Frequently Asked Questions: Anatomic Pathology and Clinical Pathology Review Committee for Pathology ACGME Effective: July 1, 2017

Transcription

1 Frequently Asked Questions: Anatomic Pathology and Clinical Pathology Review Committee for Pathology ACGME Effective: July 1, 2017 Question Program Personnel and Resources What are the most common circumstances for temporary complement increase requests? [Program Requirement: II.A.4.n).(2)] 1. When a trainee needs to take medical leave/maternity leave from a program. Example: During the course of her residency, a resident needs to take extended medical leave. In order to complete her required 48 months of pathology residency training, the resident s matriculation from the program will need to be extended by three months. The additional trainee made available through the temporary increase in complement would accommodate this three-month extension. The program explains the situation and documents that they have sufficient resources and training experiences to accommodate this additional resident. 2. When a trainee requires remediation. Example: Toward the end of his first year of training, the program determined that a resident was not ready to be promoted to his second year and two months of remedial training were required. Based on his performance during this remediation, the program promoted the resident to the second year of training. Because the two months of remedial training do not count toward his required 48 months of pathology residency training, the resident s matriculation from the program will need to be extended by two months. The additional trainee made available through the temporary increase in complement would accommodate this two-month extension. The program explains the situation and documents that they have sufficient resources and training experiences to accommodate this additional resident. 3. When a trainee is on an extended leave from a program, or if a trainee starts the program outside of the July 1-June 30 training cycle Accreditation Council for Graduate Medical Education (ACGME) Page 1 of 9

2 Example: One resident in the program is a member of the military and is currently on active duty. The trainee does not know the exact date of his separation from the military, but he expects it to be sometime in the first half of the current academic year. Both he and the program would like to hold the space for him in the residency program. The additional trainee made available through the temporary increase in complement would maintain the same number of trainees in all years of the program. The program explains the situation and documents that they have sufficient resources and training experiences to accommodate this additional resident. 4. When the request for a temporary increase in complement will be followed immediately with a request for a permanent increase in complement, as the educational resources of a program (most commonly a fellowship) have significantly expanded and will support an additional trainee. Example: A cytopathology service has grown significantly in clinical volumes, specialized techniques, and clinical sites, thereby enabling a more diverse training experience, including different practice settings. This expansion provides an excellent training experience for an additional fellow, while not compromising the educational experience of the current fellows. Funding and all other additional resources (e.g., dedicated office space, computer, etc.) are available for this additional position. These and other circumstances for a temporary increase in trainee complement are considered on a case-by-case basis. What constitutes faculty scholarly activity? [Program Requirement: II.B.5.] Of note, sequential temporary complement increases as a means to avoid submitting a request for a permanent complement increase are not acceptable. Faculty members must be engaged in ongoing scholarly activity in order to foster an environment of inquiry and provide mentorship to trainees. Programs should strive to demonstrate a wide variety of activity among the members of the core and teaching faculty. Departments and institutions are responsible for providing faculty members with sufficient time and resources to engage in scholarly activity, and to support engagement with trainees. Examples include: 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 2 of 9

3 What is the rationale for the evaluation of faculty scholarly activity by the Review Committee? [Program Requirement: II.B.5.] Educational Program publication of basic science or clinical research review articles in peer-reviewed journals, or chapters in textbooks publication or presentation of case reports presentations at local, regional, or national professional and scientific society meetings participation in national committees or educational organizations peer-reviewed funding Faculty activities listed in PR II.B.5.a) (clinical discussions, rounds, journal clubs, and conferences at the local institutions), while essential to the program s environment of inquiry and included within the definition of scholarly activity for trainees, are considered separate from faculty scholarship, reflecting the higher standard to which faculty scholarly activity is held. Scholarly activity by core faculty members is a quality indicator reported annually to the ACGME as a marker for environment of inquiry and scholarship, and as an indicator of ongoing self-directed learning and practice improvement. It is evaluated, along with other markers, such as scholarly activity by trainees and the responses to the annual Resident/Fellow and Faculty Survey questions related to the learning environment, in assessing program quality. Programs in which only a minority (less than 50%) of core faculty members report scholarly activity that falls within the categories listed in PRs II.B.5.b).(1)-(4) may be considered for more in depth review by the Committee to further investigate the quality of the learning environment for trainees. Completeness and accuracy of reporting faculty scholarly activity by the program is essential to the accurate assessment of program compliance Accreditation Council for Graduate Medical Education (ACGME) Page 3 of 9

4 Does the Review Committee expect programs to develop specific goals and objectives (skills and competencies) for each rotation/educational experience during the residency? [Program Requirement: IV.A.2] What constitutes a shared autopsy? [Program Requirement: IV.A.6.f)] It is recognized that many programs are structured to provide continuous rotations throughout the 12 months of education, with more emphasis on some competencies and skills during certain components of the fellowship. For example, a resident may be involved in performing procedures or interpreting specific specimens during defined days or weeks; these competencies and skills, however, may occur at multiple times during the educational program. In contrast, some programs may have specific rotations that focus on a set of competencies or skills only during a defined time period; these, however may be provided in a different geographic area and with different faculty members than available at the primary clinical site. An example would be a molecular rotation with designated faculty scheduled during a non-molecular rotation. In these circumstances a separate listing of skills and competencies is expected. Separate evaluations should be included as part of these experiences. When a program operates with a continuous rotation structure, a separate list of goals and objectives is not needed for each type of experience. The overall competencies and skills should be specific and should address the spectrum of education that occurs during the educational program. A shared autopsy has each resident participating in all components of an autopsy case (listed below for reference). It is understood that certain cases may not include all eight components, hence the qualifier as appropriate to the case. However, no component should be skipped on a routine basis. Review of history and circumstances of death External examination of the body Gross dissection, including organ evisceration Review of microscopic and laboratory finding appropriate to the case Preparation of written description of gross and microscopic findings Development of opinion on cause of death Clinicopathological correlation, as appropriate to the case Review of autopsy report with a faculty member Accreditation Council for Graduate Medical Education (ACGME) Page 4 of 9

5 A shared autopsy must be a collaborative process, even if one resident assumes a more primary role in the work-up of the case. Examples of what is and is not acceptable follow. Example: Two residents participate in the prosection of an autopsy, but only one performs the microscopic examination. This is not acceptable as this compromises the experience of the second resident. Can a limited autopsy count toward the required 50 autopsies? [Program Requirement: IV.A.6.f)] How many forensic autopsies can count toward the required 50 autopsies? [Program Requirement: IV.A.6.f)] To what extent must residents have exposure to fetal autopsies? [Program Requirement: IV.A.6.g)] Can a fetal demise count as an autopsy? Example: A senior resident assists and supervises a junior resident in performing and completing an autopsy as part of his/her graduated responsibility. This is acceptable as this is practice is a beneficial, though different, autopsy experience for both residents. Yes. However, the program director and the autopsy service director should be vigilant that the number of limited autopsies does not compromise any resident s overall autopsy experience or attainment of competency and learning with the full autopsy procedure. In addition, the majority of a resident s experience in autopsies should involve all components. While the Review Committee has not established a maximum number regarding forensic autopsies, as above, these should not compromise any resident s overall autopsy experience or attainment of competency and learning with the full autopsy procedure. The Review Committee considers adequate the requirements set forth by the American Board of Pathology with regards to fetal autopsies. For fetal autopsies to count towards the required 50 autopsies, the fetus must be intact, and gross and microscopic examination of the placenta must be part of the report. Receipt of a separate accession number by the placenta does not preclude review by the autopsy resident and inclusion of the gross and microscopic findings in the autopsy report of the fetus. Furthermore, the American Board of Pathology also puts limits on the number of unexplained fetal demise cases (5) and cases in which maceration of the fetus precludes a diagnosis (2) that can count toward the resident s minimum of 50 autopsies; and it is the responsibility of the program to ensure that the resident can meet these numerical requirements. Yes. A fetal demise may count as an autopsy provided it has an autopsy permit Accreditation Council for Graduate Medical Education (ACGME) Page 5 of 9

6 [Program Requirement: IV.A.6.g)] The Learning and Working Environment Can pathology assistants supervise residents? [Program Requirement: VI.A.2.a).(1)] When can a PGY-1 resident be indirectly supervised? [Program Requirement: VI.A.2.e).(1).(b)] Who is qualified to supervise residents in bone marrow biopsies? [Program Requirement: VI.A.2.e).(1).(b).(iii)] Who is qualified to supervise residents in apheresis procedures? [Program Requirement: VI.A.2.e).(1).(b).(i)] Who is qualified to supervise residents in gross dissection of surgical pathology specimens and/or autopsies? [Program Requirements: VI.A.2.e).(1).(b).(ii) and VI.A.2.e).(1).(b).(vi)] Although pathology assistants are not licensed independent practitioners, they may be authorized by a department to provide supervision or oversight of dissection of surgical specimens and autopsies. The ultimate responsibility for a patient s care, however, lies with the attending physician, and cannot belong to a pathology assistant. In order for a PGY-1 resident to be indirectly supervised, he or she must have performed the requisite three procedures in the categories specified in the requirements [apheresis, autopsies (complete or limited), bone marrow biopsies and aspirates, fine needle aspirations and interpretation of the aspirate, frozen sections, gross dissection of surgical pathology specimens by organ system]. Example: The resident who has met the requirement for direct supervision may be indirectly supervised by a more senior resident, a fellow, a pathology assistant, or an attending physician. The identified supervisor must be available for consultation and assistance, but does not need to be immediately available or in the hospital. Residents at the PGY-2 level or above in a CP-only track, residents at the PGY-3 level or above in an AP/CP track, hematology-oncology fellows, hematopathology fellows, and attending pathologists may supervise the performance of bone marrow biopsies. Residents at the PGY-2 level or above in a CP-only track, residents at the PGY-3 level or above in an AP/CP track, blood banking/transfusion medicine fellows, and attending pathologists may supervise the performance of apheresis procedures. Hematopathology fellows may also supervise apheresis procedures if approved to do so by their respective program directors. Residents in the PGY-2 level or above in an AP/NP or AP-only track, residents in the PGY-3 or -4 level, fellows, pathology assistants, or attending pathologists may supervise gross dissection of surgical pathology specimens and/or autopsies Accreditation Council for Graduate Medical Education (ACGME) Page 6 of 9

7 What is the optimal clinical workload for residents? [Program Requirement: VI.E.1] What constitutes adequate resident scholarly activity? [Program Requirement: IV.B.1.] The program director must make an assessment of the learning environment with input from faculty members and residents. There must be an adequate clinical workload to develop competency in all areas specified in the Program Requirements. Optimal workload may vary from program to program, and will depend on the patients, patient material, program resources, and testing/consultations/procedures done in the primary and participating sites. Clinical workload should include patients and patient material for testing, as well as study sets and other case-based teaching tools. Residents must participate in scholarly activity to advance their knowledge of the basic principles of research, including application of that research to patient care. The Review Committee recognizes that institutional practice patterns and resources vary, and it therefore has broadly defined what constitutes resident scholarly activity. Residents may meet the scholarly activity requirement through a variety of educationrelated and research-related activities either inside or outside of the training institution. Examples include: Why should residents participate in scholarly activity? [Program Requirement: IV.B.1.] presentations at journal clubs or grand rounds teaching medical students, residents, or ancillary staff poster or oral presentations of abstracts at local, regional, or national meetings authorship of textbook chapters or a review articles participation in basic science or clinical research publication in a peer-reviewed journal Scholarly activity by residents is a quality indicator reported annually to the ACGME as a marker for environment of inquiry and scholarship within the program, and as an indicator of ongoing self-directed learning and practice improvement. It is evaluated, along with other markers, such as scholarly activity by core faculty members and responses to the annual Resident/Fellow and Faculty Survey questions related to the learning environment in assessing program quality. As scholarly activity is a longitudinal process, it is not required that every resident produce formal evidence of scholarly activity during each year of training. However, the annual data submitted by the program should demonstrate scholarly activity by at least a subset of residents in order to convincingly reflect compliance with the requirements for ongoing scholarly activity by each resident. The broad definition of scholarly activity should make this possible Accreditation Council for Graduate Medical Education (ACGME) Page 7 of 9

8 Other When are autopsy permits required? What data does the Review Committee seek with regards to the Resident Survey question/category that addresses Provided data about practice habits? What does the Review Committee consider acceptable in terms of methods to improve Resident Survey compliance rates for the question/category addressing Provided data about practice habits? What are examples of quantitative or qualitative, measurable practice habits (i.e., clinical activities) on which programs can collect and report data to residents? Completeness and accuracy of reporting resident scholarly activity by the program is essential to the accurate assessment of program compliance. Programs in which ongoing scholarly activity by all residents cannot be extrapolated from the annual report may be considered for more in depth review by the Committee to further investigate the quality of the learning environment. Autopsy permits are required for all autopsies, with the exception of forensic cases. Data refers to reports of specific practice habits of residents, which may include information such as number of tests ordered or read, patient safety surveys, adherence to disease-specific standard protocols, and productivity (such as the number of patients/cases seen, or number of procedures performed). The Review Committee believes that to see improvement, the subject should be discussed with the resident during the semiannual evaluation and review period. The program director should explicitly state that within the review, the resident s progress on specific practice habits will be covered. At this point, reports and/or data that have been collected on measurable clinical activities may be reviewed with the resident, discussing his or her progress towards achievement of programmatic goals, and how this progress compares with that of his or her peer group of residents. Recognizing that each program may identify clinical activities that are both useful and practical to measure, the Review Committee believes several such performance standards are set forth in the Pathology Milestones or are implicit in the accreditation requirements. These include: Milestones PC4: Reporting: Analyzes data, appraises, formulates, and generates effective and timely reports (AP) o Level 2 is aware of accepted standards for turn-around time o Level 3 completes routine preliminary and final reports within standards o for turn-around time Level 4 completes complicated preliminary and final reports within standards for turn-around time PC6: Procedure: Intra-operative consultation/frozen sections: Demonstrates attitudes, knowledge, and practices that enables proficient performance of gross 2017 Accreditation Council for Graduate Medical Education (ACGME) Page 8 of 9

9 examination, frozen section (analysis and appraisal of findings, synthesis and assembly, and reporting) (AP) o Level 3 is able to perform high quality intra-operative consultation/frozen section/intra-operative cytology (IOC/FS) on technically difficult and multiple specimens; performs IOC/FS within turn-around time standards MK3: Procedure: Autopsy: Demonstrates knowledge and practices that enable proficient performance of a complete autopsy (analysis and appraisal of findings, synthesis and assembly, and reporting) (AP) o Level 4 performs uncomplicated gross dissection within four hours Overall requirements for case volume sufficiency, such as IV.A.6.i), IV.A.6.j), and IV.A.6.k), may be useful to track and report individually, if deemed practical by the program Accreditation Council for Graduate Medical Education (ACGME) Page 9 of 9