in peripheral blood smear and bone marrow reporting.
A. Blood Bank and Transfusion Medicine
The resident undertakes a two-week refresher course in the Blood Bank, and ensures that the objectives
listed for this area in the first rotation are covered.
B. General Laboratory Hematology
A short refresher course is provided to allow the resident to re-familiarize himself/herself in the main
areas of laboratory hematology. The resident is asked to refer to the objectives listed in the first rotation
for this area (including Morphology) to ensure that all topics have been covered.
In addition, the following topics will be addressed:1. The principles of flow cytometry, and quality control measures in flow
cytometry.
2. Applications of flow cytometry in:(a)
subtyping of acute leukemias
(b)
T-lymphocyte subset enumeration
(c)
Detection of antiphospholipid antibodies
C. Coagulation
Coagulation topics not covered in the first hematology block are taught in this rotation. The subject
material to be covered includes:1.
2.
3.
4.
Hereditary hypercoagulable states, their diagnosis and management
Acquired hypercoagulable states
Diagnosis of thromboembolism and management
Anticoagulant therapy, including prophylactic therapy, treatment of established thrombosis,
monitoring of heparin and oral anticoagulant therapy, newer antithrombotic drugs, complications of
anticoagulant therapy
5. Antiplatelet drugs
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6. Thrombolytic therapy
At the end of his/her coagulation training, for each of the following assays, the resident will understand:(a) The principle of the assay
(b) Indications for the assay
(c) Test requirements, including special precautions/specimen handling
(d) Interpretation of results
(e) Limitations of the assay (including interferences, false positives and false negatives)
(f) Quality control
(g) Common alternative methods of performing the assay
Assays:1. Lupus anticoagulant detection
2. Dilute Russel’s Viper Venom
time
3. Antiphospholipid antibodies
4. Antithrombin III assay
5.
6.
7.
8.
Protein C assay
Protein S assay
APC resistance (clot-based)
APC resistance (Factor V
Leiden)
9. Plasminogen assay
10. Heparin-induced
thrombocytopenia assay
11. Unfractionated heparin assay
12. Low mol. wt. heparin assay
Dr.
(a)
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(b)
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(c)
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(d)


(e)
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(f)
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(g)
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has demonstrated knowledge of the above topics.
Preceptor for this rotation:-
Signature
Date
99
D. CANADIAN BLOOD SERVICES
This short rotation through the Edmonton branch of the Canadian Blood Services familiarizes the
resident with the organization of a blood transfusion service and its functions and responsibilities in the
procurement, preparation and distribution of blood products.
At the end of this rotation, the resident will:1. Understand the structure of the Canadian Blood Services organization, its functions and
responsibilities and its relationship to health care facilities.
2. Be familiar with the management of blood donation, including
(a) donor recruitment
(b) donor acceptability criteria
(c) confidential self-exclusion
(d) collection of blood
(e) potential complications of donation
(f) mobile collection facilities
3. Understand the processing and testing of donated blood:(a) Automated methods for ABO and Rh testing and for detection of unexpected alloantibodies
(b) Testing for transfusion-transmitted viruses (including hepatitis viruses, human immunodeficiency
virus 1 and 2, HTLV-I and HTLV-II, and cytomegalovirus in selected units), and syphilis. The
resident will also be familiar with confirmatory tests for positive cases.
4. Understand the methods used for preparation of blood components
 red cell concentrates
 plasma - fresh frozen plasma
 stored plasma
 apheresis plasma
 cryosupernatant plasma
 cryoprecipitate
 platelets (including prestorage leukodepletion)
 granulocytes
5. Understand the principles of apheresis donations
 types of apheresis machines and their principles of action
 applications in obtaining apheresis plasma, single donor platelets, harvesting stem cells and
granulocytes
 care of donor, including monitoring of frequency of donation and laboratory monitoring
 potential complications of apheresis donation
6. Know the special requirements for transportation of blood and blood components, including different
storage temperature requirements for different products.
7. Understand antenatal testing
 mechanism of maternal immunization
 serological testing of pregnant women, including antibody titres
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8. Be aware of special manipulations required for certain products and their indications, such as
irradiation of blood products, washing of red cells.
9. Understand relevant quality assurance and administration issues, eg.
 quality control procedures for maintaining standards in blood components
 quality control measures in testing for markers of infectious agents
 blood inventory management
 donor counseling
Dr.
has demonstrated knowledge in the above topics.
Preceptor for this rotation:
Signature
Date
101
Hematopathology Rotation Teaching Schedule
1st rotation:
4 weeks of blood bank (2 weeks - full time; 2 weeks - half time)
2 weeks core lab
3 weeks special coagulation lab
1 week Canadian Blood Services
1 week HLA/flow cytometry
1 week vacation
+ longitudinal: bone marrow and peripheral blood smear morphology and special hematology
2nd rotation:
2 weeks blood bank (refresher)
2 weeks core lab
2 weeks special coagulation lab
1 week cytogenetics
1/2 week FANA's
2 weeks Royal Alexandra Hospital Laboratory
1 week vacation
1 week miscellaneous (whatever is resident's interest)
+ longitudinal: bone marrow and peripheral blood smear morphology and special hematology
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E. CYTOGENETICS
A two- week rotation in conventional cytogenetics will expose the resident to the basic concepts and
techniques of conventional cytogenetics and its application to hematological disorders.
At the end of this rotation, the resident will:1.
Understand the basic principles and limitations of conventional cytogenetic studies.
2.
Understand basic techniques of cytogenetic analysis.
3.
Be familiar with common cytogenetic terminology.
4.
Know the common cytogenetic abnormalities encountered in hematological malignancies,
including those seen in acute leukemias (pediatric and adult), chronic myelogeneous leukemia
and other myeloproliferative disorders, myelodysoplastic syndromes (de novo and therapyrelated cases), follicular lymphoma, chronic lymphocytic leukemia/small lymphocytic
lymphoma, mantle cell lymphoma, diffuse large cell lymphoma.
5.
Be familiar with the specific chromosomal changes that are helpful for diagnosis of certain
hematological disorders (eg. t(9;22) in chronic myelogenous leukemia) or for subtyping acute
leukemias (eg. t(15;17) in acute promyelocytic leukemia).
6.
Understand the prognostic significance of cytogenetic changes in certain hematological
disorders, such as pediatric acute lymphoblastic leukemia, and implications for therapy.
7.
Understand the utility of conventional cytogenetics in the monitoring of chronic myelogenous
leukemia, with respect to (a) karyotypic evolution and impending blast crisis, (b) assessment of
therapy (eg. -interferon).
8.
Be aware of the use and limitations of conventional cytogenetics in minimal residual disease
detection.
Dr. _____________ has demonstrated knowledge in the above topics.
Preceptor for cytogenetics block:-
Signature
Date
103
F. HLA TYPING
This brief rotation is intended to provide the resident with an understanding of the role of the major
histocompatibility complex (MHC), its relevance in bone marrow and solid organ transplantation and
the principles of HLA typing.
At the end of this rotation, the resident will:1. Understand the genetics of the MHC region and the inheritance of HLA haplotypes.
2. Be familiar with the biochemical nature of the MHC.
3. Understand the role of the MHC in normal and abnormal immunology.
4. Understand the principles of HLA typing, lymphocytotoxicity testing and mixed lymphocyte
reactions.
5. Recognize the importance of HLA typing to bone marrow and solid organ transplantation.
6. Be familiar with methods of anti-HLA and anti-platelet antibody detection and with the principles of
the platelet crossmatch, and recognize the utility of these assays in the selection of donors for
patients who are refractory to random platelet transfusions.
Dr. ___________ has demonstrated knowledge of the above topics.
Preceptor for this rotation:-
Signature
Date
104
ROTATION SPECIFIC OBJECTIVES
LYMPH NODE PATHOLOGY
Selection: Mandatory
Site: Cross Cancer Institute
Preceptor: Dr. Raymond Lai
Length of Rotation: Four weeks
Prerequisites: PGY3
MEDICAL EXPERT











To be familiar with the updated lymphoma classification schemes
To develop a practical approach in assessing lymph node morphology
To be familiar with the diagnostic criteria for major subtypes of lymphoma
To be familiar with benign conditions that mimic lymphoma
To have basic knowledge of using ancillary studies in making diagnosis
function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care
establish and maintain clinical knowledge, skills and attitudes appropriate to their practice
perform a complete and appropriate assessment of a patient
use preventative and therapeutic interventions effectively
demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic
seek appropriate consultation from other health professionals, recognizing the limits of their
expertise
COMMUNICATOR







To communicate effectively with medical colleagues, nursing and technical staff verbally and in
written reports
To present cases effectively at lymphoma treatment planning meetings held weekly
develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed)
accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals
accurately convey relevant information and explanations to colleagues and other professionals
develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families
convey effective oral and written information about a medical encounter
COLLABORATOR
 To ensure that reports are generated in a timely fashion for optimal patient management and
treatment
 participate effectively and appropriately in an interprofessional healthcare team
 effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict
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MANAGER


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


To utilize time and resources effectively to balance patient care, budget restrictions,
professional expectations and personal life
To allocate finite health care and health education resources effectively
participate in activities that contribute to the effectiveness of their healthcare organizations and
systems
manage their practice and career effectively
allocate finite healthcare resources appropriately
serve in administration and leadership roles, as appropriate
HEALTH ADVOCATE
 To recognize how technologic advances may apply to improvement in hematologic diagnosis,
and advocate to introduce those technologies locally
 respond to individual patient health needs and issues as part of patient care
 respond to the health needs of the communities that they serve
 identify the determinants of health of the populations that they serve
 promote the health of individual patients, communities and populations
 acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports
SCHOLAR






To develop and implement a personal continuing educational strategy
To apply the principles of critical appraisal to sources of medical information
To contribute to the development of new knowledge through researchmaintain and enhance
professional activities through ongoing learning
critically evaluate information and its sources, and apply this appropriately to practice decisions
facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate
contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices
PROFESSIONAL






To deliver the highest quality of care with integrity, honesty and compassion
To practice medicine in an ethnical manner
emonstrate commitment to excellence and ongoing professional development
demonstrate a commitment to their patients, profession, and society through ethical practice
demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation
demonstrate a commitment to physician health and sustainable practice
Outline of Rotation:
The lymph node pathology block will take place at the Cross Cancer Institute (CCI) over a 4-week
period. This may be followed by a second refresher rotation in the final year, or if the resident has an
interest in this area, by an extended elective rotation with more in-depth training. In addition, while on
the adult clinical oncology-hematology rotation at the CCI, the resident will have the opportunity to
review lymph node pathology with the pathologist at the CCI whenever time permits.
106
The resident will review all the new and consultation cases related to malignant lymphoma received
during the lymph node pathology rotation. The laboratory has been receiving an average of 150
cases per month. The resident will develop a practical approach in assessing lymph node pathology,
and become familiar with the use of ancillary tests (including flow cytometry, fluorescence in situ
hybridization and molecular diagnostic testing) in facilitating the diagnosis of lymphoma. The resident
will also experience an average of 5 bone marrow biopsies or peripheral blood smears received daily
for assessment of lymphoma and myeloma involvement. An additional 5 body fluid samples will be
received per week for assessing lymphoma involvement. The resident will be actively involved in
ordering ancillary tests and generating final reports under the supervision of staff pathologists.
Lastly, over 2000 archival lymphoma cases on file are readily available for study.
At the completion of training, the resident will:
 Understand normal histology of various solid lymphoreticular organs, including lymph node,
spleen , bone marrow and thymus.
 Understand the principles underlying the current WHO classification system of hematopoietic
neoplasms.
 Know the key pathologic and clinical features of the major lymphoma entities, including
Hodgkin’s lymphoma, small lymphocytic lymphoma/chronic lymphocytic leukemia,
lymphoplasmacytic lymphoma, marginal zone lymphoma, mantle cell lymphoma, follicular
lymphoma, diffuse large cell lymphoma, lymphoblastic lymphoma, Burkitt/Burkitt-like
lymphoma, peripheral T-cell lymphoma
 Be familiar with the role of immunophenotyping by flow cytometry and immunohistochemistry
in establishing a definitive diagnosis of these lymphomas.
 Understand the role of molecular diagnostic techniques in establishing a definitive diagnosis of
lymphoma (also see “molecular diagnostics” section).
Educational Materials:
Suggested reading:
 Relevant sections of general surgical pathology textbooks (Ackerman’s,
Sternberger).
 Jaffe ES, Harris NL, Stein H, Vardiman JW (Eds): World Health Organization Classification of
Tumours. Pathology and Genetics of tumours of the Haematopoietic and Lymphoid Tissues.
IARC Press: Lyon 2001.
 Reading material as provided by preceptor.
Conferences:
Lymphoma Rounds, weekly.
Clinical material:
 Current material, including consultation cases.
 Archival material.
Evaluation:


Knowledge will be assessed on daily reviews with preceptor.
Diagnostic approach, work-up and diagnostic ability assessed on an ongoing basis with
current cases.
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

End of rotation practical examination. A mark of 70% will be considered a pass mark on this
examination.
Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
April 2006
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ROTATION SPECIFIC OBJECTIVES
MEDICAL BIOCHEMISTRY
Selection:
Site:
Preceptor:
Length of Rotation:
Prerequisites:
Mandatory
University of Alberta Hospital
Dr. Fiona Bamforth
Medical Biochemistry 1A - 12 weeks
Medical Biochemistry 1B - 12 weeks
Medical Biochemistry 1A - Six months of Anatomical Pathology
Medical Biochemistry 1B - Medical Biochemstry 1A, Hematopathology
1A and Medical Microbiology 1A
Specific Objectives:
MEDICAL EXPERT
 To understand the implications of age and sex-related reference intervals and other preanalytical, analytical and post-analytical factors which may affect the interpretation of tests,
both physiological an artefactual. These tests include urinalysis, high volume tests, cardiac
markers, enzymes, lipids, proteins, toxicological testing, trace elemental environmental
toxicological testing, endocrinology, hereditary disease testing and point of care testing.
 To operate an adequate internal and external quality control program.
 To operate an adequate quality assurance program.
 To understand the implications of age and sex-related reference intervals and other preanalytical, analytical and post-analytical factors which may affect the interpretation of tests,
both physiological and artefactual.
 To be able to relate the sensitivity, specificity and predictive value of tests to the individual
patient.
 To act as consultant for clinical colleagues with respect to patient investigation and
management.
 To draw up protocols for the appropriate investigation of patients.
 To develop the management skills required to appropriately equip and staff the
aforementioned 300-bed hospital laboratory.
 To have a basic knowledge of the analytical principles involved in the instruments and
techniques used in the laboratory, including proper documentation of methodologies.
 To develop an understanding on the use of computers and expert technology in the
laboratory.
 Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
 Eestablish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
 Perform a complete and appropriate assessment of a patient.
 Use preventative and therapeutic interventions effectively.
 Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
 Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
109
COMMUNICATOR







Assist in the continuing education of physicians and other members of the hospital staff by
participating in conferences and case presentations.
Act as consultant to clinical colleagues on the interpretation and relevance of biochemical tests,
with particular regard to their significance in the management of the patient
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed)
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR



Demonstrate the ability to advise on the interpretation of biochemical tests, to advise on the
investigation of the biochemical aspects of disease in a cost-effective manner and to promote
effective test utilization.
Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
MANAGER












Review laboratory budgeting, workload units and other statistical approaches for assessing
productivity.
Review quality assurance programs available for the laboratory.
Review details required for laboratory coordination of off-site testing programs, including
selection of instruments and implementation of quality control and quality assurance programs
for such testing.
Assess details of approaches that can be used for optimizing use of laboratory tests in a costeffective manner.
Review other matters pertaining to laboratory administration, including committee structures,
WHMIS, accreditation, etc.
Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life
Allocate finite health care and health education resources effectively to optimize patient care
and life-long learning.
Understand the logistics of managing a hospital laboratory.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
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HEALTH ADVOCATE
 Identify the important determinants of health affecting patients pertaining to biochemical
disease processes.
 As a member of an interdisciplinary team of professionals responsible for patient health,
the resident will assist in regularly evaluating laboratory practices and test selections to
determine that they meet community needs.
 Recognize and reinforce to the public and to the medical profession the essential
contribution of laboratory medicine to health.
 Respond to individual patient health needs and issues as part of patient care.
 Respond to the health needs of the communities that they serve.
 Identify the determinants of health of the populations that they serve.
 Promote the health of individual patients, communities and populations.
 Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR








Develop and implement a personal continuing educational strategy.
Apply the principles of critical appraisal to sources of medical information.
Contribute to the development of new knowledge through research.
Participate in rounds, conferences and teaching sessions.
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL








Deliver the highest quality of care with integrity, honesty and compassion.
Practice medicine in an ethnical manner and with sensitivity to diverse patient and co-worker
populations.
Exhibit appropriate professional behavior and perform duties in a dependable and responsible
manner.
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
During the first rotation (twelve weeks) through the different sections of the laboratory, the associated
senior staff person will ensure that experience is gained in the performance of predominantly
Category I assays. During the first rotation, the resident also gains experience of sample collection
procedures, separation and accessioning of specimens. During this rotation, Category II and III
111
assays will also be encountered due to clustering of tests in subspecialized areas of the laboratory
and on specific instruments.
The relevant senior staff persons are expected to meet with the resident on at least a weekly basis to
discuss methodology, quality control and matters relevant to the ordering, patient preparation and
interpretation of investigations pertinent to each area of the laboratory. The resident will also be
informed of all consultation requests related to the area and be personally involved in
physician/patient/laboratory interfacing.
In the first month of the first rotation, the resident will spend time in the Core Laboratory and
TDM/Toxicology to prepare for inclusion on the on-call rota. For the remainder of the first rotation and
during the entire second rotation, the resident will be on the on-call rota as first on-call with senior
staff back-up. This will allow the resident to gain experience in both consulting and problem solving in
the Core Laboratory.
During the second twelve month rotation, the resident will be expected to review his/her knowledge
base with a shorter rotation through Core Laboratory and TDM/Toxicology. The remaining time will
be spent in area of the laboratory undertaking more specialized testing and which includes more
Category II and III assays. This rotation will emphasis definition of clinical problems in context of the
laboratory, interpretation of results and development of consultative skills. There will be increased
emphasis on quality control, quality assurance, instrument evaluation, statistics and laboratory
management.
During both rotations, the resident will have a weekly tutorial with the program director. In December,
questions on Medical Biochemistry and a practical examination consisting of several stations are
included in the in-house examination.
The resident is expected to participate in bi-weekly seminar courses in Medical Biochemistry which
cover the major topics in the field.
Educational Materials:
The Department of Laboratory Medicine and Pathology library and the John Scott library are available
on-site. Residents have access to the Cameron library on campus should they require access to
basic science journals.
Throughout the academic year, there is a bi-weekly seminar program in Medical Biochemistry.
Pathology Rounds are held weekly and the resident is expected to attend regularly and present
Rounds at least once per year.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
112
GENERAL OBJECTIVES FOR MEDICAL BIOCHEMISTRY
TRAINING OF GENERAL PATHOLOGY RESIDENTS
The duration of training in Medical Biochemistry is twenty-four weeks. This period has been
subdivided into two rotations, each of twelve weeks (Medical Biochemistry 1A and 1B). The time
interval between rotations may vary for individual residents and could be as long as three years. Both
rotations will be through the Division of Medical Biochemistry at the University of Alberta Hospitals
and DynaLIFE core laboratories.
During the first rotation through the different sections of the laboratory, the associated senior staff
person will ensure that experience is gained in the performance of Category I assays. During this
rotation, Category II and III assays will also be encountered due to clustering of tests in
subspecialized areas of the laboratory and on specific instruments.
The relevant senior staff persons are expected to meet with the resident on at least a weekly basis to
discuss methodology, Quality Control and matters relevant to the ordering, patient preparation and
interpretation of investigations pertinent to each area of the laboratory. The resident will also be
informed of all consultation requests related to the area and be personally involved in
physician/patient/laboratory interfacing.
In the first four weeks of the first rotation, the resident will spend time in the Core Laboratory to
prepare for inclusion on the on-call rota. For the remainder of the first rotation and during the entire
second rotation, the resident will be on the on-call rota as first on-call with senior staff back-up. This
will allow the resident to gain experience in both consulting and problem solving in the Core
Laboratory.
In the second twelve weeks of rotation, due to time constraints, the resident will be expected to
review their knowledge base without formal course work. This rotation will emphasize definition of
clinical problems in context of the laboratory, interpretation of results and development of consultative
skills. There will be increased emphasis on Quality Control, Quality Assurance, instrument
evaluation, statistics and laboratory management.
During both rotations, the resident will have a weekly tutorial with the program director. At the end of
each twelve week rotation there is an examination.
The resident is expected to participate in weekly seminar courses in Medical Biochemistry. There are
two one-year courses run consecutively and participants present a 45 minute
lecture followed by discussion.
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A. SPECIMEN COLLECTION/ACCESSIONING

Patient preparation, types of blood containers, anti-coagulants, collection techniques, universal
precautions.

Understand preanalytical variables and their effect on test results.

Specimen separation, patient demographics, accessioning, specimen tracking, sample handling
and storage, referral of samples to other laboratories.
B. URINALYSIS

urinalysis
test for glucose, protein, pH, bile, blood, ketones,
specific
gravity,
urobilinogen,
leucocytes.
Correlate abnormals with microscopic exam

microscopic exam
cells, casts, crystals

reducing substances
causes of positive tests

stool analysis
occult blood, fat, trypsin, microscopy

renal function tests
osmolality, water deprivation tests, ammonia,
titratable acid
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Read protocols for testing where appropriate.
3. Examine and document a minimum of 40 urine sediments.
4. Become familiar with as many abnormal urine constituents as possible.
5. Be aware of progressive testing protocols if relevant.
C. HIGH VOLUME TESTS
General tests
Include:

sodium, potassium, chloride
plasma, urine, sweat, and other body fluids

total CO2
Correlation with pH, pCO2, anion gap

urea, creatinine
Serum and urine. Clearance calculations.
Interpretation in renal disease
114

glucose
Current diagnostic criteria for diabetes
mellitus
and
gestational
diabetes.
Interpretation of glucose tolerance tests.
Physiological variations.

total protein, albumin
Standardization.
Physical properties of
proteins. Deproteinization techniques.

calcium, magnesium, phosphate, urate
Variations in bone and renal disease

bilrubin
Interpretation in different disease
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Be aware of progressive testing protocols if relevant.
3. Observe start up procedure, calibration procedure and quality control of appropriate high
throughput analyzers.
4. Compare mean, SD and CV of controls on the high throughput analyzers for electrolytes,
creatinine, urea and glucose from month-to-month.
5. Calculate mean and SD of the anion gap in 40-50 patients.
6. Calculate five creatinine clearances ± correction for surface area with normal and abnormal serum
creatinine. Understand different formulae for calculating creatinine clearance and their limitations.
7. Compare calculated vs measured osmolalities in 20 patients with normal and abnormal. Calculate
mean and SD of the difference between them.
8. Tabulate data for calculated vs measured osmolar gaps on patients with alcohol excess.
9. Understand logistics of high volume analyzers (tests per hour, accommodation of stat samples).
10. Understand relative costs - reagents, disposables, services, maintenance contracts, technologist
time, capital cost.
Cardiac Markers
Include:
CK, CKMB, troponin I
Time course variations in myocardial
infarction. Sensitivity and specificity
for myocardial infarction.
Enzymes
115
ALT, AST, GGT, alkaline phosphatase
interpretation in liver disease
Lipase, amylase
Diagnosis
of
pancreatitis
limitations of each test
and
Lipids
total cholesterol, triglycerides, HDL and
LDL cholesterol, apo A1, apo B100
screening, current guidelines for
reporting cardiac risk, calculation of
derived parameters
Miscellaneous tests
ferritin, serum iron, TIBC, vitamin B12
folate, homocysteine
Biochemical parameters in diagnosis
of
hematological
disorders.
Correlation with hematologic findings.
cholinesterase
total activity and dibucaine number
myoglobin
criteria for analysis
microalbumin
Rationale for testing and monitoring
diabetes mellitus
HbA1C
Interpretations of results, interference
from other hemoglobins
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Observe start up procedure, calibration procedure and quality control of appropriate analyzers
3. Understand rationale for testing for each analyte and be aware of progressive testing protocols.
D. TDM/TOXICOLOGY
Quantitative drug assays

automated technologies:
e.g.
phenytoin,
acetaminophen,
methotrexate, quinidine

chromatography instrumentation:

quantitative assays by manual methods
e.g.
clonazepam,
clozapine,
imipramine, alcohols, cyclosporin,
tacrolimus, sirolimus
e.g.
OKT3
(ELISA),
116
barbiturates
spectrophotometry
(UV
Other quantitative assays

quantitative assays by
chromatography instrumentation
e.g. urine metanephrines,
catecholamines
Qualitative toxicology assays

Qualitative toxicology assays by immunoassay, thin layer chromatography, GC-MS.
Include:
1. Appropriate specimen collection protocols, including reference to pertinent pharmacokinetic
principle.
2. Sample pretreatment if relevant
3. Be aware of specimen adulteration and substitution issues.
4. Review/interpret/clarify information accompanying TDM requests (communication with requesting
physicians, requisition review, gain experience in appending interpretive comment).
5. Be aware of pharmacokinetic factors influencing levels.
6. Be aware of method performance issues including sensitivity, specificity, imprecision etc.
7. Be aware of progressive testing protocols, protocols, treatment and laboratory implications (e.g.
dialysis with methanol hemodialysis prediction).
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Understand principles of:
a) quantitative drug assays on automated high throughput immunoassay analyzers e.g.:
enzyme multiplied immunoassay technique
cloned enzyme donor immunoassay
fluoroescence polarization immunoassay
microparticle enzyme immunoassay
b) Gas chromatography with nitrogen, phosphorus, electron capture and flame ionization detection
c) head space gas chromatography
117
d) high performance liquid chromatography
e) gas chromatography-mass spectrometry
f) LC/MS/MS
g) Toxilab TLC
h) manual assays - ELISA, UV spectrophotometry
E. PROTEINS
Include:

serum protein electrophoresis
interpretation of patterns, monoclonal bands

CSF protein electrophoresis
interpretation of
oligoclonal bands

urine protein
interpretation of patterns, monoclonal bands,
Bence-Jones proteins

Hemoglobin electrophoresis using
electrophoresis at different pH
identification and significance of variants

hemoglobin A2
quantitation and significance

specific proteins (e.g. transferrin, significance in disease
ceruloplasmin, alpha-1-antitrypsin)

Immunoglobulin quantitation,
Cd, C4, CH50, C1 esterase inhibitor
significance in disease

immunofixation
interpretation and significance

IgE, RAST testing
testing
interpretation and limitations of serum

tumour markers (PSA, CEA,
hCG, AFP)
limitations and uses of tumour markers
patterns,
identification
F. MISCELLANEOUS TESTS
Include:


gastrointestinal function tests:
carotene, vitamins, fecal fat,
fecal and serum bile acids
significance/limitations in assessing gut
function
renal function:
118
of
oxalate, citrate, cystine, calculus
analysis
significance of results

porphyrins, PBG, ALA
screening and quantitation

methemoglobin, sulfhemoglobin
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Understand principles of:
a)
high performance liquid chromatography
b)
manual/semi-automated enzyme kinetics
c)
fluorometric analysis
d)
spectrophotometric
G. ENDOCRINOLOGY
Include:

thyroid function tests (TSH, FT4,
T3, TBG, T3 uptake)
diagnosis of thyroid disease, progressive testing
protocols

cortisol, ACTH
diagnosis of adrenal disease

estrogens, androgens, FSH, LH
tests of gonadal/pituitary function

insulin, C-peptide, GH, glucagon
disorders of growth and glucose regulation

hCG
diagnosis and monitoring of pregnancy

calcitonin, PTH, vitamin D
test of calcium/bone function

aldosterone, renin
role in hypertension
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Understand principles of:
119
a) automated and semi-automated immunoassay analyzers
b) scintillation counters
3. Understand principles and interpretation of stimulation and suppression tests.
H. TRACE ELEMENTS/ENVIRONMENTAL TOXICOLOGY
Include:

Ca, Mg, Cu, Zn, Fe, Li
serum urine and other fluid levels.
Deficiency and therapeutic/toxic levels

Pb, Hg, A1, As
toxic levels, clinical effects and treatment
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Understand principles of atominc absorption spectroscopy (flame, graphite furnace, cold vapor).
3. Check clinical details of any abnormal results.
I. HEREDITARY DISEASE
Include:

neonatal screen on blood spots:
TSH (± T4)
amino acid chromatography
biotinidase
organization of provincial screening programs.
population statistics.

metabolic screens:
sugar identification
urine/serum amino acids,
mucopolysaccharides,
oligosaccharides,
organic acid analysis
limitations of metabolic screens

amino acid quantitation
use in diagnosis and monitoring treatment

metabolic testing:
carnitine
lysosomal enzymes
Gal-1-PUT
role in diagnosis and monitoring of
inherited metabolic disorders

maternal serum prenatal screen: principles
120
of
multivariate
analysis,
AFP, UE3, hCG
limitates in testing for NTD and Down
syndrome
Procedures
1. Read method manual for each test and understand principle of each test, sensitivity, specificity,
linearity, interferences etc. which may affect the patient results.
2. Understand principles of population screening for disease.
3. Understand principles of:
a) thin layer chromatography
b) gas chromatography-mass spectrometry for organic acid analysis
c) high performance liquid chromatography for amino acids, including total homocysteine
d) spectrophotometry
e) fluorometry
J. POINT OF CARE TESTING
Procedures
1. Become familiar with the advantages and limitations of point-of-care (POC) testing.
2. Know how to compare the costs of POC testing to central laboratory testing.
4. Know how to evaluate and introduce POC testing into a hospital or ambulatory care environment.
Check list:
A. Specimen collection/accessioning
B. Urinalysis
Analytes
‫ٱ‬
Procedures
‫ٱ‬
General Tests
Analytes
‫ٱ‬
Procedures
‫ٱ‬
Cardiac markers
Analytes
‫ٱ‬
Procedures
‫ٱ‬
Enzymes
Analytes
‫ٱ‬
Procedures
‫ٱ‬
C. High Volume Tests
121
Lipids
Analytes
‫ٱ‬
Procedures
‫ٱ‬
Miscellaneous tests
Analytes
‫ٱ‬
Procedures
‫ٱ‬
Quantitative drug assays
Analytes
‫ٱ‬
Procedures
‫ٱ‬
Other quantitative assays
Analytes
‫ٱ‬
Procedures
‫ٱ‬
Qualitative Toxicology
Analytes
‫ٱ‬
Procedures
‫ٱ‬
E. Proteins
Analytes
‫ٱ‬
Procedures
‫ٱ‬
F. Miscellaneous tests
Analytes
‫ٱ‬
Procedures
‫ٱ‬
G. Endocrinology
Analytes
‫ٱ‬
Procedures
‫ٱ‬
H. Trace elements/
environmental toxicology
Analytes
‫ٱ‬
Procedures
‫ٱ‬
I. Hereditary disease
Analytes
‫ٱ‬
Procedures
J. Laboratory management
Procedures
‫ٱ‬
K. Point of care testing
Procedures
‫ٱ‬
D. TDM/Toxicology
122
Medical Biochemistry Rotation Schedule
Rotation 1
Week
1
Staff contact
George Cembrowski
2
3
4
5
6
7
8
9
10
11
12
Area
Specimen handling,
accessioning,
urinalysis
TDM/toxicology
TDM/toxicology
Core Laboratory
Core Laboratory
Hereditary diseases
Point of care/QA
Special investigations
DynaLIFE
DynaLIFE
DynaLIFE
DynaLIFE
Rotation 2
Week
1
2
3
4
5
6
7
8
9
10
11
12
Area
TDM/Toxicology
QA/lab management
Core Laboratory
Molecular genetics I
Molecular genetics II
Hereditary diseases
Endocrinology
Special investigations
DynaLIFE
DynaLIFE
DynaLIFE
DynaLIFE
Staff contact
Don LeGatt
George Cembrowski
George Cembrowski
Martin Somerville
Raymond Lai
Fiona Bamforth
Connie Prosser
Connie Prosser
Trefor Higgins
Trefor Higgins
Trefor Higgins
Trefor Higgins
Don LeGatt
Don LeGatt
George Cembrowski
George Cembrowski
Fiona Bamforth
George Cembrowski
Connie Prosser
Trefor Higgins
Trefor Higgins
Trefor Higgins
Trefor Higgins
123
ROTATION SPECIFIC OBJECTIVES
MEDICAL MICROBIOLOGY
Selection:
Site:
Preceptor:
Length of Rotation:
Prerequisites:
Mandatory
University of Alberta Hospital
Dr. Kinga Kowalewska
Medical Microbiology 1A – 12 weeks
Medical Microbiology 1B – 12 weeks
Microbiology 1A – Six months of Anatomical Pathology (minimum)
Microbiology 1B – Microbiology 1A, plus Haematopathology 1A,
Plus Medical Biochemistry 1B, plus, at least, fifteen months of
Anatomical Pathology (minimum)
Specific Objectives:
MEDICAL EXPERT
 To become familiar with testing and reporting practices in medical microbiology in acute
care and community based medical microbiology
 To interact with medical colleagues to assist in making decisions about correct
microbiological diagnoses
 To understand how microorganisms respond to various therapies and to assist other
physicians in selection of the most appropriate treatments.
 Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
 Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
 Perform a complete and appropriate assessment of a patient.
 Use preventative and therapeutic interventions effectively.
 Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
 Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR







Assist in the continuing education of physicians and other members of the hospital staff by
participating in conferences and case presentations
Act as consultant to clinical colleagues on the interpretation and relevance of microbiological
findings, with particular regard to their significance in the management of the patient
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
124
COLLABORATOR



Demonstrate the ability to advise on the appropriateness of obtaining microbiological specimens
and to advise on further appropriate investigations
Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
MANAGER






Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life
Allocate finite health care and health education resources effectively to optimize patient care
and life-long learning
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE
 Identify the important determinants of health affecting patients pertaining to medical
microbiological processes
 As a member of an interdisciplinary team of professionals responsible for patient health,
the resident will assist in regularly evaluating laboratory practices and test selections to
determine that they meet community needs
 Recognize and reinforce to the public and to the medical profession the essential
contribution of laboratory medicine to health
 Respond to individual patient health needs and issues as part of patient care.
 Respond to the health needs of the communities that they serve.
 Identify the determinants of health of the populations that they serve.
 Promote the health of individual patients, communities and populations.
 Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR








Develop and implement a personal continuing educational strategy
Apply the principles of critical appraisal to sources of medical information
Contribute to the development of new knowledge through research
Participate in rounds, conferences and teaching sessions
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
125
PROFESSIONAL








Deliver the highest quality of care with integrity, honesty and compassion
Practice medicine in an ethnical manner and with a sensitivity to diverse patient and co-worker
populations
Exhibit appropriate professional behavior and perform duties in a dependable and responsible
manner
Demonstrate commitment to excellence and ongoing professional development
Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
Microbiology 1A.
 The resident will develop an understanding of appropriate specimens, transport
conditions and laboratory techniques for optimal recovery of microorganisms causing
infections. Most of this time will be spent in bacteriology
 The resident will learn the differences between normal flora and the conditions where
potential pathogens cause infections.
 The resident will develop an understanding of laboratory bench protocols by observation
and hands on experience so that they become good communicators with their clinical
colleagues.
 The resident will learn the mechanisms of antimicrobial action and the most appropriate
methods for identification of antimicrobial resistance.
 The resident will learn the units of medical microbiology and how they are incorporated
into the laboratory report.
 The resident will participate in rounds conferences and seminars on various topics of
medical microbiology
 The resident will take graded call responsibilities in the last 7-8 weeks with immediate
staff person backup in order to develop the skills necessary to interact with other
clinicians.
Microbiology 1B
 The resident will undertake further rotations in medical microbiology to broader the base
of understanding in all aspects. These rotations include, viral culture and serology,
parasitology, mycology, molecular diagnostics (identification of specific pathogens,
strain typing, sexually transmitted diseases identification, etc).
 The resident will take part in infection prevention and control activities
 The resident will develop an understanding of laboratory management tools by
participating in senior microbiology meetings.
 The resident will participate in community based microbiological investigations to
develop an understanding of differences between tertiary care, general hospital, and
community microbiology.
 The resident will participate in regular conferences, rounds and seminars
 The resident will have an opportunity to engage in short term research activities to
develop investigative skills.
126

The resident will participate actively in on call service and act as a senior resident in
these duties, with back up by a staff person.
Educational Materials:
These materials are available to the residents in the Resident’s Room, Staff Personnel offices or
the main diagnostic laboratories.
Texts:
 Manual of Clinical Microbiology , 8th Edition ASM Press
 Color Atlas and Textbook of Diagnostic Microbiology. Koneman et al. Lippincott
 Principles and Practice of Infectious Diseases. Mandell et al. Churchill Livingstone
Manuals:
 Clinical Microbiology Procedures Handbook. Isenberg. ASM Press.
 University of Alberta Hospital, Laboratory Procedures Manual
 Dynacare Kasper Medical Laboratories Procedures Manual
Journals: (available in the Microbiology and Public Health Library)
 Journal of Clinical Microbiology. ASM
 Antimicrobial Agents and Chemotherapy. ASM
 Diagnostic Microbiology and Infectious Diseases. Elsevier
 Journal of Clinical Virology. ASM
 Medical Mycology and Mycoses.
Other journals are available in the John Scott Library, University of Alberta
Computer: Residents have a computer available to them in the residents’ room. Access to
PubMed and other sites is available on-line.
Evaluation:
 Regular topic sessions are held with the preceptor to evaluate progress.
 End of rotation examinations (held in conjunction with General Pathology or with
Medical Microbiology residents)
 Final examinations at the end of rotation 1B, including written, practical and oral
exams.
 Evaluations of co-workers (other staff persons, technologists, and clinicians) and of
the preceptor.
 Overall assessment is based on a pathology resident evaluation form distributed
through Webeval.
May 2007
127
GENERAL OBJECTIVES
MEDICAL MICROBIOLOGY
INTRODUCTION
Regardless of the size and degree of sophistication of the laboratory, there are five basic steps
involved in the process of microbial identification and antibiotic susceptibility testing. These are:





collection of the specimen to be processed
initial processing of the specimen for culture
identification of potentially pathogenic bacteria in the specimen
antibiotic susceptibility testing of selected medically important bacteria, and
final report of results to the physician
The purpose of this handout is to describe the various ways specimens are collected for the
Diagnostic Microbiology Laboratory.
SPECIMEN COLLECTION
BASIC CONCEPTS
1.
The clinical specimen must be material from the actual infection site and must be collected
with a minimum of contamination from adjacent tissues, organs, or secretions.
2.
Optimal times for specimen collection must be established for the best chance of recovery of
causative micro-organisms.
3.
A sufficient quantity of specimen must be obtained to perform the culture techniques
requested.
4.
Appropriate collection devices and specimen containers must be used to ensure optimal
recovery of microorganisms.
5.
Whenever possible, obtain cultures prior to the administration of antibiotics.
6.
The culture container must be properly labelled:





name
hospital number (PHN number)
source
physician
date/hour
128
A.
SPECIMENS FROM DIFFERENT BODY SITES
1.
Specimens from Body Sites that Harbor a Normal Flora
A specimen obtained from a body site that harbors normal flora will always have components
of the flora in it. Thus, no attempt is made to prevent contamination of these specimens.
Since components of the normal flora are expected to be in these specimens, they will be
examined only for the presence of unexpected organisms that are not members of the normal
flora. Table 1 lists those sites that harbor normal flora.
2.
Specimens from Normally Sterile Body Sites Located Near an Area that Harbors
Normal Flora
For certain body sites that do not harbor normal flora, specimens are collected from secretions
or excretions that must pass through a second site that does harbor normal flora. Such
specimens will often contain components of the flora of the second site. However, certain
steps can be taken to minimize contamination of these specimens so that the normal flora will
not interfere with recovery of the etiologic agent. For example, the kidney and bladder are
sterile in health. However, urine is voided through the external opening of the genitourinary
tract which harbors normal flora. Thus, to minimize contamination of the urine, the external
genitalia are cleaned with soap and water and the first several milliliters of urine are discarded
before the urine is collected for culture. Examples of body sites that are normally sterile but
secretions/excretions from them must pass through a second site with normal flora are listed in
Table 1.
3.
Specimens from Normally Sterile Body Sites that do not Produce Secretions or
Excretions
There are certain body sites that do not harbor normal flora and do not produce secretions or
excretions (Table 1). Specimens from such sites are collected by aseptic invasive procedures
and thus the presence of any microorganism is indicative of disease. All precautions must be
taken to avoid any contamination of these specimens. Since many of these invasive
procedures involve insertion of a sterile needle through the skin which harbors normal flora,
the skin is cleansed with alcohol and an iodine solution to prevent contamination of the
needles. Examples of body sites that fall into this third category are listed in Table 1.
129
TABLE 1
Goals in Prevention of Specimen Contamination
with Normal Flora Based upon the Body Site Infected
I.
Body sites that harbor a normal flora. No attempt is made to reduce contamination of the specimen
with the flora.
Examples:
Skin
Conjunctiva
Upper respiratory tract (nose, throat)
Mouth
Lower gastrointestinal tract
External genitalia
Anterior urethra
Vagina/Endocervix
II.
Body sites that are normally sterile but produce secretions/excretions that pass through a second site
harboring a normal flora. Attempts are made to reduce contamination of secretion/excretion by normal
flora from second site.
Examples:
Urinary tract (bladder, ureter, kidney)
Salivary glands
Lower respiratory tract
Sinuses
III.
Body sites that are normally sterile and do not produce secretions/excretions. Any contamination of the
specimen must be prevented.
Examples:
Blood, Brain, Joint, Bone
130
B.
SPECIMEN COLLECTION TO MAXIMIZE RECOVERY OF THE ETIOLOGIC AGENT
Certain factors influence the recoverability of etiologic agents of infection. These are:
1.
the material used to collect the specimen,
the environment in which the specimen is placed, and...
the time delay between obtaining the specimen and transporting it to the laboratory
Material Used to Collect the Specimen
Certain types of swabs and fluids that are used to collect specimens may contain substances
that are inhibitory to various pathogenic bacteria. Thus, in certain instances, the type of
material used to collect the specimen must be selected on the basis of the pathogen
suspected to be present. For example, in cases of suspected gonorrhea, special calcium
alginate swabs must be used to collect the specimen. Cotton swabs should not be used
because they are inhibitory to the pathogen responsible for this disease.
2.
Environment of the Specimen
Once the specimen is obtained, it must be placed in an environment that will maintain the
viability of the pathogen. Some pathogens are very sensitive to drying and thus specimens
should always be kept in a moist environment. The use of special transport media often
provide adequate moisture if the specimen is on a dry swab. Also, some pathogens are
extremely sensitive to oxygen. Specimens suspected of containing these pathogens (obligate
anaerobes) must be kept in an oxygen free environment. The use of an oxygen-free syringe to
collect the sample or a variety of commercially available anaerobic containers will provide an
adequate environment for these oxygen sensitive organisms.
3.
C.
Avoid Time Delays
INITIAL PROCESSING OF SPECIMENS FOR CULTURE
Some specimens are examined immediately upon receipt in the laboratory.
examination is either for the purpose of:
1.
This direct
determining the probable identity of the etiologic agent, or ...
assessing the acceptability of the sample for culture.
Probable Identity of the Etiologic Agent
Certain specimens are examined microscopically when they are received in the laboratory in
an attempt to rapidly identify the etiologic agent of infection. Most of these examinations are
performed on specimens that have been stained, although some are performed on unstained
preparations. Most of the tests provided on presumptive identification of the etiologic agent
and must be confirmed by further tests. In general, direct examination of a specimen can yield
useful information about the etiologic agent of disease if the specimen:
-
does not contain contaminating normal flora (thus the presence of any bacteria indicates
infection), or...
131
-
contains a pathogen with a distinct morphology and/or staining reaction that allows it to be
recognized even in the presence of contaminating normal flora.
2. Acceptability of Specimen for Culture
Many laboratories have begun to perform Gram stains on all sputum specimens they receive
for culture. This is to determine if the specimen is truly a good sputum (that has been
expectorated from the lower respiratory tract) and not merely saliva from the upper respiratory
tract. If, on Gram stain, the specimen is found to contain numerous inflammatory cells with few
or no epithelial cells, this indicates that the specimen is sputum and therefore acceptable for
culture. If, on the other hand, the specimen contains few inflammatory cells and many
epithelial cells (sloughed from the mucous membranes of the upper respiratory tract), it is not
acceptable for culture, and another specimen must be obtained from the patient. This process
of screening sputums for acceptability prevents expensive cultures from being performed on
specimens that are inappropriately obtained and would not be likely to yield the etiologic agent.
D.
IDENTIFICATION OF MEDICALLY IMPORTANT BACTERIA
Initial Examination of Primary Cultures
After overnight incubation of the primary cultures, they are examined for bacterial growth that
is indicative of the presence of infection. As mentioned previously, the mere presence of
bacteria on the cultures is not always indicative of infection. The precise interpretation of the
cultures varies with the type of specimen involved.
1.
Cultures of Specimens that Should be Sterile in the Absence of Infection
The presence of any bacteria in cultures inoculated with specimens obtained by an aseptic
procedure from a body site that is normally sterile is indicative of infection. Examples of
specimens that would fall into this category are listed in Table 2. The only situation in which
infection is not indicated is if there is some reason to suspect the specimen was inadvertently
contaminated when it was obtained.
2.
Cultures of Specimens that are Contaminated with Normal Flora
As mentioned previously, specimens from body sites that either normally harbor flora or are
near another site that harbors flora are usually contaminated to some degree (Table 2). In
some instances, selective media have been used to inhibit the normal flora and cultures are
more easy to interpret. However, in many instances, selective media cannot be used. Many
agents that inhibit the flora also inhibit the pathogens that might be present. Thus, cultures of
these specimens must be examined for the presence of bacteria that are not components of
the normal flora. Since the bacteria that comprise the normal flora vary widely with each body
site, what is normal flora for one site may be a pathogen for another site. Therefore, the
interpretation of what is normal and what is potentially pathogenic, changes with the type of
specimen involved. Those bacteria considered to be potentially pathogenic are subjected to
further tests.
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TABLE 2
General Guidelines for the Initial Examination of Primary Cultures
Specimens Expected to be
Sterile in the Absence of Infection
Specimens Expected to be
Contaminated with Normal Flora
blood
urine
spinal fluid
sputum
joint fluid
swabs of infected site **
tissue biopsy*
drainage from infected site**
aspirate from infected tissue*
feces
*
if body site normally sterile
**
if body site normally harbors a flora or is near a site that harbors a flora
133
E.
LABELING AND REJECTION OF SPECIMENS
1.
Requisitions
It is important that the laboratory requisitions include enough information to enable the
laboratory to do the best job. All that the laboratory knows about the patient is learned from
the requisition. All microbiology requisitions should include information about the source, the
diagnosis and/or history, and the test requested.
Source
The source should be specific. It is not enough to list wound or drainage. The source should
include the anatomic location and type of wound. Is it from the head or the leg? Is it a bite, a
puncture wound, a surgical incision or a skin abrasion?
Diagnosis/History
The diagnosis can sometimes help the technologist suspect growth of a specific organism that
may require special media, a different incubation environment, or a longer incubation time.
Additionally, knowing that the patient has osteomyelitis or pyelonephritis can affect the extent
to which an organism is characterized and can determine the need for antimicrobial
susceptibility testing. Knowledge of a patient’s antibiotic therapy is useful for correlation of test
results.
Test Requested
Every test requested should have a written order on the patient’s chart.
2.
Unacceptable Specimens
The information on the requisition must match the information on the specimen label. If names
or sources do not match, the specimen should be recollected. The laboratory should not
assume the responsibility of liability of questionable information.
Perhaps the best approach to this issue is to divide specimens into two groups - invasive and
noninvasive. A noninvasive specimen, such as urine, sputum, stool, and wounds, must always
be recollected if it is received unlabeled or there is a misidentification. An invasive specimen,
such as blood culture, sterile body fluid, amniotic fluid or an operating room specimen, may be
processed if the person responsible for the error comes to the laboratory and signs a release
form. This places all responsibility and liability on the person signing the form.
All rejected specimens have written documentation sent to the collection site to verify receipt of
the specimen in the laboratory and the reason for its rejection.
134
Other suboptimal specimens that are rejected include the following:








leaking specimens
syringes with needles attached
stools contaminated with urine or barium
anaerobes on inappropriate sources
unpreserved specimens older than 2 hours
refrigerated blood cultures
dried up specimens
specimens in formalin
Processing a suboptimal specimen will always yield suboptimal results.
TABLE 3
Direct Examination of Specimens for Identification of Etiologic Agents
Suspected
Infection
Meningitis
Specimen
Test
Etiologic Agent
Spinal fluid
Gram stain
Any bacteria seen
Syphilis
Scraping from
chancre
Darkfield
Spirochetes (Treponema
pallidum)
Gonorrhea
Urethral exudate
(males only)
Gram stain
Gram-negative diplococci
(Neisseria gonorrhoeae)
Septic arthritis
Joint fluid
Gram stain
Any bacteria seen
Abscess
Aspirate from
abscess
Gram stain
Any bacteria seen
Anaerobic soft tissue Aspirate from
infection
Gram stain
Tuberculosis
Sputum
Acid-fast
stain
Predominant bacteria
possessing bizarre
morphology characteristic
of certain anaerobes
Acid-fast bacilli
(Mycobacterium
tuberculosis)
Pneumocystis
pneumonia
Sputum/deep
respiratory
secretions
Gomori’s
methenamin
e-silver stain
135
(Pneumocystis carinii)
F.
INOCULATION OF PRIMARY CULTURES
Once a specimen has been received by the laboratory and appropriate direct examination has
been performed, it is inoculated onto a series of media for culture. These initial cultures are
called
primary cultures.
1.
Selection of Media for Primary Cultures
Two major factors determine the media to be inoculated for primary cultures. They are the
source of the specimen and the organisms most likely to be in the specimen. Certain types of
organisms cause infections at particular sites more frequently than at other sites. Media for
the recovery of organisms unlikely to be present are not routinely inoculated unless specifically
requested by the physician. Finally, those specimens, like blood and spinal fluid that usually
contain only a single type of pathogen in low numbers, are inoculated into liquid media to
ensure recovery of the pathogen.
Once the media for the primary cultures have been selected, they are inoculated with a small
portion of the specimen. As mentioned previously, if the specimen is urine, cultures must be
inoculated in such a fashion as to allow counting of the number of bacteria present as well as
their recovery. After the appropriate media have been inoculated, the cultures are incubated
overnight at 37˚C (normal human body temperature) either in a normal air atmosphere (media
for nonfastidious Gram-negative organisms), at atmosphere with increased C0 2 (media for
Gram-positive and fastidious Gram-negative organisms), or an anaerobic atmosphere (media
for obligate anaerobes).
2.
Identification of Pathogenic Organisms
From the initial examination of the primary cultures, potentially pathogenic organisms are
selected for further identification tests. The degree to which an organism is identified varies
among laboratories and is determined to some extent by the organism itself.
G.
ANTIBIOTIC SUSCEPTIBILITY TESTS
Pathogenic bacteria recovered on primary cultures are tested for their susceptibility to a variety
of antibiotics. These tests are usually performed at the same time as identification tests. The
results of the tests are ultimately used by the physician as a guide for selection of antimicrobial
therapy for the patient.
Susceptibility tests are not performed on bacteria that are predictably susceptible to
antimicrobial agents commonly used to treat infections caused by these bacteria (e.g.
Streptococcus pyogenes is universally susceptible to penicillin).
In addition to the unpredictable susceptibility profile of a potential pathogen, other factors must
be considered when determining whether antimicrobial susceptibility is warranted:

body site - susceptibility tests are not performed on bacteria that are isolated from the
anatomic site of which they are normal inhabitants (i.e., do not test E. coli isolated from
stool but would if E. coli isolated from blood).
136


presence of other bacteria and quality of specimen - e.g. colony count is important in urine.
host status - some bacteria, which may be normal, may cause disease in an
immunocompromised patient.
A primary objective of antimicrobial therapy is to use the least toxic, most cost-effective, and
most clinically appropriate agents and to refrain from more costly, broad-spectrum agents
when they are unnecessary.
There are certain guidelines that are used when reporting antimicrobials. As a general
guideline, it is suggested that with a particular antimicrobial class, primary (group A) agents be
reported first, and that secondary (group B) agents are reported only if one of the following
conditions exists:




the isolate is resistant to the primary agents
the patient cannot tolerate the primary agents
the infection has not responded to the primary agents OR
a secondary agent would be a better clinical choice for the particular infection.
For example, a primary cephalosporin, such as cephalothin or cefazolin (first generation
cephalosporin), would be a reasonable choice for a susceptible ≥ - 2nd generation (cefoxitin)
or 3rd generation (cefoxaxime) would not be required. An exception would occur in meningitis,
because only 3rd generation cephalosporins effectively cross the blood-brain barrier.
H.
Role of Normal Flora
In the diagnostic approach to all types of infections, one must consider the types or organisms
normally found at the site to be able to determine whether diagnostic microbiology data
indicate the presence of a pathogen. This requires a knowledge of the normal flora to be
expected at each site, the clinical setting and the patient’s presentation.
1.
Discriminating Between Normal Flora and Pathogenic Microorganisms
The consensus concerning what is considered “normal flora” can change with time as new
associations between organisms and disease states are recognized.
2.
The Immune Status of the Host
The defenses of the host with a suspected infection must be evaluated when determining
whether the identification of a specific microorganism is likely to be significant in causing
disease. When considering the likelihood that a microorganism will cause infection in a given
host, both the virulence of the organism and the defenses available to the host to counteract
the establishment and progression of infection must be considered. At one end of the
spectrum of organisms are the normal flora that usually exist as “commensals” for the life of
the normal host without causing disease. At the other end are organisms that often establish
infection and cause disease in the normal host when present in numbers above a certain
threshold. For our purposes, a normal host is considered to be one with mature immunologic
defenses but without specific immunity against the microorganism in question.
In an immunocompromised host, however, microorganisms that are usually not pathogens in a
normal host may cause serious infection. This type of infection is referred to as an
“opportunistic” infection to indicate that a combination of a reduced host response and a
137
pathogen of low virulence has resulted in the establishment of infection. Of course, organisms
exhibiting high levels of virulence also cause disease in immunocompromised hosts. Since the
host response is diminished, infections with virulent pathogens are usually more severe and
more rapidly progressive than in the normal host.
3.
History
Travel and food ingestion history are particularly important in gastrointestinal infections and
food poisoning. A history of travel to countries with less effective sewage sanitation facilities
greatly increases the risk of acquiring an enteric infectious pathogen.
I.
Laboratory Diagnosis of Viral Infections
The cardinal rules in specimen collection are as follows:
1.
Proper Time
Obtain the specimen early in the disease process.
2.
Appropriate Means of Transport
Keep the specimen cool and moist (i.e. refrigerated or on ice).
3.
Proper Specimens
Go “where the action is”.
Methods in Diagnostic Virology
There are three major ways for the laboratory to diagnose viral infections:
1.




2.
Direct Detection of the Virus in the Clinical Specimens
immunofluorescence staining (IF)
enzyme linked immunosorbet assay (ELISA)
electron microscopy (EM)
nucleic acid probes (DNA probes)
Serologic Assays
Indications to perform serologic assays for diagnosis of viral infections are limited. With a few
exceptions, paired sera (acute and convalescent) demonstrating seroconversation or four-fold
rise are required to establish diagnosis of recent infection. Serologic studies are also usually
retrospective because of the need for paired sera. Indications for serology include:




diagnosis of infections with nonculturable organisms such as hepatitis viruses
determination of immune status to rubella, measles, varicella-zoster, hepatitis B
monitoring of immunosuppressed and transplant patients
epidemiologic or prevalence of studies
138
3.
Virus Isolation
In clinical virology, isolation of the virus is the “gold” standard. Traditionally, there are three
methods used for isolation of viruses are cell culture, animal inoculation and the use of
embryonated eggs. Of these methods, cell culture is most commonly used.
139
BENCH OBJECTIVES FOR DIAGNOSIS OF BACTERIAL SEPSIS
REFERENCES:
1.
2.
3.
Cumitech #1A Blood Culture II
Microbiology and Public Health Laboratory Manual
Selected Reference Articles
GENERAL OBJECTIVES:
The goals of this rotation are to ensure that the trainee is capable of understanding the clinical and
technical aspects of laboratory diagnosis of sepsis.
The trainee should understand and be able to communicate the following:
1.
Pathogenesis of septicemia.
2.
Difference between bacteremia and septicemia.
3.
Clinical reasons for collection of blood cultures.
4.
General principles in determining volume, frequency, and number of blood culture collections
in various clinical situations.
5.
Role of instrumentation (e.g. central venous or arterial lines) in the development of bacteremia
and septicemia.
6.
Principles of blood/broth ratios.
7.
Procedures for working up of positive blood cultures including notification of preliminary and
final results.
8.
Role of the medical microbiologist interacting with the attending physician in the care of the
patient with positive blood cultures.
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
Describe the principles, operation, uses, advantages and disadvantages of the following blood
culture systems:
a.
b.
c.
d.
Conventional broth
Lysis centrifugation (Isolator)
i.
Radiometric
ii.
Bactec - infrared
Continuous-monitoring systems
i.
Bactec - fluorigenic
ii.
Colorimetric (Bacti/Alert)
iii.
Other new systems
140
e.
f.
Pressure (Signal)
Bi-phasic media (Roche)
2.
Describe the importance of various ingredients of blood culture media including lytic agents,
resins, SPS, etc.
3.
Describe methods to make early decisions on the presumptive identification and susceptibility
of organisms isolated from blood cultures (e.g. rapid methods according to cell morphology,
pellets, direct I.D./susceptibility).
4.
Understand and recognize difficulties in accurate morphological identification of organisms in
Gram stains from blood cultures.
5.
Understand when incubation of blood cultures should be extended, when blood cultures should
be subcultured, and causes of false positive and false negative blood cultures.
6.
Distinguish contaminants from significant pathogens in blood cultures.
141
BENCH OBJECTIVES FOR INFECTIONS ASSOCIATED WITH
STERILE BODY FLUIDS
REFERENCES:
1.
2.
3.
4.
Cumitech #14
Microbiology and Public Health Manual
(Koneman)
(ASM Manual)
GENERAL OBJECTIVES:
The goal of this rotation is to ensure that the trainee is capable of understanding the clinical and
technical aspects of infections in sterile body sites. The trainee should understand and be able to
communicate the following:
1.
Outline infections of the central nervous system, and other normally sterile body systems
including host-related and virulence-related factors.
2.
List common pathogens in (1)
3.
Compare and contrast the physical, chemical, and cellular features of bacterial, mycobacterial,
fungal, syphilitic, viral and parasitic central nervous system (CNS) infections.
4.
As (3) for other sterile body system infections.
SPECIFIC OBJECTIVES:
At the end of this rotation, the trainee should be able to:
1.
Describe the collection, transportation and processing of:
CSF
synovial fluid
pericardial fluid
peritoneal fluid
vitreous fluid
amniotic fluid
pleural fluid
2.
Describe the characteristics of normal CSF.
3.
Correctly interpret direct Gram stains from sterile body fluids, especially CSF.
4.
Understand the principles of rapid diagnostic tests, specifically antigen-detection tests.
BENCH OBJECTIVES FOR BACTERIAL ANTIGEN DETECTION
REFERENCES:
142
1.
2.
3.
Cumitech #14
Microbiology and Public Health Laboratory Manual
Selected References
GENERAL OBJECTIVES:
The goals of this rotation are to assure that the trainee understands the principles and application of
direct antigen detection for the diagnosis of microbial infections.
The trainee should understand and be able to communicate the following:
1.
Pathogenic mechanisms that result in the appearance of microbial antigens in body fluids and
tissues.
2.
Recognize and be able to differentiate clinical situations where antigen detection may be of
value for early diagnosis.
3.
Timing and collection of appropriate specimens for antigen detection.
4.
Interpretation of antigen results for the provision of appropriate treatment of patients.
SPECIFIC OBJECTIVES:
At the end of the rotation the trainee should be able to:
1.
Describe methods for the detection of microbial antigens in body fluids, including;
a.
b.
c.
d.
Latex agglutination
Enzyme immunoassay (EIA)
Immunofluorescence
PCR
2.
Develop criteria to estimate the sensitivity and specificity of each method.
3.
Describe the most appropriate methods and specimens for identification of antigens from;
a.
b.
c.
d.
e.
f.
Haemophilus influenzae
Streptococcus pneumoniae
Neisseria meningitidis
Escherichia coli
Streptococcus agalactiae
Cryptococcus neoformans
4.
Understand and interpret false positive and negative results.
5.
Determine clinical situations and laboratory manipulations which may prevent a positive result.
6.
Use other clinical information (e.g. CSF protein, glucose, etc.) as aids to antigen detection for
diagnosis of invasive I
143
BENCH OBJECTIVES FOR UPPER AND LOWER
RESPIRATORY TRACT INFECTIONS
REFERENCES:
1.
2.
3.
4.
Cumitech #7A and #10
Microbiology and Public Health Manual
(Koneman)
(ASM Manual)
GENERAL OBJECTIVES:
The goals of this rotation are to ensure that the trainee is capable of understanding the clinical and
technical aspects of respiratory infections.
The trainee should understand and be able to communicate the following:
1.
Define the importance of normal flora in the respiratory tract and explain how alterations may
lead to infectious diseases.
2.
Discuss the basic pathogenic mechanisms of infections diseases of the respiratory tract and
associate the virulence factors of the organisms that cause that disease.
3.
Given the clinical picture presented and the symptoms, associate the most probable organisms
that cause upper and lower respiratory tract infections.
4.
Describe the pathogenesis, risk factors and complications associated with these infections as
well as the types of specimens collected for diagnosis.
5.
Describe the principles and methods of proper specimen collection and transport of respiratory
secretions.
6.
Determine the acceptability for culture of respiratory specimens.
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
Discriminate between normal flora and pathogenic microorganisms, based on colonial and
Gram-stain morphology.
2.
Outline the laboratory diagnosis (to include specimen collection, direct microscopic
examination and culture) for specimens from patients with:
pharyngitis
sinusitis
otitis media
epiglottitis
pertussis
bronchitis and bronchiolitis
144
pneumonia
empyema
3.
Determine the appropriate level of identification and antimicrobial susceptibility testing.
4.
Be able to communicate information on clinical utility of antimicrobials used for respiratory
infections.
145
BENCH OBJECTIVES FOR GASTROINTESTINAL INFECTIONS
CAUSED BY BACTERIA
REFERENCES:
1.
2.
3.
4.
Cumitech #12
Microbiology and Public Health Manual
(Koneman)
(ASM Manual)
GENERAL OBJECTIVES:
The goal of this rotation is to ensure that the trainee is capable of understanding the clinical and
technical aspects of infections in gastrointestinal specimens.
The trainee should understand and be able to communicate the following:
1.
Explain the role of normal microbial flora of the GI tract.
2.
Explain the role of pathogenic mechanisms involved in acute bacterial diarrheas.
3.
List the infectious bacteria known to cause diarrhea.
4.
Give the sources of these infectious agents and describe how they are acquired.
5.
Describe the parameters used for presumptive differential diagnosis.
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
State the common enteric pathogens.
2.
State the differential, selective and enrichment media used in the isolation of enteric
pathogens.
3.
Identify enteric pathogens from stool cultures
recognize possible pathogens on primary culture.
perform and correctly interpret screening tests.
confirm identity of possible pathogens biochemically and/or serologically.
4.
Outline appropriate specimen collection and handling of enteric specimens.
146
BENCH OBJECTIVES FOR URINARY TRACT INFECTIONS
REFERENCES:
1.
2.
3.
Cumitech #2A. Laboratory Diagnosis of Urinary Tract Infection
Microbiology and Public Health Laboratory Manual
Selected References (e.g. Stamm)
GENERAL OBJECTIVES:
The goals of this rotation are to assure that the trainee understands the clinical and technical aspects
of laboratory diagnosis of urinary infections.
The trainee should understand and be able to communicate the following:
1.
Pathogenesis of urinary tract infections.
2.
Prevalence of urinary infections in certain age groups and gender populations.
3.
Clinical reasons for collection of a urine culture.
4.
Methodologies for collection of a urine culture, including timing, volume of culture, etc.
5.
Role of instrumentation (e.g. indwelling catheters, in-out catheters, stents, suprapubic
catheters, etc.) in the collection, analysis and interpretation of urine cultures.
6.
Procedures for working up positive urine cultures including notification of preliminary and final
results.
7.
Role of the medical microbiologist interacting with the attending physician in the care of the
patient with positive urine cultures.
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
Understand and communicate the limitations of reporting of numerical colony counts.
2.
Understand and interpret the quantitation of the urine culture in various patient groups and
according to the type of sample collected.
3.
Distinguish probable causative agents of infection from contaminants of the urine.
4.
Interpret the significance of isolates according to the colony count, type of specimen and
relative degree of contamination, if any.
5.
Determine the appropriate level of identification and susceptibility testing according to the
isolate and colony count.
147
6.
Understand the principles, operation, advantages and disadvantages of alternative methods
for detection of organisms in urine including:
a.
b.
c.
d.
Urine Dip Slides
Chemiluminescence
Leukocyte Esterase and Nitrate
Bactometer
148
BENCH OBJECTIVES FOR MISCELLANEOUS INFECTIONS
(NON-STERILE BODY SITES)
REFERENCES:
1.
2.
3.
Manual of Clinical Microbiology
Microbiology and Public Health Laboratory Manual
Selected References
GENERAL OBJECTIVES:
The goals of this rotation are to assure that the trainee understands the clinical and technical aspects
of cultures from wounds and other non-sterile body sites.
The trainee should understand and be able to communicate the following:
1.
Mechanisms of infections in non-sterile body sites.
2.
Recognize and differentiate pathogens from commensal flora in the culture.
3.
Methodologies for collection of specimens from non-sterile body sites, including aspirates,
biopsies, etc.
4.
Value of anaerobic cultures (see specifics of anaerobic rotation) in the diagnosis of infection
from a wound.
5.
Procedures for working up cultures from non-sterile body sites, including recognition of
circumstances when a preliminary result should be communicated to the attending physician,
and when full identification and susceptibility testing should be performed.
6.
Role of the medical microbiologist interacting with the attending physician in the care of the
patient with a positive wound culture.
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
Demonstrate skill in interpretation of direct Gram smears.
2.
Understand the use of differential and selective media for isolation and identification of
pathogens.
3.
Understand, select and interpret the results of antibiotic susceptibilities for appropriate agents
that may be used to treat pathogens isolated from wounds, etc.
149
4.
Identify potential pathogens from these sites, including both usual organisms such as S.
aureus, and unusual organisms; i.e., Stenotrophomonas, Acinetobacter, Eikenella, Pasteurella,
etc.
5.
Identify anaerobes as causative agents in these infections (e.g. Clostridium species,
Bacteroides species) - also see Bench Objectives for Anaerobes.
150
BENCH OBJECTIVES FOR BACTERIAL INFECTIONS
OF THE GENITAL TRACT
REFERENCES:
1.
2.
3.
4.
Cumitech #4, #17
Microbiology and Public Health Manual
(Koneman)
(ASM Manual)
GENERAL OBJECTIVES:
The goal of this rotation is to ensure that the trainee is capable of understanding the clinical and
technical aspects of infections in genital specimens.
The trainee should understand and be able to communicate the following:
1.
Describe the clinical manifestations produced by the following agents:
Neisseria gonorrhea
Candida albicans
Chlamydia trachomatis
Gardnerella vaginitis
Treponema pallidum subsp. pallidum
Haemophilus ducreyi
Trichomonas vaginalis
2.
Describe the proper specimen collection and laboratory methods used to diagnose the
diseases caused by each of the previously listed organisms.
3.
Differentiate between vaginosis and vaginitis.
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
Define bacterial vaginosis and understand the N-score procedure.
2.
List and recognize, by colonial appearance, probable pathogens from commensal flora in the
following sites:
vagina
cervix
penis
urethra
3.
Identify specimens appropriate and inappropriate for N. gonorrhoea culture
4.
Identify N. gonorrhoeae:
151
5.
conventional methods
enzymatic methods
coagglutination methods
Identify Trichomonas vaginitis:
N-score
wet preps
6.
Outline the method, to include specificity and sensitivity, for direct detection of Chlamydia
trachomatis.
152
BENCH OBJECTIVES FOR BACTERIAL INFECTIONS
OF THE GENITAL TRACT
REFERENCES:
1.
2.
3.
4.
Cumitech #4, #17
Microbiology and Public Health Manual
(Koneman)
(ASM Manual)
GENERAL OBJECTIVES:
The goal of this rotation is to ensure that the trainee is capable of understanding the clinical and
technical aspects of infections in genital specimens.
The trainee should understand and be able to communicate the following:
1.
Describe the clinical manifestations produced by the following agents:
Neisseria gonorrhea
Candida albicans
Chlamydia trachomatis
Gardnerella vaginitis
Treponema pallidum subsp. pallidum
Haemophilus ducreyi
Trichomonas vaginalis
2.
Describe the proper specimen collection and laboratory methods used to diagnose the
diseases caused by each of the previously listed organisms.
3.
Differentiate between vaginosis and vaginitis.
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
Define bacterial vaginosis and understand the N-score procedure.
2.
List and recognize, by colonial appearance, probable pathogens from commensal flora in the
following sites:
vagina
cervix
penis
urethra
3.
Identify specimens appropriate and inappropriate for N. gonorrhoea culture
4.
Identify N. gonorrhoeae:
153
5.
conventional methods
enzymatic methods
coagglutination methods
Identify Trichomonas vaginitis:
N-score
wet preps
6.
Outline the method, to include specificity and sensitivity, for direct detection of Chlamydia
trachomatis.
154
BENCH OBJECTIVES FOR ANTIMICROBIAL SUSCEPTIBILITY TESTING
REFERENCES:
1.
2.
3.
4.
Cumitech #25, #6A
Microbiology and Public Health Laboratory Manual
NCCLS Documents M2 and M7
Lorian: Antibiotics in Laboratory Medicine
GENERAL OBJECTIVES:
The goals of this rotation are to ensure that the trainee understands the clinical and technical aspects
of antimicrobial susceptibility testing.
The trainee should understand and be able to communicate the following:
1.
Mode of action and primary uses of each class and specific antimicrobial agents.
a.
b.
c.
d.
e.
f.
g.
h.
h.
i.
Penicillins and their derivatives
Cephalosporins - 1st to 4th generation
Aminoglycosides
Macrolides
Tetracyclines
Glycopeptides
Metabolic inhibitors (e.g. sulphas, trimethoprim)
Nucleic acid antagonists (e.g. rifampin, nitrofurantoin, fluoriquinolones)
Membrane inhibitors (detergents)
Others
2.
Mechanisms of microbial resistance to antimicrobial agents.
3.
Methodologies used for in vitro and in vivo testing of antimicrobial agents.
4.
Correlation between in vitro testing and in vivo response.
5.
Role of the medical microbiologist interacting with the attending physician to provide clinically
relevant antibiotic susceptibility data.
6.
Appropriate issue preliminary antibiotic susceptibility information.
7.
Indications for performing antimicrobial susceptibility tests.
8.
Develop a program for comparative susceptibility testing of new antimicrobial agents.
9.
Describe a rational, cost-effective program for antibiotic susceptibility testing and reporting in a
small, medium or large hospital or community setting.
SPECIFIC OBJECTIVES:
155
At the end of the rotation, the trainee should be able to:
1.
Understand the principles and techniques for antibiotic susceptibility testing, including:
a.
b.
c.
d.
e.
2.
Describe the quality control of antibiotic susceptibility testing, including:
a.
b.
c.
d.
e.
f.
g.
h.
3.
Disk diffusion test (Kirby Bauer)
Agar diffusion test (replicator method)
Broth dilution (macro and micro)
Gradient endpoint (e.g. E-Test)
Automated systems (e.g. Vitek, Microscan)
Selection of Q.C. strains
Maintenance of antibiotic disks, stock, solutions, etc.
Preparation of antibiotics for testing
Interpretation of NCCLS quality control data
Media
Inoculum and preparation of inoculum
Incubation
McFarland standards, etc.
Describe the rational development of panels for antibiotic susceptibility testing of the following
groups of organisms:
a.
b.
c.
d.
e.
f.
Aerobic Gram negative bacilli
Enterobacteriaceae
Pseudomonads
Aerobic Gram-positive cocci (Staphylococci, Streptococci, and Enterococci)
Aerobic Gram positive bacilli (Corynebacteria, etc.)
Miscellaneous organisms (Stenotrophomonas, Haemophilus, Moraxella, etc.)
Anaerobes
Yeasts and/or fungi
4.
Describe and provide the rationale for cascading of antimicrobial susceptibility results.
5.
Describe screening tests for the detection of resistance in various groups of bacteria, including:
a.
b.
c.
d.
e.
f.
g.
Methods for beta-lactamase testing (e.g. nitrocefin, iodometric, etc.)
Oxacillin screening for pneumococci and staphylococci
Vancomycin screening for enterococci
Screening for extended spectrum beta-lactamase in Enterobacteriaceae
Detection of beta-lactamase negative, ampicillin, resistant (BLNAR) trains of
Haemophilus
Detection of chloramphenicol acetyltransferase (CAT)
Other new problems as they become evident
6.
Understand the basis for MIC and MBC tests and their interpretation.
7.
Describe methodologies for MIC/MBC tests including:
156
a.
b.
c.
d.
e.
f.
8.
Describe the techniques, uses, advantages and disadvantages of methodologies for
determination of antibiotic concentrations in body fluids:
a.
b.
c.
d.
9.
Media
Preparation of antibiotic solutions and dilutions
Incubation
Inoculum preparation, standardization and inoculation
McFarland standards
Interpretation of data (e.g., skipping, Eagle phenomenon, etc.)
Serum bactericidal tests
Bioassays
Enzyme immunoassays
Fluorimetric immunoassays
Explain the meaning of susceptible, intermediate and resistant as applied to antimicrobial
susceptibility test results.
157
BENCH OBJECTIVES FOR ANAEROBES
REFERENCES:
1.
2.
3.
Microbiology and Public Health Manual
Wadsworth Anaerobic Bacteriology Laboratory Manual
ASM Manual.
GENERAL OBJECTIVES:
1.
Differentiate obligate anaerobes from facultative organisms.
2.
Describe how anaerobes, as part of normal flow, initiate and establish infection.
anaerobes at specific
gastrointestinal tracts)
3.
anatomical
sites
(respiratory
tract,
skin,
genitourinary
and
Given the clues to an anaerobic infection (signs and manifestations), give the most probable
etiologic agent of the following:
wound
botulism
gas gangrene
actinomycosis
Lung abscess
peritonitis
4.
Give the bacteriologic indications used to recognize anaerobes as the possible causative
agent.
5.
Describe the clinical infections associated with the following organisms and how they are
acquired and manifested:
Clostridium species
Anaerobic, non-spore forming, Gram-positive bacilli
Actinomyces species
Bacteroides species
Fusobacterium species
Gram-positive cocci
Veillonella sp
SPECIFIC OBJECTIVES:
1.
Describe the laboratory methods of performing and identifying anaerobes:
acceptable/unacceptable specimens
culture environments
isolation media
identification systems (to include disc tests) (presumptive and definitive identification).
158
2.
Outline the parameters to be used to determine susceptibility testing:
when to test
antimicrobial agents to be tested
quality assurance considerations
3.
Describe the acceptable methods for performing anaerobic antimicrobial susceptibility testing.
4.
Give the microscopic, colonial morphology and key reactions in tests used to identify the
following organisms:
C. perfringens
C. tetanus
C. botulinum
Actinomyces israelii
Actinomyces odontolyticus
Bifidobacterium species
Enbacterium species
Mobiluncas species
Prevotella species
Propionibacterium species
Bacteroides species
Porphyromonas species
159
BENCH OBJECTIVES FOR MYCOLOGY
REFERENCES:
1.
2.
3.
4.
Kwon-Chung, Bennett: Medical Mycology
Rippon: Medical Mycology
Microbiology and Public Health Laboratory Manual
Koneman, Roberts: Practical Laboratory Mycology
GENERAL OBJECTIVES:
The goals for this rotation are to assure that the trainee understands the clinical and technical aspects
of examination of laboratory specimens for yeasts and filamentous fungi.
The trainee should understand and be able to communicate the following:
1.
Pathogenesis of different types of fungal infection:
a.
b.
c.
d.
Superficial
Cutaneous or dermatophytic
Subcutaneous
Invasive
2.
Clinical reasons for collection of specimens for fungal examination.
3.
Methodologies of collection of specimens including decontamination, appropriate collection
vehicles (i.e. scraping, biopsies, aspirates, etc.)
4.
Methodologies for transport of fungal specimens.
5.
Rapid techniques for primary identification of the presence of fungal elements in clinical
specimens.
6.
Principles underlying the use of differential incubation temperatures, and length of incubation
required to demonstrate different fungal pathogens.
7.
Differences between primary and opportunistic infections, and the role of “contaminants” in
opportunistic fungal infections.
8.
Interaction of the microbiologist with the pathologist in the examination of samples for fungi.
9.
Interaction of the medical microbiologist with the attending physician in the care of the patient
with a positive fungal specimen.
10.
Issues of safety in the mycology laboratory.
160
SPECIFIC OBJECTIVES:
At the end of the rotation, the trainee should be able to:
1.
Discuss the importance of direct microscopy for examination of fungal elements, including:
KOH
Calcofluor or Fungifluor
Silver stains (e.g. GMS)
PAS
Giemsa
India ink
The trainee should be able to discuss the uses and advantages or disadvantages of these
direct techniques.
2.
Describe the principles, uses, advantages and disadvantages of various primary and selective
media for the isolation of fungi.
3.
Demonstrate the following methods for the identification of yeasts, including their sensitivity
and specificity:
a.
b.
c.
d.
e.
f.
g.
4.
Demonstrate procedures for the identification of molds including;
a.
b.
c.
d.
5.
Germ tube
Cornmeal with or without Tween
Oxgall
Assimilation and fermentation tests
API 20C
Vitek Yeast Card
Other methods
Scotch tape preparations
Tease mounts
Slide cultures
Differential media
Demonstrate and be able to identify where applicable to genus or species level, fungi from the
following groups:
a.
Superficial:
Malassezia furfur
Hendersonula toruloidea
Piedra (Trichosporon beigelii)
b.
Cutaneous (Dermatophytic):
Trichophyton species
Microsporum species
161
Epidermophyton species
c.
Subcutaneous (Demateacious molds)
Cladosporium
Alternaria
Pseudoallescheria boydii
Exophiala
Fonsecaea
d.
Dimorphic:
Histoplasma capsulatum
Blastomyces dermatitidis
Coccidioides immitis
Sporothrix schenckii
Paracoccidioides brasiliensis
e.
Opportunistic:
Aspergillus
Fusarium
Rhizopus, Mucor, etc.
f.
Contaminants:
Penicillium
Scopulariopsis, etc.
g.
Yeasts:
Candida species
Cryptococcus
6.
Understand and be able to interpret serological tests used for the demonstration of fungal
infections including:
a.
b.
c.
d.
methodologies used - immunodiffusion, EIA, latex agglutination
exoantigen tests
use of PCR
new test modalities
7.
Interpret by microscopic and serological results and develop reports that are clinically
meaningful to the attending physician.
8.
Understand the advantages and disadvantages of anti-fungal susceptibility tests and be able to
communicate when such tests may be of value in the management of the patient with a fungal
infection.
162
BENCH OBJECTIVES - ENVIRONMENTAL MICROBIOLOGY
REFERENCES:
1.
2.
Microbiology and Public Health Laboratory Manual
Selected articles
GENERAL OBJECTIVES:
The goals of this rotation are to ensure that the trainee gains an understanding of the role that public
health plays in disease prevention, focusing on:
1.
The testing and monitoring of drinking, recreational and surface water supplies.
2.
The investigation of food- and water-borne disease outbreaks caused by bacterial, viral or
parasitic agents.
3.
The testing of pharmaceutical agents, blood products and other agents purporting to be sterile.
4.
The monitoring of autoclaves to ensure sterility of equipment (i.e. dental instruments, tattoo
needles, and syringes).
The trainee will also understand the interaction of the Public Health Laboratory with Alberta Health,
Alberta Agriculture, Health Protection Branch and Alberta Environmental Protection.
The purpose of epidemiological investigations and the importance of the interaction of public health
personnel, the Medical Officer of Health and the private physicians will be reviewed.
SPECIFIC OBJECTIVES:
1.
Understand the significance of the presence or recovery of “indicator” organisms in water
samples.
2.
Understand the importance of submitting clinical specimens (feces, vomitus, serum), as well as
a complete history, when investigating disease outbreaks.
3.
Understand the procedure for toxin detection in cases of infant or food-borne botulism.
4.
Understand that the recovery of organisms from food and water sources may involve the
concentration of large volumes of sample, and that special pre-enrichment and selective
enrichment methods are ofter required.
5.
Have an awareness of the increasing numbers of pathogens such as Salmonella from sources
including snakes, iguanas and hedgehogs.
6.
Understand the “EPI” protocol for infectious disease outbreaks.
163
ROTATION SPECIFIC OBJECTIVES - VIROLOGY
GENERAL OUTLINE:
1.
Total duration of this rotation will vary according to the season.
2.
The rotation objectives would include hands-on supervised experience through processing one
or more known positive sample(s), - previously tested by the technologists and reported to the
user (discard specimens) in both serology and isolation areas.
3.
A set of 2-3 “unknowns” - positive specimens (viral suspension or clinical specimens) will be
provided to the rotating trainee to be worked on individually. The trainee will keep a log of all
procedures performed and record all results for each step as they arise in addition to final
result. A flow chart-style task/project design should be a starting point of this assignment.
The results and workbook will then be presented to the preceptor (or designate) for review and
discussion.
4.
A fixed time will be set aside for laboratory based and clinical consultation in the field of
virology, done periodically throughout the rotation period with the trainee and the preceptor (or
designate). This period is of great importance, since it will be a basis for development of
graded responsibility, serve as a tool for evaluation of cognitive skills as well as attitudes, and
monitor trainee’s progress. Proposed format - informal laboratory/clinical rounds with virologist
or designate, 3-4 times a week.
5.
Material to be covered in the rotation is contained in rotation-specific objectives; however, any
additional clinical/laboratory experience beyond the objectives is an asset and should be
added on as needed and deemed appropriate by the preceptor and/or trainee.
6.
An evaluation sheet will be filled out by the preceptor and the resident half-way (mid-rotation)
and at the end of rotation period.
164
2A.
SPECIMEN SELECTION FOR MAJOR CLINICAL SYNDROMES
Summary of appropriate specimen collection sites and timing. The information below should be used
as a general guideline. Agent-specific information is presented in the virus isolation chapters.
Agent
Specimen of Choice
Time of Collection
Adenovirus
Throat swab/wash, rectal swab/stool, urine
urine
During symptomatic disease
Chlamydia
Cervical/urethral swab
During symptomatic disease
C. difficile toxin
Stool
During symptomatic disease
Cytomegalovirus
Urine, throat swab/wash, buffy coat
During symptomatic disease
Enterovirus
Throat swab, CSF, stool/rectal swab
First week of symptoms
Herpes simplex
Vesicle fluid/swab, throat/mouth swab,
vaginal swab
First 3 days of lesion
Hepatitis A
Serum, stool, liver, kidney
First 8 days of symptoms
Influenza
Throat/NP wash or swab, BAL
First 3 days of symptoms
Measles
Throat swab, urine, blood
First 2 days of symptoms
Mumps
Throat swab, urine, blood
First 7 days of symptoms
Parainfluenza
Throat/NP wash or swab
First 3 days of symptoms
RSV
NP wash/aspirate/swab, throat swab
First 3 days of symptoms
Rhinovirus
NP wash/swab
First 2 days of symptoms
Rotavirus
Stool
First 4 days of symptoms
Rubella
Throat swab, stool, urine
First 4 days of symptoms
Varicella-Zoster
Vesicle fluid/swab, lesion swab
First 2 days of symptoms
Summary of appropriate specimen collection sites associated with various clinical presentations. This
information is provided as a general collection guide. Agent-specific information is presented in the
virus isolation chapters.
Clinical Presentation
Specimen of Choice
Other Specimens
Bronchitis/Bronchiolitis
Nasopharyngeal swabs, washes, and
aspirates
Broncheoalveolar lavage
Colds, Upper Respiratory Tract
Infections
Nasopharyngeal swabs, washes, and
aspirates
Throat swabs
Croup
Nasopharyngeal swabs, washes or
aspirates
Throat swabs
Exanthems
Vesicle swab and/or fluid
Gastroenteritis
Stool
Rectal swab
Influenza syndrome
Nasopharyngeal swabs, washes, and
aspirates, sputum
Throat swabs or throat washes
Meningitis
Cerebrospinal fluid (CSF)
Throat swab, stool, or
rectal swab
Pharyngitis
Nasopharyngeal swab, wash, or
aspirates, throat wash or swab
Pneumonia or Lower Respiratory
Tract Infections
Nasopharyngeal or tracheal aspirates
or washes, broncheoalveolar lavages
165
Nasopharyngeal or throat swabs
2B.
SPECIMEN SELECTION FOR MAJOR CLINICAL SYNDROMES
Specimens for virus isolation and direct detection
Source or clinical symptoms
and common etiologic agenta
Upper respiratory
Rhinovirus
Influenza virus
Parainfluenza virus
Adenovirus
Enterovirus
Cytomegalovirus
Epstein-Barr virusb
Reovirus
Lower respiratory
Specimen source for virus isolation and direct detection
Clinical
Biopsy tissue
Naospharyngeal swab, nasal wash (throat
Tonsil, lymph node
swab)
Endotracheal aspirate, bronchial wash,
bronchoalveolar lavage (sputum)
Lung, bronchus, trachea
Lesion swab, lesion fluid
Multiple organs
Influenza virus
Respiratory syncytial virus
Parainfluenza virus
Cytomegalovirus
Chlamydia pneumoniae
Mycoplasma pneumoniae
Vesicular lesions
Herpes simplex virus
Varicella-zoster virus
Enterovirus
Exanthemas
Herpesvirus 6
Parvovirus (B19)b
Enterovirus
Rubeola (measles) virus
Rubella virus
Rickettsia spp.b
Central nervous system
Enterovirus
Herpesvirus family
Arbovirus
Posttransplantation syndromes
Herpes simplex virus
Cytomegalovirus
Epstein-Barr virus
Herpesvirus 6
Congenital anomalies
Cytomegalovirus
Herpes simplex virus
Rubella virus
Varicella-zoster virus
Enteritis and diarrhea
Rotavirus
Enteric adenovirus
Astrovirus
Calicivirus (Norwalk agents)
Nasopharyngeal swab (throat swab, stool)
CSF, nasopharyngeal swab
Brain
Throat swab (urine)
Transplanted organ
Nasopharyngeal swab, urine
Affected organ(s)
Stool
Colon
aSpecimens
b
in parentheses are secondary choices.
Diagnosis by serology, rarely by isolation or direct detection.
166
3.
CELL CULTURE SYSTEMS - AN OVERVIEW

Common cell lines: species origin, tissue origin, cell morphology
 Primary
MK, RK (HEK, GPE, CE and other)
 Passaged cell strain or line
MRC 5, Hep-2, HeLa, Vero, KB, Hel (BSC-1, RK-13, BHK-21, A549, HDF and other)
 Cell culture preparation and maintenance:
Media/solutions: MEM, Hanks BSS, etc.
Incubator, roller drum apparatus
Contaminants: bacterial/viral/mycoplasma

Selection of appropriate/relevant cell lines
Cell lines indicated for processing of routine* specimens
Source
Respiratory
Expected Virus
Cell Line
RSV
Influenza A/B
AGMK
RHMK
Adenovirus
HEP2
Enterovirus
VZV, HSV
Skin / mucous membranes
VZV, HSV
AGMK
Coxsackie A
Eye
CSF
HSV
AGMK
Adenovirus
HEP2
Enterovirus
AGMK
HSV
RHMK
Mumps
HEP2
AGMK
Stool
Adenovirus
RHMK
Enterovirus
HEP2
Suspected CMV
MRC-5 shellvials
HEL
* For details, see virology manual
167
4.
INOCULATION OF CELL LINES

Inoculation techniques

Enhancement of viral infectivity
 Postinoculation centrifugation
 Biochemical enhancement (theory only)
5.
EXAMINATION OF CELL CULTURES FOR VIRAL ACTIVITY/VIRAL ISOLATION AND
IDENTIFICATION (METHODS)

CPE in susceptible culture (HSV, VZV)

Hemadsorbtion/hemagglutination (Influenza, parainfluenza, measles)

Embryonated egg inoculation (VZV, influenza)

Spin-amplification shell vial assay (CMV)

Virus inclusions (SSPA) (demo only - slides/kodachromes)

Confirmation of viral identity:
 Antibody-based techniques (Fluorescent Ab)
 Electron microscopy
 DNA hybridization (Refer to Molecular Diagnostics for theory, demonstration and
practical experience)
 PCR (Refer to Molecular Diagnostics for theory, demonstration and practical
experience)
 Neutralization tests (theory only)
6.
DIRECT VIRAL ANTIGEN DETECTION: COLLECTION AND PROCESSING

Principle of immunofluorescent/immunoenzyme staining - EM, FA, EIA, other: PCR,
DNA probes (theory; see appendices for diagrams)
168

Specimen handling, preparation and processing:
 Vesicular lesion smears
 nasopharyngeal smears
 Cell sediments smears (buffy coats, tissues, etc.)

Electron microscopy
 Sensitivity
 Specimen selection: diagnostic utility (diseases/organisms)
 Laboratory procedures:
Thin section (theory)
Negative staining technique(s)
Agar diffusion
Immune EM
 Review of photomicrographs of major viruses
6A.
PRACTICAL EXAMPLES
EM for: Rotavirus, Norwalk
FA testing for: HSV, VZV, RSV, Adenovirus, influenza, parainfluenza
PCR for: HSV, Enteroviruses, VZV (to be done in Molecular Diagnostics)
7.
DIAGNOSTIC TESTS FOR IDENTIFICATION OF SPECIFIC VIRAL INFECTIONS
Herpes
VZV
RSV
Parainfluenza
Mumps
Rhinovirus
Hepatitis A, B, C, D, E
Enteroviruses
HIV/HTLV
Other (Arbovirus, Hantavirus)
CMV
EBV
Influenza
Measles
Rubella
Adenovirus
Rotavirus
Rabies
Pox
169
8.
VIRAL SEROLOGY

Specimen collection, transport and storage

Basic concepts review: screening vs. confirmatory testing, sensitivity/specificity PPV, NPV
- low/high prevalence population

Method overview
Discussion and demonstration:
 Neutralization
 EIA
 IFA
 Western blot (Refer to Molecular Diagnostics for theory, demonstration and practical
experience)
 PCR (Refer to Molecular Diagnostics for theory, demonstration and practical
experience)
Discussion only:
 CFT
 FIAX
 Hemagglutination assays
 Hemolysis inhibition
8A.
AVAILABLE TESTS - OBSERVE/PERFORM
IgG/IgM antibody detection for:
CMV, EBV, VZV, HSV
HIV, HTLV
Hepatitis A, B, C
Rubella, measles, mumps
Parvovirus
8B.
SERODIAGNOSIS OF MAJOR VIRAL INFECTIONS

Discussion of: methods, advantages/disadvantages, clinical utility/interpretation, limitations
of the procedures
170
 HIV
 Hepatitis
 Rubella
 Other (EBV, HSV, measles, influenza/parainfluenza)
9.
TEST OPTIMIZATION IN VIROLOGY
e.g.:
10.
RSV for DFA - when to test (seasonality)
HSV in patients with lesions: culture vs. serology
INTERPRETATION OF VIROLOGY RESULTS:

Laboratory problem solving/troubleshooting
 Blood sample crushed in a centrifuge
 Mycoplasma contamination of tissue cultures
 Positive control reading as (-) in an automated EIA test
 Inadequate specimen collected and/or wrong timing
 Cell culture ? contaminated with an animal virus

Clinical consultations:
PBL - style illustrative mini case discussions:
 Pregnant contact of varicella
 Newborn with multiple congenital abnormalities
 IV drug abuser donating blood
 Needlestick injury in a lab worker
 MVA victim as a potential organ donor
 Returning traveller with fever and jaundice
 Toddler with fever and maculopapular rash
 Elderly bronchitic in the settling of a large influenza epidemic
 Infant in severe respiratory distress
171
 Outbreak of diarrhea in a daycare centre/nursing home
 Otherwise healthy young male with encephalitis
 Student with sore throat and lymphadenopathy
 Teenager bitten by a stray dog
 Returning missionary (Africa) with fever, DIC and multiorgan failure
 Painful corneal ulcer in a cold sore sufferer
 Advice to pathologist working in autopsy suite
11.
UNKNOWN SPECIMENS
The trainee will keep a log of all procedures performed and record all results for each step as
they arise in addition to final result.
A flow chart-style task/project design should be a starting point of this assignment.

Viral Isolation
 Identify virus in suspension or patient’s sample (source provided)

Serology
 Identify a positive serum (a short clinical history provided)
172
MODIFIED OBJECTIVES - DERMATOLOGY
(Short Rotation)
1.
LABORATORY ORIENTATION AND SPECIMEN RECEIVING
A.
Introduction to diagnostic laboratory and staff
B.
Basic principles of laboratory safety:
Universal precautions
Basic understanding of WHMIS
General safety and protective measures
Use of biosafety cabinets
Use of disinfectants
C.
Overview of specimen collection, transport and storage
Types of specimens
Sites of collection
Quantity and timing
Collection devices
D.
Initial sorting and handling of clinical specimens:
Swabs
Tissues/sterile fluids
Aspirates (pus, wound drainages, etc.)
Specimens for anaerobe investigation
Bloods
Urines
Sputums
Stools
Other (if not listed above)
E.
Laboratory techniques:
Proper handling of biological specimens and culture media
Preparation of smears for direct microscopic examination
Sterile inoculation techniques
Incubation of cultures (atmosphere/temperature)
F.
Specimen rejection criteria and policies
173
G.
Initial processing of selected specimens / choice of culture media:
Wound swabs
Purulent exudates (including anaerobic cultures)
Tissues
Skin scrapings for Mycology (may be covered in Mycology rotation)
Burns
Intravenous catheters (IV tips)
H.
Direct staining of clinical specimens:
Gram smear
Ziehl-Neelsen/Auramine-rhodamine
FA staining (any example - may be covered in virology rotation)
Calcofluor white (may be covered in mycology or parasitology rotation)
2.
PARASITOLOGY
A.
Brief overview of methods:
Stool preservatives
Concentration techniques
Routine (stool) stains, tissue stains and microscopy:
Wet mount
Trichrome or Iron Hematoxylin, Kinyoun
Giemsa
Calcofluor white, GMS
B.
Demonstration of parasites of skin and subcutaneous tissues:
Arthropods (Lice, mites/scabies, fleas, ticks, myiasis)
Amoebae (free living and E. histolytica)
Leishmania sp
Strongyloides stercoralis and hookworm larvae
Filariae (discuss skin snip procedure)
C.
Self study: parasitic diseases involving skin and subcutaneous tissue

Dermatitis
Leishmania sp
Schistosoma spp
Strongyloides stercoralis
Cutaneous larva migrans
Ankylostoma brasiliense, canis
other
Filaria spp
Loa loa
174
Onchocerca volvulus
Gasterophilus sp
Sarcoptes scabiei, mites, lice

Rash/Hives
Ascaris lumbricoides
Schistosoma spp
Trichinella spiralis
Toxoplasma gondii
Trypanosoma gambiense/rhodesiense

Abscess
Filaria spp
E. histolytica

Nodule/Swelling
Calabar swelling (L. loa)
Chagoma (T. cruzi)
Taenia solium
Onchocercoma (O. volvulus)
Coenurosis (Multiceps multiceps)
Echinococcus granulosus
Sparganum sp
Hypoderma sp
Dermatobia sp
Winterbottom’s sign (Trypanosoma gambiense/rhodesiense)

Trophic Skin Changes, Various
L. donovani
S. haematobium
W. bancrofti
Brugia malayi
O. volvulus
Prediculus humanus

Cutaneous Ulcer
L. tropica complex
L. brasiliensis
T. gambiense/rhodesiense
E. histolytica
Dracunculus medinensis
3.
MYCOLOGY (Superficial mycosis)
175
A.
Specimen selection
B.
Brief overview of methods:
Direct microscopy: KOH/wet mount, PAS, calcofluor white
Overview of selective media and growth characteristics
Germ tube test for yeast identification
Brief overview of (relevant) commercial kits
C.
Demonstration of direct microscopical appearance and colonial morphology
Candida spp (including, but not limited to C. albicans)
Geotrichium
Rhodotorula
Sporothrix schenkii
Dermatophytes (including a selection of unknowns to be identified from microscope or
Kodachrome slides)
Aspergillus sp
Penicilium spp
Other as deemed necessary/interesting
D.
Self study:
Saprophytic vs. opportunistic fungi
Diagnosis of superficial mycoses
4.
GENERAL BACTERIOLOGY
A.
Function and primary purpose of media
Blood agar (BAP)
Chocolate
MacConkey
Mannitol salt
Brain heart infusion (BHI)
Supplemented peptone broth (SPB)
PEA
B.
Primary purpose of biochemicals/tests
Catalase
Coagulase (slide and tube)
DNA se
Bacitracin
Optochin
Bile solubility
Strep grouping
Bile esculin
PYR
176
Oxidase
Satellitism
ALA
Indole
Urea
C.
Brief overview of Vitek automated identification system (demo only)
D.
Common microbiology tests/procedures: lab workup and interpretation
Demonstration of plates with mixed flora and how pure cultures are obtained.
Demonstration of common potential pathogens and contaminants/normal flora of the
wound, abscesses, skin/subcutaneous tissue specimens, central and peripheral line
tips, burns, etc. (swabs, aspirates, tissues, other).
Interpretation and assessment and significant quantitation/colony count of common
pathogens on the primary plates.
Correlation of direct smear results with colony types and numbers of primary culture
plates.
Demonstration of correct recognition and assessment of amounts of common aerobic
and anaerobic organisms.
E.
Review of isolation and identification procedures for selected (special emphasis)
organisms:
Staphylococci
Streptococci
Hemophilus influenzae
Corynebacteria
Pseudomonas
Enterobacteriaceae
177
F.
Self study:
Surface skin flora and its relative pathogenicity in skin and soft tissue infections.
Agents of wound, superficial skin infections, cellulitis and fasciitis/myositis /myonecrosis
(aerobic and anaerobic).
Special protocols: quantitative burn biopsies, semiquantitative line tip cultures.
5.
ANAEROBIC BACTERIOLOGY
A.
Review of anaerobic specimen collection and transport systems: diagnostic value of
different specimen types (e.g.: swabs vs. aspirates or tissue biopsies, specimens
unsuitable for anaerobic cultures).
Syringe/needle
tube/vial
swab/plastic jacket system
bio-bag/plastic pouch
B.
Anaerobic cultivation systems - demonstration:
Anaerobic jar/holding jar
Anaerobic glove box
C.
Function and primary purpose of media:
Anaerobic BAP
PEA
Anaerobic BHI
BBE
Other
D.
Identification of major anaerobic pathogens:
Clostridium sp (Nagler reaction)
Bacteroides sp
Actinomyces sp
Anaerobic cocci
E.
Gas liquid chromatography for bacterial identification (demonstration)
F.
Self Study:
Relationship of bacteria to oxygen: oxygen tolerance/redox potential, anaerobe-aerobe
synergism.
Normal human anaerobic flora
 mouth/oral cavity
178



upper respiratory tract
skin/mucous membranes
other sites: gastrointestinal tract, genital tract, urethra, etc.
Indications for cultures: problems, pitfalls and limitations of anaerobic bacteriology.
Human anaerobic infections of exogenous and endogenous origin, with particular
emphasis on:







superficial skin/wound infections
cellulitis
myonecrosis
actinomycosis
animal/human bites
pseudomembraneous colitis
antibiotic-associated diarrhea
179
Medical Microbiology Rotation Schedule
This is the general guide for Medical Microbiology Rotations for General Pathology Residents. Topics
and timing may be altered as required to fit both resident and laboratory schedules.
Week
General Area/Topic
Location
Number
1
General Orientation – Maria Ackney UAH
2.
Specimen Receiving
UAH
3
Quality Control /Culture Media
UAH
4
General Bacteriology Pods
UAH
5
General Bacteriology Pods
UAH
6
General Bacteriology Pods
UAH
7
Blood cultures
UAH
8
Enterics
UAH/PL
9
Antimicrobial susceptibility Testing I
UAH
10
Anaerobes
UAH
11
Genitals
UAH
12
Infectious Diseases Pod
UAH
13
Review and examination
UAH
End of First Rotation
14
Mycobacteriology
PL
15
Mycology
UAH/National Centre
16
Reference Microbiology
UAH/PL
17
Viral Culture/Direct Detection
UAH/PL
18
Viral serology
UAH/PL
19
Viral serology
UAH/PL
20
Chlamydia/Mycoplasma
UAH/PL
21
Molecular Diagnostics
UAH/PL
22
Parasitology
UAH
23
Infection Prevention and Control
UAH
24*
Community Microbiology
DynaLIFE
25*
Community Microbiology
DynaLIFE
26
Review and Examination
UAH
End of Second Rotation
* Residents usually spend the last 6 months of their program at DynaLIFE and are again exposed to
Microbiology during that time. They also attend regular microbiology sessions given by RP Rennie as
Royal College Examination preparation
In addition, the residents are expected to attend the following seminars, rounds, etc.
Daily: Infectious diseases plate rounds.
Monday AM (optional): Infectious Diseases Journal Club
Tuesdays: Academic half day – microbiology seminars and central didactic teaching series.
Thursdays: Infectious Diseases Rounds
Fridays (usu.) Topic sessions with RP Rennie
Graded Responsibility for service on-call is established after the resident has been in the laboratory
for 4 – 5 weeks. A senior microbiologist is always available for back-up.
180
ROTATION SPECIFIC OBJECTIVES IN NEUROPATHOLOGY
General Pathology Residents
Selection: Mandatory
Site: University of Alberta Hospital
Preceptors: Dr. E.S. Johnson and Dr. L. Resch
Length of rotation: Four weeks
Prerequisites: PGY 2
Specific Objectives:
MEDICAL EXPERT



















To have a general knowledge of the macroscopic neuroanatomy of the brain and spinal cord, including
blood supply.
To be familiar with the microscopic anatomy of major neuroanatomic structures of the brain.
To acquire in depth knowledge of the major classes of tumors of the nervous system.
To be acquainted with the macroscopic and microscopic pathologic features of cerebral infarcts and
ischemia, cerebral hemorrhages of different causes, infections of the nervous system, craniocerebral
trauma, and common neurodegenerative diseases.
To demonstrate an understanding of the appropriate use of basic histologic techniques, including
immunohistochemistry and electron microscopy, in the examination of the nervous system.
To understand the applicability of enzyme histochemistry in the examination of muscle biopsies, and to
recognize the microscopic features of denervation, muscular dystrophy, myopathy and inflammatory
myopathies and vasculopathies.
To perform basic dissections in the removal of the brain and spinal cord, and to prepare these tissues
for subsequent study.
To be familiar with standard safety precautions in the removal of the brain in situations of infectivity (i.e.,
HIV infection, prion disease).
To be able to dissect the brain and spinal cord in accordance with standard neuropathologic
techniques, and select appropriate tissues for microscopic examination.
To be able to handle neurosurgical specimens for frozen section, preparation of smears, and
interpretation of these techniques to render a verbal diagnosis.
To be able to examine macroscopically neurosurgical specimens and to appropriately sample these
specimens for microscopy.
To gain confidence and develop an interest in examining tissue from the nervous system.
To understand the methodological differences required in examining neuropathological specimens
compared to general surgical pathology.
function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care
establish and maintain clinical knowledge, skills and attitudes appropriate to their practice
perform a complete and appropriate assessment of a patient
use preventative and therapeutic interventions effectively
demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic
seek appropriate consultation from other health professionals, recognizing the limits of their
expertise
COMMUNICATOR

To be able to formulate reports based upon macroscopic and microscopic observations for autopsy and
neurosurgical specimens, with suitable clinicopathologic correlations.
181







Assist in the continuing education of physicians and other members of the hospital staff by participating
in conferences and case presentations
To act as consultants to clinical colleagues on the interpretation and relevance of pathological findings,
with particular regard to their significance in the management of the patient.
develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed)
accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals
accurately convey relevant information and explanations to colleagues and other professionals
develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families
convey effective oral and written information about a medical encounter
COLLABORATOR

To demonstrate the ability to advise on the appropriateness of obtaining histological, cytological and
autopsy specimens and to advise on further appropriate investigations including infection control and
safety.


participate effectively and appropriately in an interprofessional healthcare team
effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict

Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life
Allocate finite health care and health education resources effectively to optimize patient care and lifelong learning
MANAGER





participate in activities that contribute to the effectiveness of their healthcare organizations and
systems
manage their practice and career effectively
allocate finite healthcare resources appropriately
serve in administration and leadership roles, as appropriate
HEALTH ADVOCATE



Identify the important determinants of health affecting patients pertaining to neuropathological
processes
As a member of the interdisciplinary team of professionals responsible for patient health, the resident
will assist in regularly evaluating laboratory practices and test selections to determine that they meet
community needs
Recognize and reinforce to the public and to the medical profession the essential contribution of
laboratory medicine to health





respond to individual patient health needs and issues as part of patient care
respond to the health needs of the communities that they serve
identify the determinants of health of the populations that they serve
promote the health of individual patients, communities and populations
acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports




Develop and implement a personal continuing educational strategy
Apply the principles of critical appraisal to sources of medical information
Contribute to the development of new knowledge through research
Participate in rounds, conferences and teaching sessions
SCHOLAR
182




maintain and enhance professional activities through ongoing learning
critically evaluate information and its sources, and apply this appropriately to practice decisions
facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate
contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices
PROFESSIONAL








Deliver the highest quality of care with integrity, honesty and compassion
Practice medicine in an ethnical manner and with a sensitivity to diverse patient and co-worker
populations
Exhibit appropriate professional behavior and perform duties in a dependable and responsible manner
Demonstrate commitment to excellence and ongoing professional development
demonstrate commitment to excellence and ongoing professional development
demonstrate a commitment to their patients, profession, and society through ethical practice
demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation
demonstrate a commitment to physician health and sustainable practice
Outline of Rotation:
1.
2.
3
4.
5.
6.
7.
8.
9.
Residents are expected to undertake the reading assignments as listed in “Educational Materials”.
Residents are to attend and participate as necessary in Neuropathology-Braincutting Conferences,
Muscle Biopsy Conference, and Neuroscience Rounds.
Residents are expected to be present at all frozen sections and to gross neurosurgical specimens
under supervision of attending neuropathologist.
Residents will attend sign-out of neurosurgical specimens, and prepare reports on assigned cases.
Residents will review muscle biopsy specimens with neuropathologist.
Residents will participate in dissection and blocking of autopsy brains, and review microscopy and
dictate reports on assigned cases.
Residents will undertake with attending neuropathologist autopsies on neuropathology cases and
complete these cases.
Residents are expected to learn techniques of removal of the brain on all cases coming to autopsy.
Residents will review teaching cases in slide boxes with neuropathologists.
Educational Materials:
Suggested reading 1.
Burger, P.C., Scheithauer, B.W. Tumors of the Central Nervous System, Atlas of Tumor Pathology,
Third Series, Fascicle 10, AFIP, 1994.
2.
Kleihues, P., Cavenee, W.K. Pathology and Genetics of Tumors of the Nervous System, International
Agency for Research for Cancer, Lyon, 2000.
3.
Gray, F., DeGirolami, U., Poirier, J., Escourolle and Poirier’s Manual of Basic Neuropathology, 4 th
edition, Butterworth Heinemann, 2004.
4.
Parent, A. Carpenter’s Human Neuroanatomy, 9th edition, Williams and Wilkins, Baltimore, 1996
(Chapters 1,2, and 4)
5.
Ellison, D., Love, S., et al. Neuropathology, 2nd edition, Mosby Ltd., 2004.
6.
Graham, D.I., Lantos, P.L. Greenfield’s Neuropathology, 6th edition, Arnold, London, 1997.
7.
Bigner, D.D., McLendon, K.E., Bruner, J.M. Russell and Rubinstein’s Pathology of Tumors of the
Nervous System, 6th edition, Arnold, London, 1998.
183
Residents are expected to read references 1 or 2, assigned chapters in references 3 and 4, and be able to use
as resources for further depth of reading references 5, 6, and 7.
Conferences 1.
Neuropathology Conference, weekly (Friday, 10:00 – 11:00 a.m.)
2.
Neuroscience Clinical Conference, weekly (Friday, 9:00 – 10:00 a.m.)
Evaluation:
1.
2.
On-going daily oral examination of the resident.
Assessment of ability to make correct microscopic diagnosis, and quality of completed reports.
3.
Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
April 2006
184
ROTATION SPECIFIC OBJECTIVES
PEDIATRIC AND PERINATAL PATHOLOGY
CYTOGENETICS AND MOLECULAR CYTOGENETICS
Selection:
Sites:
Preceptors:
Teachers:
Length of Rotation:
Prerequisites:
Mandatory.
University of Alberta/Stollery Children’s Hospital;
Royal Alexandra Hospital.
Dr. Atilano Lacson/Dr. Consolato Sergi
Dr. Atilano Lacson
Dr. Consolato Sergi
Dr. Nenad Lilic
Dr. Suzanne Chan
Five weeks.
PGY 3 OR higher.
OBJECTIVES:
MEDICAL EXPERT







Function effectively as pathology consultants, integrating all of the CanMEDS Roles to provide
optimal, ethical and patient-centered diagnostic care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to Pediatric and
Perinatal Pathology, Cytogenetics and Molecular Cytogenetics.
Perform a complete and appropriate assessment of gross and histologic aspects of pediatric
and perinatal patient specimens.
Demonstrate proficient and appropriate use of procedural diagnostic skills, including triage of
tissues for specialized studies, including Cytogenetics and Molecular Cytogenetics.
Seek appropriate consultation from other pathologists, recognizing the limits of their expertise.
Utilize all knowledge databases to bear to help with the diagnostic efforts and dilemmas that
he/she encounters.
Demonstrate sufficient scientific curiosity to convey new information to colleagues, superiors
and the medical community locally and internationally, when possible.
COMMUNICATOR





Develop rapport, trust and professional relationships with other physicians and allied laboratory
workers and, where appropriate, with patients and families.
Accurately elicit and synthesize relevant information and perspectives of clinical colleagues and
other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on diagnostic issues and problems; plans and discusses
solutions accordingly with colleagues and other professionals to develop a shared plan of care in
the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR

Participate effectively and appropriately in interprofessional diagnostic and clinical healthcare
teams
185

Effectively work with other colleagues and superiors within the Department, other health
professionals and human resource experts to prevent, negotiate, and resolve interprofessional
conflict.

Participate in clinical-pathologic discussions that contribute to the effectiveness of the healthcare
organizations and systems.
Manage their practices and careers in a goal-directed fashion to recognize and/or create
opportunities for advancement in a progressive manner.
Use diagnostic resources effectively and allocate finite healthcare resources appropriately by
streamlining diagnostic algorithms and balancing this with opportunities for learning.
Serve in administrative and leadership roles, when called upon to do so, or during unforeseen
events, as appropriate.
MANAGER



HEALTH ADVOCATE





Respond to individual patient diagnostic needs and issues as part of patient care promptly,
appropriately, and respectfully.
Respond to the larger pathology diagnostic needs of the pediatric communities that they serve.
Identify the determinants of health of the pediatric populations that they serve.
Promote the health of individual children, pediatric communities and pediatric populations and
their caregivers.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of pathology
diagnostic reports.
SCHOLAR




Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL




Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
186
Outline of Rotation:
Rotation
Duration
Site
Pediatric and Perinatal Surgical and
Autopsy Pathology
4 weeks
University of Alberta / Stollery
Children’s Hospital
Royal Alexandra Hospital
At the end of this rotation, the learner will be able to:
1.
Discuss the gross and microscopic pathological characteristics of commonly encountered
benign and malignant neoplasms in children of various age groups.
2.
Describe the features of various congenital syndromes leading to malformations based on
pathogenetic mechanisms where possible.
3.
Illustrate the pathophysiology of commonly encountered conditions in the fetal and neonatal
period, and their clinical effects.
Cytogenetics and Molecular Cytogenetics
1 week
University of Alberta
Cytogenetics Laboratory
At the end of this rotation, the learner will be able to:
1.
Integrate a sound understanding of the principles behind cytogenetic and molecular
cytogenetic testing and interpretation and how these principles are utilized to guide genetic
counseling.
2.
Generate a morphogenetic differential diagnosis of cases based on major features.
3.
Describe possible molecular pathogenetic mechanisms of commonly encountered inherited or
sporadic diseases.
187
Educational Materials:
1.
Pediatric Pathology Textbooks housed in pathologists’ offices.
2.
Resident Library
3.
University of Alberta Library Services
4.
Online journals and websites for additional learning materials.
5.
Proceedings of recent national and international conferences.
6.
Glass and photograph slide collections of teaching cases with individual pathologists.
Evaluation:
Overall assessment is based on a standard resident evaluation form distributed through Webeval.
To be approved by RPC
188
ROTATION SPECIFIC OBJECTIVES
SURGICAL PATHOLOGY
Selection:
Site:
Co-preceptors:
Length of Rotation:
Prerequisites:
Mandatory
DynaLIFE DX Diagnostic Laboratory Services Core Lab
Dr. Carolyn O’Hara
Minimum of 4 weeks
Minimum experience of a PGY3 resident.
Only one resident in AP and one in Cytology (ie two individuals) will be
accommodated at DynaLIFE at any one time.
Specific Objectives:
MEDICAL EXPERT














Develop expertise in the examination, description, accessioning and record-keeping,
dissection and sampling of gross surgical pathology specimens for pathologic examination
Develop expertise in the pathologic examination of surgical specimens, including the use of
special stains and immunoperoxidase phenotyping techniques
Develop expertise in the accurate and timely compilation of surgical pathology reports to
communicate pathological findings and make relevant clinical assessment and appropriate
recommendations with regard to the subsequent management of patients
Develop the ability to consult with both clinical and pathology colleagues to effectively assist in
the management of patients
Develop critical reading skills to evaluate and incorporate new information as published in the
scientific pathologic literature, and to share with and teach such information to colleagues and
peers and develop and adopt appropriate continuing educational habits
Develop leadership, managerial and communication skills related to the effective and efficient
running of a pathology laboratory
Develop an understanding of evidence-based medicine, and good laboratory practice
Become familiar with laboratory accreditation procedures and appropriate quality assurance
and quality control mechanisms, including acceptance of and participation in peer review
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice
Perform a complete and appropriate assessment of a patient
Use preventative and therapeutic interventions effectively
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise
COMMUNICATOR



Assist in the continuing education of physicians and other members of the staff by participating in
conferences and case presentations
Act as consultant to clinical colleagues on the interpretation and relevance of pathological
findings, with particular regard to their significance in the management of the patient
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed)
189




Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals
Accurately convey relevant information and explanations to colleagues and other professionals
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families
Convey effective oral and written information about a medical encounter
COLLABORATOR




Demonstrate the ability to advise on the appropriateness of obtaining histological and cytological
specimens and to advise on further appropriate investigations
Collaborate with colleagues at all levels in the pathology laboratory, particularly in respect of
consultation, peer review and continuing professional development
Participate effectively and appropriately in an interprofessional healthcare team
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict
MANAGER







Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life
Allocate finite health care and health education resources effectively to optimize patient care
and life-long learning
Develop skills in the management of technical and support staff in the laboratory
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems
Manage their practice and career effectively
Allocate finite healthcare resources appropriately
Serve in administration and leadership roles, as appropriate
HEALTH ADVOCATE








Identify the important determinants of health affecting patients pertaining to pathological
processes
As a member of an interdisciplinary team of professionals responsible for patient health, the
resident will assist in regularly evaluating laboratory practices and test selections to determine
that they meet community needs
Recognize and reinforce to the public and to the medical profession the essential contribution
of laboratory medicine to health
Respond to individual patient health needs and issues as part of patient care
Respond to the health needs of the communities that they serve
Identify the determinants of health of the populations that they serve
Promote the health of individual patients, communities and populations
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports
SCHOLAR






Develop and implement a personal continuing educational strategy
Apply the principles of critical appraisal to sources of medical information
Contribute to the development of new knowledge through research
Participate in rounds, conferences and teaching sessions
Develop learning techniques and skills to present information in written and oral examinations
Maintain and enhance professional activities through ongoing learning
190



Critically evaluate information and its sources, and apply this appropriately to practice decisions
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices
PROFESSIONAL








Deliver the highest quality of care with integrity, honesty and compassion
Practice medicine in an ethnical manner and with a sensitivity to diverse patient and co-worker
populations
Exhibit appropriate professional behavior and perform duties in a dependable and responsible
manner
Demonstrate commitment to evidence-based medicine, excellence and ongoing professional
development
Demonstrate commitment to excellence and ongoing professional development
Demonstrate a commitment to their patients, profession, and society through ethical practice
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation
Demonstrate a commitment to physician health and sustainable practice
Outline of Rotation:








Rotations will commence with orientation and familiarization of the resident with the
laboratory layout, and introduction of the resident to the pathologists and staff in the
DynaLIFE laboratory
The resident will be familiarized with work routines in the DynaLIFE laboratory
The resident will spend time in the histology processing lab to enable familiarization with
procedures in the histology laboratory regarding the reception, accession, gross
examination, dissection, processing, cutting and staining of sections
The resident will be integrated into the routine work schedules and will be allocated
grossing and reporting duties, and will be encouraged to rotate for periods of tutoring with
each of the DynaLIFE pathologists
An emphasis will be placed on the resident developing appropriate communication and
professional collaborative skills with all support staff and pathologists at DynaLIFE
Residents will be encouraged to develop self sufficiency and an ability to formulate a
considered pathological opinion and to present that opinion for evaluation to the
supervising pathologist
Emphasis will be placed on timely accurate reporting with an effort to maintain an average
turnaround time of 24 hours per specimen
Residents are expected to make an forty minute educational presentation of a topic of
current interest during the rotation at DynaLIFE
Educational Materials:

The DynaLIFE library and pathologists are well equipped with current textbooks and many
journal which are available for use by residents
191





Each DynaLIFE pathologist has a multihead teaching microscope enabling simultaneous
examination of slides by consulting pathologist and resident
An office dedicated for the use of residents is equipped with a computer workstation and
high speed internet connection, a good quality binocular microscope, a dictaphone and
telephone
A multihead microscope with video monitors is available for peer review meetings held
every two weeks
A learning centre with computer projection facilities is available for resident and staff
presentations and scientific meetings
DynaLIFE staff includes pathologists with a wide range of pathology expertise and a
willingness to teach
Evaluation:
 Overall assessment is based on the Uof A pathology resident evaluation form
 The final evaluation will as a rule be discussed with the resident who will be encouraged to
respond to and discuss any adverse comment
 Informal, oral weekly evaluation will provide regular feedback on the appropriateness of the
resident’s activities
 An open and honest atmosphere of critical appraisal will prevail. Residents will have the
opportunity to share problems and areas of difficulty with either or both of the preceptors if
necessary or desired
 Overall assessment is based on a pathology resident evaluation form distributed through
Webeval.
July 2007
192
ROTATION SPECIFIC OBJECTIVES
SURGICAL PATHOLOGY
Selection: Mandatory
Site: Misericordia Community Hospital
Preceptor: Dr. John Danyluk
Length of Rotation: Three to four weeks minimum
Prerequisites: Previous rotation in Breast and Urologic Pathology at the Misericordia Hospital.
Specific Objectives:
MEDICAL EXPERT






Gross and report a variety of surgical pathology specimens appropriate to level of training.
Participate in frozen section coverage.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient’s medical history relevant to
diagnostic surgical pathology.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR






Assist in the continuing education of physicians and other members of the staff by participating in
conferences and case presentations.
Act as consultant to clinical colleagues on the interpretation and relevance of pathological
findings, with particular regard to their significance in the management of the patient.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals verbally and in the form of surgical pathology reports.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
COLLABORATOR




Demonstrate the ability to advise on the appropriateness of obtaining histological and cytological
specimens and to advise on further appropriate investigations.
Collaborate with colleagues at all levels in the pathology laboratory, particularly with respect to
consultation, peer review and continuing professional development.
Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
193
MANAGER





Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life.
Allocate finite health care and health education resources effectively to optimize patient care
and life-long learning.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE








Identify the important determinants of health affecting patients pertaining to pathological
processes.
As a member of an interdisciplinary team of professionals responsible for patient health, the
resident will assist in regularly evaluating laboratory practices and test selections to determine
that they meet community needs.
Recognize and reinforce to the public and to the medical profession the essential contribution
of laboratory medicine to health.
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR






Develop and implement a personal continuing educational strategy.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
Apply the principles of critical appraisal to sources of medical information.
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
PROFESSIONAL







Deliver the highest quality of care with integrity, honesty and compassion.
Practice medicine in an ethical manner and with a sensitivity to diverse patient and co-worker
populations.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Ddemonstrate a commitment to physician health and sustainable practice.
Exhibit appropriate professional behavior and perform duties in a dependable and responsible
manner.
Demonstrate commitment to excellence and ongoing professional development.
194
Outline of Rotation:



The resident is assigned cases by the preceptor and other pathologists on a weekly rotation.
These weekly rotations include gross dissection, microscopic evaluation and dictation of
reports, and sign-out with the assigned staff pathologist.
Residents will also participate in frozen sections during the weekly rotation.
Educational Materials:


General and specialty text books.
Collection of teaching material for review, glass slides, etc.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
195
ROTATION SPECIFIC OBJECTIVES
SURGICAL PATHOLOGY
Selection: Mandatory
Site: Royal Alexandra Hospital
Preceptor:
Dr. Robert West
Length of Rotation: 6 weeks
Prerequisites: PGY2
Specific Objectives:
MEDICAL EXPERT







Demonstrate the ability to handle complex surgical specimens including complex genitourinary,
gastrointestinal, gynecological and thoracic cases. Residents should be able to appropriately
gross these cases and independently prepare and dictate completed reports prior to reviewing
with a supervising pathologist. The resident should demonstrate appropriate knowledge of
appropriate ancillary investigations (i.e., histochemical, immunohistochemical stains etc.)
Demonstrate the ability to perform a complete post mortem examination, with appropriate full
description and diagnosis at gross and microscopic levels. Resident must be able to interpret
their findings in the light of the clinical history and communicate these in an effective written and
oral fashion. They must be completely familiar with the rules governing consent for post mortem
examination and the type of case that should be reported to the coroner or the medical
examiner’s office.
Demonstrate the ability to perform frozen sections. The resident should develop the ability to
appropriately interact with physicians requesting frozen sections to determine the
appropriateness of the request as well as to determine pertinent clinical information. The resident
should develop the skills to appropriately sample specimens. The resident will be expected to
develop the skills to allow for technical processing of the specimens (cutting sections and
performing stains) without technical support. Finally the resident will develop a level of
competency to properly interpret the frozen sections.
Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient’s medical history relevant to
diagnostic surgical pathology.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR





Assist in the continuing education of physicians and other members of the staff by participating in
conferences and case presentations.
Act as consultant to clinical colleagues on the interpretation and relevance of pathological
findings, with particular regard to their significance in the management of the patient.
Convey effective oral and written information about a medical encounter.
Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals verbally and in the form of surgical pathology and autopsy
reports.
196


Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
COLLABORATOR




Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
Demonstrate the ability to advise on the appropriateness of obtaining histological and cytological
specimens and to advise on further appropriate investigations.
Collaborate with colleagues at all levels in the pathology laboratory, particularly with respect to
consultation, peer review, and continuing professional development.
MANAGER





Utilize time and resources effectively to balance patient care, budget restrictions, professional
expectations and personal life.
Allocate finite health care and health education resources effectively to optimize patient care
and life-long learning.
Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Serve in administration and leadership roles, as appropriate.
HEALTH ADVOCATE








Identify the important determinants of health affecting patients pertaining to pathological
processes.
As a member of an interdisciplinary team of professionals responsible for patient health, the
resident will assist in regularly evaluating laboratory practices and test selections to determine
that they meet community needs.
Recognize and reinforce to the public and to the medical profession the essential contribution
of laboratory medicine to health.
Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR





Develop and implement a personal continuing educational strategy.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices by participating in research, rounds, conferences and teaching sessions..
Apply the principles of critical appraisal to sources of medical information.
Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
197

Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
PROFESSIONAL







Deliver the highest quality of care with integrity, honesty and compassion.
Practice medicine in an ethical manner and with a sensitivity to diverse patient and co-worker
populations.
Exhibit appropriate professional behavior and perform duties in a dependable and responsible
manner.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Demonstrate commitment to excellence and ongoing professional development.
Outline of Rotation:
Senior AP (R4 and R5) and GP residents (R4 and R5) will rotate through the RAH on a 6 week
basis. During each week of rotation, the resident will be expected to gross surgical specimens for two
half days, attend and perform frozen sections with a staff pathologist for one half day, be responsible
to cover the autopsy service for a day and under the supervision of the attending pathologist prepare
reports on the majority of cases which they have been exposed to. Depending on the abilities and
interest of the residents, they will also be able to access smaller biopsy material for review with the
attending pathologists. The residents will be expected to be available from 8:00 am until 5:00pm daily
unless it is their academic half day, they are off work sick or they have made special arrangements
with the supervising pathologist.
When scheduled to assist the attending pathologist with frozen sections, the resident will have
to ensure that they are available in the hospital and available by pager to attend the frozen sections.
This will require the residents to be on site at 8:00 am when they are scheduled for morning frozens.
Residents will be expected to learn how to properly sample material in order to chose frozen section
blocks. They will also be expected to learn how to perform the technical skills for handling such
specimens (i.e. cutting and staining of slides) and learn how to appropriately interpret frozen sections.
Finally they will be expected to interact with surgeons and gynecologists requesting the frozen
sections to determine appropriate clinical information and to determine the appropriateness of
performing the frozen section.
When scheduled on the autopsy service they will be expected to perform no more then one
autopsy in a given day. The resident will be expected to review the chart for appropriate clinical
information and ensure proper consent. With the assistance of a pathology assistant they will perform
an external examination, internal examination dissection and assessment of the organs prior to
reviewing the organs and other pertinent findings with the supervising pathologist. They will be
expected to prepare a provisional diagnostic report and to dictate the clinical history, external and
internal examinations within 24 hours. They will be expected to review the microscopic slides with the
supervising pathologist and complete the report prior to the end of their rotation.
The resident will be expected to cut specimens for two half days and to cut any frozen section
cases in which they participated. The supervising pathologist and the resident will then decide an
appropriate number of cases which the resident will be required to examine microscopically. The
workload will therefore vary depending on the capability of the resident. Residents will be given the
opportunity to examine smaller biopsy specimens known as pool cases which they were not involved
with grossing. The residents will be expected to dictate completed reports on the more straight
198
forward cases prior to review by the supervising pathologist. For more complicated cases, the
resident will discuss the cases with the supervising pathologist and appropriate additional studies will
be decided upon prior to dictating any report.
It is the expectation that the resident attend all academic half days during their rotation unless
prevented from doing so because of health reasons or vacation.
Finally it is the expectation that each resident perform a half an hour formal presentation to all
of the attending staff pathologists once during the rotation. The presentation should be centered
around an interesting case which they encountered during their rotation. The resident will also be
expected to present at the monthly journal clubs.
Educational Materials:
The CH is presently replacing the pathologists’ microscopes with new microscopes, all of
which possess sidearms. The CH has also promised to buy a new multiheaded microscope for the
resident’s room. The residency teaching program has made a commitment to provide two
microscopes for use by residents on the site. The residency program has also made a commitment to
provide a computer and a C-phone for use by the residents.
 The department subscribes to the College of American Pathologists PIP in Surgical Pathology.
 A small library is available within the resident’s room. Residents are also able to borrow
pathologists’ textbooks.
 There is a digital camera present within the department but no other audiovisual equipment or
computers are available for preparing presentations for rounds.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
February 2007
199
ELECTIVE ROTATIONS
200
ROTATION SPECIFIC OBJECTIVES IN DERMATOPATHOLOGY
Selection: Elective.
Site: DynaLIFE core laboratory. Dr. Schloss’s office, College Plaza.
Preceptor: Dr. E Schloss.
Prerequisites: PGY3/4/5.
Length of rotation: Four weeks. (Minimum two weeks).
Educational Objectives:
MEDICAL EXPERT







Develop and improve diagnostic skills for the recognition of common skin conditions both
inflammatory and neoplastic.
Understand the principles and applications of special diagnostic testing to dermatopathology.Function effectively as consultants, integrating all of the CanMEDS Roles to
provide optimal, ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR





Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR


Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.
MANAGER




Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.
201
HEALTH ADVOCATE





Respond to individual patient health needs and issues as part of patient care.
Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.



Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
SCHOLAR

PROFESSIONAL




Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:



Review current cases with preceptor at DKML and his office.
If time permits, review archival material.
Attend Dermatology Rounds weekly.
Educational Materials:
Suggested reading –
Histopathology of the Skin. Lever, Walter F.
Conferences –
Dermatology Rounds.
Clinical Material –
Current and archival cases.
202
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
203
ROTATION SPECIFIC OBJECTIVES FOR PULMONARY PATHOLOGY
Selection:
Site:
Elective
Grey Nuns Hospital
Royal Alexandra Hospital
Preceptor:
Dr. I. Sin
Prerequisites:
PGY 3/4
Length of rotation: Minimum two weeks.
Specific Objectives:
MEDICAL EXPERT






Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal,
ethical and patient-centered medical care.
Establish and maintain clinical knowledge, skills and attitudes appropriate to their practice.
Perform a complete and appropriate assessment of a patient.
Use preventative and therapeutic interventions effectively.
Demonstrate proficient and appropriate use of procedural skills, both diagnostic and
therapeutic.
Seek appropriate consultation from other health professionals, recognizing the limits of their
expertise.
COMMUNICATOR





Develop rapport, trust and professional relationships with other physicians and allied health care
workers and patients and families (as needed).
Accurately elicit and synthesize relevant information and perspectives of patients and families,
colleagues and other professionals.
Accurately convey relevant information and explanations to colleagues and other professionals.
Develop a common understanding on issues, problems and plans colleagues and other
professionals to develop a shared plan of care in the best interests of patients and families.
Convey effective oral and written information about a medical encounter.
COLLABORATOR


Participate effectively and appropriately in an interprofessional healthcare team.
Effectively work with other health professionals to prevent, negotiate, and resolve
interprofessional conflict.




Participate in activities that contribute to the effectiveness of their healthcare organizations and
systems.
Manage their practice and career effectively.
Allocate finite healthcare resources appropriately.
Serve in administration and leadership roles, as appropriate.

Respond to individual patient health needs and issues as part of patient care.
MANAGER
HEALTH ADVOCATE
204




Respond to the health needs of the communities that they serve.
Identify the determinants of health of the populations that they serve.
Promote the health of individual patients, communities and populations.
Acquire appropriate QA/QC knowledge to ensure patient safety and accuracy of medical reports.
SCHOLAR




Maintain and enhance professional activities through ongoing learning.
Critically evaluate information and its sources, and apply this appropriately to practice decisions.
Facilitate the learning of patients, families, students, residents, other health professionals, the
public, and others, as appropriate.
Contribute to the creation, dissemination, application, and translation of new medical knowledge
and practices.
PROFESSIONAL




Demonstrate commitment to excellence and ongoing professional development.
Demonstrate a commitment to their patients, profession, and society through ethical practice.
Demonstrate a commitment to their patients, profession, and society through participation in
profession-led regulation.
Demonstrate a commitment to physician health and sustainable practice.
Outline of Rotation:
The resident shall be expected to:
 Perform gross examination and dissection of lung specimens and demonstrate ability to handle fresh
lung specimens appropriately.
 Perform microscopic examination and report the lung cases.
 Perform intra-operative consultation and frozen sections.
 Review cases in the lung teaching files.
 Demonstrate the ability to correlate pathologic findings with clinical and radiologic findings.
 Demonstrate the ability to use special stains and immunohistochemical studies appropriately.
 Demonstrate the ability to communicate effectively with the clinicians and radiologists.
 Attend and participate, if required, in clinical rounds.
 Understand the importance of a multidisciplinary approach.
 Demonstrate the ability to appraise relevant literature and application.
 Understand the bioethical and medicolegal issues.
 Understand the importance of quality assurance and risk management.
 Function as an effective team member with the hospital and laboratory staff.
 Demonstrate professional maturity.
 Demonstrate ability to perform self-assessment.
 Demonstrate self-motivation and ability to do self-directed learning.
Evaluation:
Overall assessment is based on a pathology resident evaluation form distributed through Webeval.
April 2006
205
ROTATION SPECIFIC OBJECTIVES
LABORATORY MANAGEMENT TRAINING
T
The general pathology resident should develop a basic knowledge of the following, particularly as they
apply to larger hospitals:
A.
The administrative structure and relationships of a hospital and laboratory, including:
(i)
Hospital organizational structure
(ii)
Medical staff organizational structure
(iii)
Laboratory organizational structure
(iv)
Hospital administrator's role
(v)
Laboratory director's role
(vi)
Technical director's (laboratory manager, chief technologist) role
(vii)
Medical staff and hospital committees
(viii)
Hospital and laboratory accreditation.
B.
The administrative structure and relationships with the Laboratory,
including:
(i)
Laboratory organizational structure
(ii)
Laboratory director's role
(iii)
Technical director's (laboratory manager, chief technologist) role
(iv)
Staff pathologist's role
(v)
Ph.D. clinical chemist's, clinical microbiologist's role
(vi)
Pathologist-technologist relationships.
C.
Laboratory management decisions, including:
(i)
Personnel selection and evaluation - hiring and firing
(ii)
Job descriptions and their preparation
(iii)
Personnel problems
(iv)
Union agreements and legal considerations
(v)
Budget preparation and control
(vi)
Canadian workload units
(vii)
Staffing requirements
(viii)
Workflow patterns with and between laboratory departments
(ix)
Program and facility planning
(x)
Equipment selection and evaluation
(xi)
Quality control procedures
(xii)
Data processing - including effective methods for filing, retrieval and distribution of
specimens and results.
D.
Managerial Skills:
Other areas in which specific managerial skills are required of an general pathologist in the direction of a
laboratory include:
ability to determine those procedures required on-site vs. those that can be referred in the
light of medical needs and human and financial resources available
understanding of technical staff qualifications related to level of training
ability to select and develop new technical methods
preparation and maintenance of procedure manuals
206
-
-
preparation and maintenance of user manuals for physicians and nursing staff
ability to conduct an effective quality control program
provision of an efficient external referral mechanism for tests not performed in the hospital
laboratory
maintenance of an appropriate safety program which will ensure the protection of
personnel, patients and the laboratory environment from fire, toxic or explosive chemicals
and gases, infectious agents and radiation hazards
an understanding of the federal government safety standards for the use of low-level
radioisotopes in in-vitro test procedures
adoption of an efficient method for reporting of results and for their indexing which will allow
for rapid reporting and data retrieval
the ability to advise on budget preparation with an understanding of the costs involved in
laboratory operation, i.e. personnel, supplies, and capital equipment.
207
PROGRAM EVALUATION OF RESIDENTS
Throughout the program, each resident will be evaluated regularly by means of on-going evaluation of
overall performance (completed through an on-line evaluation system) and by formal examinations. The
evaluations will be discussed with the residents and their results will be retained on file. Evaluations in
the final year will form the basis of the Final In-training Evaluation Report to the Royal College. A
resident may appeal any evaluation report considered unfair. The resident has the right to appeal to: (a)
The Program Director, Departmental Chair and Associate Dean for Postgraduate Education. (b) The
appeals process defined by the University of Alberta Residency Training Programs. The first year of the
residency program is probationary and will be subject to a more vigorous evaluation procedure.
Evaluations will be done at the end of specific rotations and at least every three months. Formal
examinations will be held throughout the year. Oral, written and practical examinations are conducted
twice a year. Oral examinations are structured similar to those of the RCPSC. The content of the oral
examination will be determined by the level of training of the resident. The written examination in the
Fall will also be mirrored on the RCPSC Fellowship Examination and is designed primarily to test senior
residents preparing for the forthcoming Fellowship Examination. It is expected that more junior residents
will not do as well as their senior colleagues but there is an expectation on the part of the program that
performances will improve in subsequent years. The written examination in the Spring will be the
Resident In-Service Examination of the American Society of Clinical Pathologists (ASCP). Despite the
emphasis on evaluation, we are confident that you will enjoy your training experience, and hope that you
will accept the periodic evaluation in the constructive spirit in which it is intended.
208
RESIDENT EVALUATION OF THE PROGRAM AND FACULTY
Resident feedback is important in providing information about the effectiveness of our training programs
and will be used to improve the program where necessary.
Each resident completes an evaluation of their rotation immediately upon completion of it (through an
on-line evaluation system). When the system flags a low performance for a resident, this is brought
immediately to the attention of the Program Director. The residents are also encouraged to bring any
issues or concerns directly to the Program Director, if they prefer.
In addition to evaluating rotations, residents are asked to evaluate the teaching faculty on an annual
basis (again, through an anonymous on-line evaluation system). These evaluations are similar to
those used in the undergraduate program. The numerical scores for each teacher are forwarded to
the Academic Chair and the Program Director for their review. Both the numerical score and the
narrative comments are distributed to the individual teacher. It is expected that resident evaluation of
the program will be conducted in a collegial and constructive fashion.
Each year the residents recognize a member of the faculty who has excelled in teaching, through the
Teacher of the Year Award. Award recipients are recognized at the department annual Resident and
Graduate Student Research Day.
209
POLICY OF THE GENERAL PATHOLOGY RESIDENCY TRAINING PROGRAM
REGARDING RESIDENTS WORKING AS
PHYSICIAN EXTENDERS
1.
Eligibility

The Resident must be in his 2nd year of training or later and meet the requirements
laid out by the Royal College of Physicians and Surgeons of Alberta

The Resident’s application for licensure must be reviewed and approved by the
Residency Program Director

The resident must have CMPA coverage as specified by the Royal College of
Physicians and Surgeons of Alberta guidelines
2.
Time Commitment

To be negotiated between the Resident, Residency Program Director, and Residency
Program Committee

The Resident must maintain a satisfactory level of academic standing and
performance within the program

At no time shall physician extender work interfere with residency training commitments

At no time shall physician extender work impose extra duties or time constraints onto
fellow residents

The time committed to physician extender work must not interfere with normal service
and educational responsibilities of the Resident the following day.

The after hours coverage as part of the educational experience, taken together with
shifts as a physician extender, must not breach the PARA/CAHCA agreement.

3.
Any violation of the above may result in suspension of licensure
Type of Training

Wherever possible, an attempt should be made to engage in physician extender work
that will provide as much relevance as possible to the discipline within which the
Resident is engaged in training at that time
4.
Monitoring

There will a review of physician extender activities semi-annually by the employer and
the Residency Program Director
210

There will be a review of the Resident’s academic standing, performance, and
physician extender licensure semi-annually by the Residency Program Director
November
2004
211
VACATION
Residents are entitled to twenty days vacation annually.
Vacation time must be approved by the Program Administrator who is to be notified of the leave six
months in advance.
A resident may take all of his/her vacation entitlements at one time or divided into two blocks of 1 & 3
weeks or 2 & 2 weeks. Vacation time for the academic year must be taken within that year. This is in
accordance with the current PARA agreement.
212
FACULTY CODE OF CONDUCT
The Code of Conduct document of the Department of Laboratory Medicine and Pathology, Faculty of
Medicine and Dentistry can be accessed at:
http://www.med.ualberta.ca/deansoffice/code_of_conduct_2.pdf
213