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Journal ListAcad Patholv.4; Jan-Dec 2017PMC5496684

Logo of apathol
Acad Pathol. 2017 Jan-Dec; 4: 2374289517714283.
Published online 2017 Jun 27. doi: 10.1177/2374289517714283
PMCID: PMC5496684
PMID: 28725792
Entrustable Professional Activities for Pathology
Recommendations From the College of American Pathologists Graduate Medical Education
Committee
Cindy B. McCloskey, MD,corresponding author1 Ronald E. Domen, MD,2 Richard M. Conran, MD,
PhD, JD,3 Robert D. Hoffman, MD, PhD,4 Miriam D. Post, MD,5 Mark D. Brissette, MD,6 Dita A.
Gratzinger, MD, PhD,7 Patricia M. Raciti, MD,8 David A. Cohen, MD,9 Cory A. Roberts, MD,10 Amyn
M. Rojiani, MD, PhD,11 Christina S. Kong, MD,7 Jo Elle G. Peterson, MD,1 Kristen Johnson, PhD,12
Sue Plath, MA,12 and Suzanne Zein-Eldin Powell, MD9
Author information Article notes Copyright and License information Disclaimer
This article has been cited by other articles in PMC.
Associated Data
Supplementary Materials
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Abstract
Competency-based medical education has evolved over the past decades to include the
Accreditation Council for Graduate Medical Education Accreditation System of resident evaluation
based on the Milestones project. Entrustable professional activities represent another means to
determine learner proficiency and evaluate educational outcomes in the workplace and training
environment. The objective of this project was to develop entrustable professional activities for
pathology graduate medical education encompassing primary anatomic and clinical pathology
residency training. The Graduate Medical Education Committee of the College of American
Pathologists met over the course of 2 years to identify and define entrustable professional activities
for pathology graduate medical education. Nineteen entrustable professional activities were
developed, including 7 for anatomic pathology, 4 for clinical pathology, and 8 that apply to both
disciplines with 5 of these concerning laboratory management. The content defined for each
entrustable professional activity includes the entrustable professional activity title, a description of
the knowledge and skills required for competent performance, mapping to relevant Accreditation
Council for Graduate Medical Education Milestone subcompetencies, and general assessment
methods. Many critical activities that define the practice of pathology fit well within the entrustable
professional activity model. The entrustable professional activities outlined by the Graduate Medical
Education Committee are meant to provide an initial framework for the development of entrustable
professional activity–related assessment and curricular tools for pathology residency training.
Keywords: anatomic and clinical pathology, assessment, competency-based feedback, medical

education, entrustable professional activities (EPAs), Milestones, resident training
Go to:
Introduction
Competency-based medical education (CBME) has emerged throughout the world as the driving
concept behind innovations in curricula for medical training spanning undergraduate to graduate
medical education. The International CBME Collaborators define CBME as “an outcomes-based
approach to the design, implementation, assessment, and evaluation of medical education
programs, using an organizing framework of competencies.”1(p.641) Unlike previous
objective-driven education models, CBME places the emphasis for curriculum development and
assessment on the desired outcome of the learner instead of the goals and objectives of the
educational process. Competency-based medical education also melds concepts from various
educational frameworks such as the “does” component of Miller’s pyramid2 (Figure 1) for the
assessment and the evaluation of learner progression in conjunction with adaptation of teaching
style of the Dreyfus model (Figure 2).3
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Figure 1.
Miller’s framework for clinical assessment (Miller’s pyramid). Adapted from Miller, 1990.2

Figure 2.
Dreyfus stages of learning. Adapted from Holmboe, Hawkins, Durning, 2008.3
In the United States, CBME has evolved over the past decades to include the current system of
formal resident evaluation required by the Accreditation Council for Graduate Medical Education
(ACGME) in the form of outcome-based Milestones. The domains of competence employed in
graduate medical education in the United States were first introduced by the ACGME and American
Board of Medical Specialties in 1999 as part of the Outcomes Project and include the domains of
patient care, medical knowledge, practice-based learning and improvement, interpersonal and
communication skills, professionalism, and systems-based practice. With this original requirement to
educate residents based on competency domains, the ACGME initially relied on the education
community to innovate and develop methods to teach using this competency-based framework.4
Organizations, including the Institute of Medicine and the Medicare Payment Advisory Commission,
felt that improvement in resident education based on this initial effort was insufficient and
encouraged further innovation within the ACGME.5 With the phased implementation of the Next
Accreditation System (NAS) beginning in 2013, the ACGME sought to accredit programs “based on
outcome” in the hopes of better preparing residents for practice and reducing the burden of the
previous administrative structure. The NAS assigns the responsibility for maintaining a clinical
learning environment to the designated institutional official at the training site, with clinical learning
environment review inspections of the sponsoring institution scheduled approximately every 18
months. Instead of on-site individual program inspections every 1 to 5 years, programs are now
assessed on the basis of biannual evaluation of resident progress on specialty-specific “Milestones,”
annual scrutiny of ACGME faculty and resident survey data, and review of resident case logs.
Self-study and program inspection site visits occur less frequently in the NAS, with intervals of up to
10 years between visits.6 The development of specialty-specific “Milestones” was a significant step
forward in advancing CBME in graduate medical education in the United States, but the 27
subcompetencies or “Milestones” in Pathology are not intended to serve as a comprehensive
curriculum. Rather, they were developed as a broad view of the expected progression of trainees in a
variety of domains. The subcompetencies and Milestones have specific limitations in a discipline like
pathology, where trainees traditionally gain knowledge, skills, attitudes, and behaviors
discontinuously in the many distinct rotation subdisciplines that comprise both anatomic pathology
and clinical pathology. For example, the Milestone subcompetencies contain several assessments
that rate a trainee across all of anatomic pathology or all of clinical pathology, when the trainee may
have a relative strength in transfusion medicine and a relative weakness in clinical chemistry or a
relative strength in surgical pathology and a relative weakness in cytopathology. The Milestone
subcompetencies therefore leave room for more focused assessments of the progress of pathology
trainees as they earn the trust of their instructors to accept the responsibility for independent
practice in specific areas.
Other competency-based assessment models have been developed independent of the ACGME
Milestones framework. Entrustable professional activities (EPAs) were first proposed by ten Cate in
2005 and represent an additional way to implement an outcome-based model of acquisition of
observable knowledge, skills, and attitudes by a learner.7 Per ten Cate, EPAs “are units of
professional practice, defined as tasks or responsibilities to be entrusted to the unsupervised
execution by a trainee once he or she has attained sufficient specific competence.”8(p.157)
Furthermore, EPAs should be activities that define the practice of a specialty. Specific attributes of
EPAs as defined by ten Cate (Table 1) also require that they have a recognizable output and be
executed within a specific time frame with observation and measurement of both the process and
the outcome.7 Based on a resident’s demonstrated level of competence, differing levels of
supervision can be entrusted (Table 2), with the highest levels of entrustment allowing for distant or
post hoc supervision and the ability of the resident to provide supervision to more junior trainees.8
Table 1.
ten Cate’s Attributes of an Entrustable Professional Activity (EPA).7
EPA: Attributes
1. EPAs are part of essential professional work in a given context
2. EPAs must require adequate knowledge, skill, and attitude, generally acquired through training
3. EPAs must lead to recognized output of professional labor
4. EPAs should usually be confined to qualified personnel
5. EPAs should be independently executable
6. EPAs should be executable within a time frame
7. EPAs should be observable and measurable in their process and their outcome, leading to a
conclusion
8. EPAs should reflect one or more of the competencies to be acquired
Table 2.
ten Cate’s Five Levels of Supervision for the Entrustable Professional Activity (EPA) Framework.8
EPA: Five Levels of Supervision

1. Observation but no execution, even with direct supervision
2. Execution with direct, proactive supervision
3. Execution with reactive supervision
4. Supervision at a distance and/or post hoc
5. Supervision provided by the trainee to more junior colleagues
In the EPA model, EPAs can be mapped back to relevant individual subcompetencies of the ACGME
Milestones framework, often spanning multiple core competencies, with proficiency across multiple
subcompetencies required for acceptable performance of an EPA. Less complicated than the
Milestones-based framework, EPA-based assessment tools should in theory be easier to implement
in a clinical training setting. Entrustable professional activities rely on repetitive units of work familiar
to physicians from their daily clinical activities. Therefore, the language and descriptions used in
assessment tools can be less complex, avoiding cognitive overload.9 In addition to serving as a tool
for assessment and assignment of the appropriate level of supervision for individual residents, EPAs
and other CBME-based tools may also eventually allow for a major shift in the structure of training
programs. For instance, by developing well-defined performance levels of expected outcomes at the
completion of training, programs may be able to transition from a time-dependent to
outcome-dependent model tailored to the pace of achievement of the individual learner.7
Much of the literature to date on EPAs has served to delineate the concept and establish EPAs for
various specialties, including internal medicine,10,11 family medicine,12,13 pediatrics,14
developmental-behavioral pediatrics,15 geriatrics,16 pulmonary and critical care,17
hematology/oncology,18 gastroenterology,19 and radiology,20 in the United States and abroad, and
for undergraduate medical education.21,22 In their recent publication in Human Pathology, Powell
and Wallschlaeger provide examples of possible EPAs for pathology, give a detailed description of
performance of an autopsy as an example of an EPA, and advocate for the development of EPAs for
pathology on the national level.23 To this end, the Graduate Medical Education Committee (GMEC)
goal was to develop practical EPAs for pathology graduate medical education encompassing primary
anatomic and clinical pathology residency training.
Go to:
Materials and Methods
The GMEC met over approximately 2 years to explore the concepts set forth in CBME and to develop
a preliminary list of EPAs for resident training in pathology. The GMEC’s charge includes identifying
the impact of trends in medical education on the ability to effectively recruit and train pathologists
throughout the continuum of medical education and to facilitate the exchange of information, tools,
and resources across pathology training programs; therefore, delineation of EPAs for pathology
training aligns well with the goals of the committee. As background, the GMEC consists of a cross
section of the pathology community, including members from academic, private, and military
practice environments, with expertise in many subspecialty areas of anatomic and clinical pathology,
including neuropathology, hematopathology, pediatric pathology, autopsy pathology, gynecologic
pathology, gastrointestinal pathology, transfusion medicine, and medical microbiology. Graduate
Medical Education Committee membership also represents a variety of departmental and
institutional administrative positions including residency program and fellowship directors, directors
of undergraduate medical education, designated institutional officials, and department chairs. A
resident member is also included in the committee. Several members of the working group who
participated in drafting the Milestones for Pathology (SZP, MDP, MDB, RDH) were members of the
GMEC during the EPA project.
The GMEC initially examined the feasibility of developing pathology-specific CBME content for
residency training in November 2014 and, based on a literature review, narrowed its focus to EPAs in
March 2015. After a subset of committee members drafted an initial list of EPAs for pathology, the
full committee evaluated and refined this preliminary list. Members were assigned to develop
content related to each EPA based on the “guidelines for full EPAs descriptions” and the
“components of a fully described EPA” described by ten Cate and colleagues and also based on the
example by Caverzagie et al in their EPAs for internal medicine.8,10,24 Entrustable professional
activities were then edited and refined in meetings in April, August, and November 2016.
Go to:
Results
The GMEC identified and developed 19 EPAs for anatomic and clinical pathology training. Of these, 7
are within the scope of anatomic pathology practice, 4 are within the scope of clinical pathology
practice, and 8 are generalizable to both disciplines, including 5 EPAs related to laboratory
management. The content defined for each EPA includes:
the EPA title;
a description of the EPA, including required knowledge and skills needed for competent EPA
performance;
mapping of the EPA to relevant ACGME Milestone subcompetencies;
possible assessment methods for evaluation of EPA performance.
The EPA titles are listed in Table 3, while the remainder of the content is included in a supplement to
this article. Due to the individualized nature of pathology residency program curricula and the many
ways in which EPAs could be used, the committee did not include correlation of supervision levels
with specific stages of training or expiration of entrustment in the absence of observation, as these
seemed most appropriately defined at the individual program level.
Table 3.
Entrustable Professional Activities (EPAs) for Pathology Graduate Medical Education.
Entrustable Professional Activity Titles

1. Perform gross dissection of simple and complex specimens (AP)
2. Compose a diagnostic report for surgical pathology specimens (AP)
3. Perform intraoperative consultations and frozen sections (AP)
4. Compose a diagnostic report for cytology specimens (AP)
5. Perform adequacy assessment/rapid interpretation for cytology specimens (AP)
6. Perform fine needle aspiration (AP)
7. Perform a medical autopsy (AP)
8. Compose a diagnostic report for clinical laboratory testing requiring pathologist interpretation
(CP)
9. Evaluate and report adverse events involving the transfusion of blood components (CP)
10. Evaluate and report critical values in the clinical laboratory (CP)
11. Perform other procedures, for example, bone marrow aspiration and biopsy, apheresis (CP)
12. Provide guidance for the resolution of preanalytical testing issues (AP/CP)
13. Provide pathology support for interdisciplinary conferences (AP/CP)
14. Provide patient care consultations (AP/CP)
15. Optimize test utilization (AP/CP laboratory management)
16. Improve quality and patient safety (AP/CP laboratory management)
17. Evaluate and choose a new test or instrument (AP/CP laboratory management)
18. Implement a new assay or test system (AP/CP laboratory management)
19. Perform a laboratory accreditation inspection (AP/CP laboratory management)
Abbreviations: AP, anatomic pathology; CP, clinical pathology.
The anatomic pathology-specific EPAs related to surgical pathology include gross dissection of
specimens, performance of intraoperative consultations and frozen sections, and generation of
surgical pathology reports. Entrustable professional activities in cytology include performance of fine
needle aspiration (FNA) procedures, performance of adequacy assessments, and composition of
cytology reports. Finally, performance of the medical autopsy is also included. For clinical
pathology-specific EPAs, tasks addressed include generation of interpretative reports for clinical
laboratory testing (eg, flow cytometry immunophenotyping, antibody identification, body fluid
analysis, peripheral blood and bone marrow diagnosis, etc). Management of patient care issues
including resulting critical values and managing adverse transfusion reactions is described. A general
EPA for “other” procedures is included that can be adapted to address bone marrow aspiration and
biopsy or apheresis, among others. Entrustable professional activities common to both anatomic and
clinical pathology cover guidance of preanalytical testing, support of interdisciplinary conferences,
and provision of patient care consultations. Finally, EPAs encompassing laboratory
management-specific tasks address test utilization, quality and safety, test or instrument evaluation
and implementation, and laboratory accreditation inspections. The committee also identified
obtaining informed consent as a critical EPA; however, this EPA has already been defined by the
Association of American Medical Colleges (AAMC) in their Core EPAs for Entering Residency.22
An example of the full content of 1 EPA that encompasses both anatomic and clinical pathology
training, “Provide patient care consultations,” is given in Table 4. The description of the EPA and tasks
involved in appropriately performing the activity is defined in the first section. For this EPA, a
resident is expected to provide a verbal or written consultation in response to a patient care–related
clinical provider inquiry. The knowledge and skills required to effectively complete this activity
include appropriately defining the clinical question, obtaining background information including
patient history, identifying relevant medical knowledge and laboratory procedural information,
communicating results with adequate documentation of such, handing off of information, and
following up on ongoing patient care and laboratory issues. This detailed definition of the activity to
be performed provides novice and advanced learners alike with a clear outline of expectations to
successfully complete the consultation. It also gives faculty distinct and concrete steps for evaluation
and feedback for this particular activity as opposed to simply viewing the task as a whole. The second
section of Table 4 relates the EPA back to the ACGME Milestones framework. This EPA includes
subcompetencies from across the 6 ACGME core competencies and demonstrates how EPAs pull
together knowledge and skills across the different domains of competency. The last section of Table 4
provides general ideas for assessment methods for the EPA. In the consultation example, direct
observation of the resident, 360° evaluations from laboratory staff, review of on-call activities, or
consultation documentation in a portfolio are all potential methods for assessment of the EPA.
Table 4.
Entrustable Professional Activity (EPA): Provide Patient Care Consultations (AP/CP).
Description and tasks Pathologists are able to provide timely and effective verbal or written
clinical consultations in response to clinical provider inquiries. Knowledge and skills required include
the ability to:
Define the clinical question posed by the consultation request
Evaluate patient clinical history, signs and symptoms, ancillary findings, and laboratory tests
pertinent to the consult request
Review the literature and identify outside resources necessary to manage the clinical consultation
Prepare a differential diagnosis and generate recommendations to address the consultation question
Communicate the results of the consult verbally and/or compose a written report documenting the
findings and recommendations as appropriate
Hand off information to a responsible technologist or pathologist as appropriate for consult requests

that cannot be resolved in the time frame available
Follow-up as needed on handoffs or unresolved issues regarding the clinical consult, including
monitoring patient outcomes and addressing any laboratory issues related to the consult
Relevant competencies and milestones

Patient care
PC1, PC2, PC4
Medical knowledge
MK1, MK2
Systems-based practice
SBP1, SBP5
Practice-based learning and improvement
PBLI1, PBLI2
Professionalism
PROF2, PROF3, PROF4, PROF5
Interpersonal and communication skills
ICS1, ICS2
Assessment methods
Direct observation
360° evaluations (eg, attending pathologist, medical technologists, other physicians)
Review of on call activities
Portfolio
Abbreviations: AP, anatomic pathology; CP, clinical pathology; PC, patient care; MK, medical
knowledge; SBP, systems-based practice; PBLI, practice-based learning and improvement; PROF,
professionalism; ICS, interpersonal and communication skills.
Go to:
Discussion
The EPAs outlined by the GMEC are meant to provide an initial framework for the further
development of EPA-related assessment and curricular tools for pathology residency training.
Interestingly, many of the subcompetencies identified in the Pathology Milestones Project
conceptually align with the EPA construct and are similar in content to EPAs identified by the GMEC
(Table 5).25 This overlap in scope between ACGME Pathology Milestones (or subcompetencies)
versus EPAs does contribute to confusion surrounding the 2 frameworks. In general, core
competencies refer to observable skills or abilities of an individual, while EPAs refer to a professional
task that often requires skills from across a range of competencies.10 The Milestones and EPAs differ
in several important ways. Whereas Milestones are deliberately intended to serve as a fixed reference
for measuring the progress of trainees in all programs of a discipline, EPAs are flexible and can be
adapted to the specific needs of individual programs. Whereas Milestones subcompetencies are
assigned to uniquely emphasize 1 core competency, EPAs are able to cross-reference multiple
Milestones and therefore multiple core competencies. Figure 3 provides a visual example of how a
specific EPA, “Provide patient care consultations” could be mapped to each ACGME core
competency and associated subcompetencies. The content in the milestone levels provided in the
ACGME subcompetencies could help further define observable knowledge, skills, and attitudes
associated with each EPA beyond what is outlined in the “Descriptions and Tasks” of the EPA and
could prove useful in driving curriculum development. Achievement of specific milestone levels could
also be used to designate supervision levels for associated EPAs as described by ten Cate et al.24
Table 5.
Accreditation Council for Graduate Medical Education (ACGME) Milestone Subcompetencies With
Similarity to EPA Framework.25
Competency Subcompetency
Patient care PC1: Consultation: Analyzes, appraises, formulates, generates, and effectively
reports consultation (AP and CP)
PC2: Interpretation and reporting: Analyzes data, appraises, formulates, and generates effective and
timely reports (CP)
PC3: Interpretation and diagnosis: Demonstrates knowledge and practices, interpretation and
analysis to formulate diagnoses (AP)
PC4: Reporting: Analyzes data, appraises, formulates, and generates effective and timely reports
(AP)
PC5: Surgical pathology grossing: Demonstrates attitudes, knowledge, and practices that enable
proficient performance of gross examination (analysis and appraisal of findings, synthesis and
assembly, and reporting; AP)
PC6: Procedure: Intraoperative consultation/frozen sections: Demonstrates attitudes, knowledge,
and practices that enables proficient performance of gross examination, frozen section (analysis and
appraisal of findings, synthesis and assembly, and reporting; AP)
PC7: Procedures: If program teaches other procedures (eg, bone marrow aspiration, apheresis, fine
needle aspiration biopsy, ultrasound-guided FNA, etc; AP/CP)
Medical knowledge 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)
Abbreviations: AP, anatomic pathology; CP, clinical pathology; PC, patient care; MK, medical
knowledge.

Figure 3.
Sample entrustable professional activity (EPA) mapped to the Accreditation Council for Graduate
Medical Education (ACGME) core competencies and relevant subcompetencies. Achievement of
specific milestone levels within each subcompetency could also be used to designate supervision
levels for associated EPAs.
Abbreviations: AP, anatomic pathology; CP, clinical pathology.
There is no one way to prescriptively include EPAs in graduate medical education, and a growing
number of studies demonstrate the versatility of the EPA model, which can be used for feedback,
assessment, and curricular design. Entrustable professional activities offer a simple but powerful
model for improving formative feedback for residents. Entrustable professional activities and CBME
in general stress observational evaluation of the outcome of not only units of work but also the work
process itself. In defining EPAs, the activity in question is broken down into knowledge, skills, and
attitudes demonstrated with successful, competent performance of an activity. This description of
the work process may provide guidance to the novice learner, which may otherwise only be available
through trial and error. For the supervising faculty member, EPAs may highlight specific areas for
instruction and coaching, beyond simple feedback on medical knowledge that may be otherwise
overlooked by an expert practitioner. Such a shared model of expectations for both process and
outcomes could lead to more efficient learning, which is critical in the age of duty hours, and to more
open conversation and feedback centered on the learning process. To this end, Aylward and
colleagues used an iterative process to develop a formative assessment tool for handoffs and were
able to demonstrate improvement in resident performance over multiple observations in an internal
medicine/internal medicine–pediatrics program.26 Tools such as this provide a framework to move
beyond generic feedback such as “good job,” “needs to read more,” or “enjoyed working with this
resident” and give the evaluator a set of concrete knowledge, skills, and attitudes on which to
comment for a particular activity to inform learner progress.
Entrustable professional activities can also offer a framework to implement curricular changes on a
local level. For example, Hamburger and colleagues chose 1 EPA they felt was critical to their
pediatric training and practice environment that of “Referral and Consultation.”27 Through a
comprehensive literature review and needs assessment using resident surveys and patient and
clinician focus groups, they were able to develop granular curricular elements that mapped to
competency domains. They also identified ways to deliver the curricular content, proposed a variety
of methods for assessment of competency, and outlined the need for faculty development in the use
of feedback tools. In this way, they transformed a process that had been dissatisfying for patients
and providers alike that was not formally addressed as a curricular element into something that could
be taught, observed, and improved upon by residents and faculty. At the program and institution
level, a similar application could be considered for pathology, especially utilizing EPAs related to
laboratory management. Adoption of EPA mastery into the curriculum surrounding tasks such as test
utilization review or quality improvement could lead to novel educational content in teaching
laboratory management, a more consistent experience for learners, and a constant pipeline of
improvement initiatives for clinical laboratories associated with pathology residency training
programs.
There are also multiple examples of EPAs being used to drive curricula at the national level. In 2014,
the AAMC published 13 EPAs that graduating medical students entering residency should be able to
perform unsupervised.22 Since that time, the AAMC has also moved forward with a 5-year pilot study
to develop curriculum, assessment, and faculty development tools to implement these EPAs with 10
participating institutions. Interest in this project was so great that over half of the 141 Liaison
Committee on Medical Education (LCME)-accredited schools applied to take part in the study.21
Numerous opportunities exist in pathology to use the EPA concept to help standardize training
expectations nationally.
In addition to providing a framework for assessment tools and curriculum development, EPAs may
also have additional benefits such as increasing expectations surrounding frequency of observation
of resident performance and facilitating pass/fail decisions for residents given the standardization of
assessment content.28 However, CBME and the EPA framework also pose significant challenges to
successful adoption in medical education. Klamen et al warn against repeating mistakes in
competency-based models from other fields such as K-12 education and the military, including the
overcomplication of the assessment process and the creation of time-consuming, inflexible training
systems.29 They and others also warn about the lack of consistent direct observation in medical
education and the variability in rater observations as other potential pitfalls in the implementation of
CBME-based initiatives.28-30 All of these factors may play a role in lack of faculty acceptance of
CBME or failure of competency frameworks to achieve desired educational outcomes.
A specific challenge to the development and application of EPAs for pathology practice and training
is that the scope of work performed by pathologists does not necessarily fit into the EPA framework.
Many activities performed by pathologists, especially those with administrative responsibilities, are
more longitudinal in nature, are administrative or supervisory, or occur with low frequency, limiting
the opportunity for repeated performance and assessment of trainees. Examples of such activities
include longitudinal test utilization or performance review, personnel management, participation in
internal or external laboratory inspections, managing laboratory quality and safety programs,
selection of new test platforms or laboratory information systems, application of informatics skills in
laboratory management, and test verification or validation. However, the GMEC chose to include
EPAs for many of these activities as they are critical to the practice of pathology. Residents do
participate in components of many of these activities and perhaps are able to complete smaller
discrete projects such as simple assay verifications or quality improvement projects. However,
seldom do residents have the opportunity to complete complex, longitudinal projects, let alone with
a frequency to allow for repeated observation. In these situations, documentation of participation
likely acts as a surrogate marker for competence for many programs. Perhaps assessment tools
based on EPAs could evaluate background knowledge, critical thinking skills, and situational
leadership skills in lieu of repetition.
Another challenge to the EPA model for pathology is how to apply direct observation to the work of
pathology trainees that is typically performed independently, such as microscopy. Although
attending pathologists spend time “double-scoping” with residents during case sign-out or reviewing
reports composed by residents on specific cases, they often rely upon a correct diagnosis as a marker
for adequate evaluation of a case. A better understanding of the process novice learners go through
in evaluating a case could provide an opportunity to teach a more efficient approach that is tailored
to the individual resident. Using EPAs to focus on direct observation of resident work process may
provide insight into inefficient work habits that lead to an inability to handle higher volumes and
hinder a trainee’s ability to transition to independent practice.
A final challenge to the EPA model is how programs can integrate the concept of EPAs into their
individual programs in a way that is meaningful to resident education, increases direct observation of
resident performance, and does not overcomplicate the evaluation process or overburden faculty or
program administration. The work presented here is only a preliminary list of EPAs focused on
anatomic and clinical pathology training for the purposes of primary certification and should be
expanded to include tools for assessment and curriculum development. Fellowships would also need
to refine and add to the current list to reflect the more comprehensive treatment of some topics in
fellowship training. Finally, pathology does not have a strong history of research on educational
methods, and the small size of training programs makes evaluating and demonstrating the value of
curriculum innovations or use of assessment tools difficult. Fostering a cooperative environment
among programs, sharing innovative educational ideas openly, and encouraging cooperative
research among institutions may be a way to ensure that adoption of CBME concepts such as EPAs is
actually providing the intended educational benefits.
In conclusion, many of the critical activities that define the practice of pathology fit well within the
EPA model, especially in regard to the procedural and diagnostic activities performed by
pathologists. The EPAs presented by the GMEC are meant to provide an initial framework for the
development of EPA-related assessment and curricular tools for pathology residency training. This
innovation in the CBME movement encourages educators to be more observant and articulate
teachers, to use desired outcomes to drive curriculum, and to recognize the learner’s progression
toward mastery of an EPA, with the ability to adjust teaching and supervision strategies along the
way. As such, EPAs may be one tool to address current challenges in pathology graduate medical
education.
Go to:
Supplementary Material
Supplementary material:
Click here to view.(159K, pdf)
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Acknowledgments
The authors would like to acknowledge Dr Gregory Blakey for reviewing the manuscript and
supplemental materials.
Author’s Note: For Dr. Brissette: The views and opinions expressed in this manuscript are those of the
author and do not reflect the official policy or position of the Department of Army/Navy/Air Force,
Department of Defense or the United States Government.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research,
authorship, and/or publication of this article: Funding and support of the College of American
Pathologists Graduate Medical Education Committee (CAP GMEC) is provided by the CAP in the form
of educational staff support (authors KJ and SP), travel reimbursement for committee members
(authors CBM, RED, RMC, RDH, MDP, MDB, DAG, PMR, DAC, CAR, AMR, and SZP), and funding for
publication.
Supplemental Material: The online supplemental materials [Entrustable Professional Activities (EPAs)
for Pathology Graduate Medical Education: Recommendations from the College of American
Pathologists (CAP) Graduate Medical Education Committee (GMEC)] are available at
http://journals.sagepub.com/doi/suppl/10.1177/2374289517714283.
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Journal ListAcad Patholv.4; Jan-Dec 2017PMC5528966

Logo of apathol
Acad Pathol. 2017 Jan-Dec; 4: 2374289517714767.
Published online 2017 Jul 6. doi: 10.1177/2374289517714767
PMCID: PMC5528966
PMID: 28815203
Joanna L. Conant, MD,1 Pamela C. Gibson, MD,1 Janice Bunn, PhD,1 and Abiy B. Ambaye,
MDcorresponding author1
Author information Copyright and License information Disclaimer
This article has been cited by other articles in PMC.
Go to:
Abstract
Many pathology departments are introducing subspecialty sign-out in surgical pathology. In 2014,
the University of Vermont Medical Center transitioned from general sign-out to partial subspecialty
sign-out to include gastrointestinal and breast/cervix subspecialty benches; other specimens
remained on general benches. Our experiences with the transition are described, including attending
pathologist, trainee, support staff, and clinician satisfaction. A survey was e-mailed to all University of
Vermont Medical Center anatomic pathology attendings, pathology trainees, pathologist assistants
and grossing technicians, and clinicians who send surgical pathology specimens, immediately before
and 1 year after transitioning to partial subspecialty sign-out. Quality assurance metrics were
obtained for the 18 months prior to and following the transition. Gastrointestinal and breast/cervix
attendings were more satisfied with partial subspecialty sign-out compared to those on the general
benches. Overall, trainees were more satisfied with general sign-out because of the rotation schedule
but preferred partial subspecialty sign-out due to improved teaching and more focused learning
while on subspecialty benches. Clinicians remained very satisfied with our department and our
reports; no differences were observed. Turnaround time was unchanged. After switching to partial
subspecialty sign-out, there were significantly fewer discrepancies following multidisciplinary
conference review for gastrointestinal and breast/cervix cases but remained the same for general
cases. Fewer formal internal consults were performed after transitioning to partial subspecialty
sign-out across all areas, but more notable for gastrointestinal and breast/cervix cases. Our data
show improved quality assurance metrics and trainee education in a subspecialty sign-out setting
compared to general sign-out setting.
Keywords: quality, resident education, subspecialization, surgical pathology

An increasing number of pathology departments are introducing subspecialty sign-out in surgical
pathology (SP). Potential benefits include increased efficiency, shorter turnaround time (TAT),
decreased use of immunohistochemical (IHC) stains, and the fact that the amount of information and
knowledge needed to stay current on best practices and new research can be overwhelming across a
wide spectrum of anatomic and clinical pathology. Since many of our clinical colleagues are
subspecialized, we should also have the corresponding subspecialty knowledge and expertise.
Additionally, learning for residents may be improved if their education comes from the experts in
their knowledge areas.
However, there is also concern that becoming more specialized means that over time, pathologists
lose touch with their “generalist” approach and knowledge, and some pathologists prefer to remain
generalists. Additionally, there is concern that the change may have impact on resident education.
Several editorials have been written on this topic,1-5 but there has been very little published on how
other pathology departments have made the transition from general to subspecialty sign-out nor on
the impact of this transition on education, workload, and satisfaction.6-8 A recent study published by
Liu et al9 supports the transition to subspecialty. Their focus was primarily on how subspecialization
affects the utilization of external consults. We aim to add to the limited number of published data
and include additional quality assurance (QA) parameters as well as satisfaction reports from
attending pathologists, pathology residents, and clinicians. On January 1, 2014, the University of
Vermont Medical Center (UVMMC) Pathology and Laboratory Medicine Department transitioned
from general sign-out (GSO) in SP to partial subspecialty sign-out (PSSO). Here, we describe our
experiences with the transition and evaluate the satisfaction of clinicians, attending pathologists,
pathology trainees, pathologist assistants (PAs), and grossing technicians (GTs) with SP before and
after the switch to PSSO. Additionally, QA metrics such as TAT, formal and informal
intradepartmental consults, discrepancy rate following external review, and discrepancy rate
following review for multidisciplinary conference (MDC) are compared and discussed.
Go to:
Institutional Environment
UVMMC is Vermont’s only nonprofit academic medical center and provides care for approximately 1
million people in Vermont, New Hampshire, and northern New York. It is the regional referral center
with the region’s only level 1 trauma center, Vermont’s only neonatal intensive care unit, and also is
the center for the University of Vermont Children’s Hospital and the University of Vermont Cancer
Center. The medical center has 447 active inpatient beds.
The division of SP processed approximately 38 500 cases per year during the study time frame. In
December 2013, there were 25 surgical pathologists, and in December 2014, there were 23 surgical
pathologists. At both time intervals, 2 of those attending pathologists signed out dermatopathology
specimens and 4 were only rarely signing out in SP (cross coverage pathologists). Dermatopathology
had already been subspecialized and no changes were made to the service.
There are, on average, 16 residents enrolled in the program, 4 residents in each class, and 3 fellows: 1
SP fellow, 1 cytopathology fellow, and 1 dermatopathology fellow. Additionally, the department had
2 pathology student fellows each year, who spent a year in the department between their third and
fourth year of medical school. In December 2013, there were 4 PAs and 1 GT; in December 2014, there
were 5 PAs and 1 GT. The addition of 1 PA was to address the demand of an increase in volume at our
institution.
In June 2013, barcoding of specimens, cassettes, and slides was introduced. Anecdotally, this slowed
down productivity in the gross room as it took extra time to scan cassettes and add and delete blocks
as needed. Not long after, in September 2013, a transition was made from an in-house transcription
service to a voice dictation system. The software system used in the voice dictation system was
complex and it took some time for individuals to adapt to using the system.
General Surgical Pathology System

Under the general SP system, cases were divided among 4 benches (A, B, C1, and C2), and 1
attending covered each bench. The A and B benches were resident benches, while the C1 and C2
benches were attending-only benches. The larger, more complex specimens were assigned to be
grossed in by the resident benches, while the smaller, more routine nonbiopsy specimens were
assigned to the C benches. All specimens that were grossed in by a resident were previewed by that
resident for continuity. Pathologist assistants and GTs grossed in the C bench specimens and all
biopsies. All dermatopathology specimens were grossed in by a PA or a GT and signed out by a
dermatopathologist, which was a separate rotation for the residents. Surgical pathologists signed
out lymph nodes, but hematopathologists were always available as consultants.
Three residents covered SP 1 month at a time and the SP fellow or a senior resident covered the hot
seat rotation. Hot seat previewed and triaged all large specimens on the resident benches and
divvied up the biopsies among the 4 benches. Resident benches were on a 3-day cycle with different
daily rotation schedules (Table 1). The 2 C benches were on a 2-day cycle. Senior residents were able
to rotate through these benches as a senior elective and they previewed and dictated the cases in the
morning, functioning as a junior attending, and passed them on to the attending to be signed out.
Table 1.
Sample General SP Rotation for Resident Benches.
Day 1 Day 2 Day 3

Resident 1am: sign-out A pm: preview B am: sign-out B pm: gross A am: frozen pm: gross
B/preview A
Resident 2 am: sign-out B pm: gross A am: frozen pm: gross B/preview A am:
sign-out A pm: preview B
Resident 3am: frozen pm: gross B/preview A am: sign-out A pm: preview B am: sign-out B
pm: gross A
Abbreviation: SP, surgical pathology.
On a frozen section (FS) day, the pathologist would cover all FS cases that came in that day; the FS
resident was responsible for assisting with performing and interpreting FS until noon. In the
afternoons, the hot seat covered FS and functioned as a junior attending for FS, with attending
backup and support as needed. The FS pathologist also reviewed gross-only specimens, at least 10
gastrointestinal (GI) biopsies, and outside review of slides (ROS).
Each afternoon, there was an intradepartmental consensus conference (IDCC) where pathologists
gathered together to discuss and review interesting and challenging cases. Generally, all pathologists
on service attended, and often others who were in-house would also attend. Anecdotally, on average
approximately 5 individuals attend IDCC on any given day.
Partial Subspecialty System

Under the partial subspecialty system, cases were allocated to 1 of 4 benches, with 1 attending
pathologist covering each bench: GI, breast/cervix (BR), general 1, and general 2. Both GI and BR
cases were chosen as the subspecialties due to volume of specimens, number of available
subspecialists, and following conversations with clinical specialists in these areas. Three residents
covered SP for a 4-week block (Table 2); GI, BR, and general 1 benches were covered by residents,
while general 2 bench was an attending-only bench. More complex cases were often assigned to
general 1 bench, but cases were also divvied up based on each pathologist’s expertise and interests
and daily volume on the 2 general benches. For example, if an attending with expertise in pulmonary
pathology and an attending with expertise in genitourinary pathology were on the 2 general
benches, the pulmonary cases were assigned to the first pathologist and vice versa.
Table 2.
Sample Subspecialty SP Rotation for Resident Benches.
Week 1-2 Week 3-4

Resident 1am: sign-out BR pm: gross/preview BR am: sign-out general 1 pm: gross/preview
general 1
Resident 2 am: sign-out GI pm: gross/preview GI am: sign-out BR pm: gross/preview
BR
Resident 3am: sign-out general 1 pm: gross/preview general 1 am: sign-out GI pm: gross/preview GI
Abbreviations: BR, breast/cervix; GI, gastrointestinal; SP, surgical pathology.
Resident benches signed out in the morning and grossed and previewed in the afternoon and
evening; cases remained on a 3-day cycle. General 2 (attending-only) bench remained on a 2-day
cycle. Again, senior residents were able to rotate through this bench as a senior elective and function
as junior attendings. No changes to the handling of dermatopathology specimens were made.
Neuropathology cases remained on the general benches. Rather than having hematopathologists
consult on cases, lymph nodes were signed out by a hematopathologist unless they were submitted
for workup of metastatic disease, in which case they were assigned to the appropriate bench.
FS were covered by a fifth pathologist. The FS pathologist also reviewed all gross-only specimens, at
least 10 GI biopsies (mostly polyps), and non-GI and BR ROS; GI and BR ROS were reviewed by the
appropriate subspecialty benches. Residents started assisting with performing and interpreting FS on
their fourth block on SP. One morning each week, they predictated their cases and handed them to
their attending pathologist, who signed out the cases alone and provided feedback to the trainee at a
later time. In lieu of signing out cases, the resident assisted with any FS that came in that morning.
Every afternoon, the trainee on hot seat functioned as a junior attending for FS, similar to the GSO
system.
Each specialty (GI, BR, and general) held their own separate IDCC each afternoon. Generally, most GI
and BR pathologists attend their own IDCCs, regardless of whether or not they were on service. For
the general IDCC, it was often the 2 pathologists on the general benches, the FS attending, and the
trainee on hot seat who attended. Sometimes, additional general pathologists attended if they were
in-house. Anecdotally, an average of 2 to 3 individuals attended the general IDCC on any given day.
Go to:
Materials and Methods
In December 2013, prior to implementing PSSO, a survey was e-mailed to all UVMMC anatomic
pathology attending pathologists, all current UVMMC pathology trainees (residents, fellows, and
student fellows), all UVMMC PAs and GTs, and all clinicians who send SP specimens to UVMMC
(Appendices A to D, General). Participation in the study and completion of the survey were entirely
voluntary and completely anonymous.
The same survey was sent out to the same distribution (current UVMMC pathologists, trainees, and
PAs/GTs, as well as to clinicians who send SP specimens to UVMMC) in December 2014, 1 year after
implementing PSSO. Additional questions focusing on subspecialty sign-out were included following
completion of the main survey (Appendices A to D, Partial Subspecialty).
The responses for each of the questions in the survey, GSO system (first survey) versus PSSO system
(second survey), were compared. For the second survey, attending pathologist responses were also
compared based on whether the respondent signed out subspecialty benches (GI and BR) or general
benches. For the clinician surveys, responses were evaluated overall. Additionally, individuals who
regularly utilize SP services often discuss cases with the pathologists were evaluated separately.
These clinicians include those who stated they were in colon and rectal surgery, dermatology,
gastroenterology and hepatology, general surgery, gynecologic oncology, hematology and medical
oncology, nephrology, neurosurgery, obstetrics and gynecology, otolaryngology, pulmonology,
radiation oncology, transplant surgery, and urology. While some respondents may have completed
surveys both before and after the implementation of the subspecialty sign-out system, it was
impossible to match pre- and postsurveys. Thus, results across time as well as between attendings
who signed out subspecialty versus general benches were compared using the Wilcoxon rank sum
test.
Quality assurance measures including TAT, cases shown at IDCC, formal internal consult requests,
and discrepancies after MDC were already being tracked for the department’s monthly QA review.
The results were tabulated for the 18 months prior to subspecialization (July 2012 to December 2013)
and the 18 months after subspecialization (January 2014 to June 2015). The differences in percentage
of cases shown at IDCC, formal internal consult requests, and discrepancies after MDC were
compared using the χ2 test of independence or Fisher’s exact test. The types of discrepancies were
also noted: level 1—little or no clinical impact, level 2—potential clinical impact, and level 3—definite
clinical impact.
Utilization of several IHC stains, which are specific to GI and BR, was also reviewed for the 18 months
before and after the transition to PSSO. These stains were P16 and MIB-1 in cervix specimens to
differentiate high-grade dysplasia from reactive atypia, E-cadherin in breast specimens to
differentiate lobular from ductal carcinoma, P63 and heavy chain myosin (HCM) in breast specimens
for identification of invasion, and Helicobacter pylori (HP) stain in GI biopsies. The differences in
utilization were compared using χ2 test of independence.
Go to:
Results
Attending Pathologist Satisfaction
Seventeen of 25 surgical pathologists (68.0%) completed the first survey and 15 of 23 surgical
pathologists (65.2%) completed the second survey. Two of these 15 did not answer the additional
questions focusing on subspecialty sign-out, and it is suspected that these 2 were
dermatopathologists, as those questions did not pertain to them. Of the 13 who completed the entire
second survey (56.5%), 3 were subspecialists—1 (33.3%) of 3 GI pathologists and 2 (50.0%) of 4 BR
pathologists—and 10 signed out other benches (of 16, 62.5%).
Pathologists were significantly more satisfied with the mix of cases they saw with the GSO system
compared to the subspecialty system (P = .022). Otherwise, no differences were identified, including
overall satisfaction with the sign-out systems (Figure 1), feeling more efficient with either system,
being satisfied with the ability to teach residents, number of hours worked, nor feeling the number of
hours worked was appropriate. Overall, when specifically asked which type of sign-out they
preferred, pathologists were split between preferring general versus subspecialty sign-out (46% vs
53%, respectively).

Figure 1.
Overall satisfaction of attending with sign-out presubspecialization (blue) and postsubspecialization
(red).
In comparing the 3 subspecialty pathologists (GI and BR) to the 10 general pathologists, subspecialty
pathologists were more satisfied with the mix of cases they see (P = .032). There was a trend toward
the subspecialty pathologists feeling more satisfied with their ability to teach residents (P = .088) and
overall satisfaction with the sign-out system (P = .084; Figure 2). When asked in the additional
subspecialty questions in the second survey, subspecialists felt better able to teach residents (P =
.046) and there was a trend toward feeling more comfortable signing out their cases than the
generalists (P = .084).

Figure 2.
Satisfaction with subspecialty sign-out by pathologist type, general pathologists (blue) and
subspecialty (breast and GI) pathologists (red).
Trainee Satisfaction
At the time that both surveys were sent out, there were 22 trainees in the program—17 residents, 3
fellows, and 2 student fellows. One resident did not complete either of the surveys due to being
involved in the study. Twelve (54.5%) trainees completed the first survey and 16 (72.7%) completed
the second survey. There was no difference between the 2 surveys in the number of months of SP
completed or in the number of hours worked.
Overall, trainees were significantly more satisfied with the GSO system compared to the subspecialty
sign-out system (P = .043; Figure 3). However, when residents were specifically asked in the second
survey, 9 of 10 trainees stated that they preferred subspecialty sign-out (Figure 4). In the second
survey, when asked about teaching and learning, 80% of trainees agreed or strongly agreed that they
were able to better focus their learning with PSSO and 90% agreed or strongly agreed that there was
better teaching from attending pathologists with PSSO. There was a trend toward feeling more
satisfied with teaching from pathologists with the subspecialty system (P = .094). The trainees were
significantly more satisfied with the time available to preview under the GSO format compared to
the partial subspecialty format (P = .002). Otherwise, there was no difference in response between
the 2 surveys on any other questions (including satisfaction with time to gross, support from PAs/GTs
and attending pathologists, and the mixtures of cases seen).

Figure 3.
Overall satisfaction of residents with sign-out presubspecialization (blue) and postsubspecialization
(red).

Figure 4.
Resident preference for general or subspecialty sign-out.
Pathologist Assistant/Grossing Technician Satisfaction

One hundred percent of PAs and GTs completed both surveys. There was no significant difference in
the satisfaction with the GSO system versus the PSSO system. Four (66.7%) of six PAs and GTs
preferred the subspecialty sign-out system over the general system.
Clinician Satisfaction
The first survey was e-mailed to 1048 clinicians and 96 completed it (9.16% response rate). The
second survey was e-mailed to 1168 individuals and 73 completed it (6.25% response rate). However,
many of the recipients of the e-mail do not regularly utilize our services. When looking at only the
high utilization group, 52 of 199 completed the first survey (26.1% response rate) and 35 of 195
completed the second survey (17.9% response rate).
For all clinician responses, there was no difference between the first and second surveys and the
majority of clinicians were satisfied or very satisfied overall (Figure 5). In looking at the additional
subspecialty questions in the second survey, many clinicians strongly agreed or agreed that
pathology reports were more consistent (40.8%), were more confident in the accuracy of the reports
(42.3%), and felt it was easier to obtain a pathology consult after making the switch to subspecialty
sign-out (27.8%). Additionally, a high percentage of clinicians were neutral in feeling that the
pathology reports were more consistent (46.5%), in their confidence in the accuracy of reports
(45.1%), and in feeling it was easier to obtain a pathology consult after making the switch to
subspecialty sign-out (52.8%). The majority of respondents (67.7%) stated that they did not notice a
difference in the overall quality of pathology reports and consults.

Figure 5.
Overall satisfaction of clinicians with our surgical pathology department presubspecialization (blue)
and postsubspecialization (red).
There was also no significant difference in responses between the first and second surveys when
looking at the high utilization subset of clinicians. However, there was a trend toward increased
satisfaction with pathologist accessibility for consultation after subspecialization (P = .079) and with
the consultation itself (P = .075). In looking at the additional subspecialty questions, many
respondents strongly agreed or agreed that pathology reports were more consistent (67.7%), were
more confident in the accuracy of reports (67.7%), and felt it was easier to obtain a pathology consult
after making the switch to subspecialty sign-out (45.2%). Additionally, many clinicians were neutral
in feeling that pathology reports were more consistent (32.3%), in their confidence in the accuracy of
the reports (32.3%), and in feeling it was easier to obtain a pathology consult after making the switch
to subspecialty sign-out (45.2%). In this group, 50% of respondents stated that they noticed a
difference in the overall quality of the pathology reports and consults, while 50% did not.
Quality Assurance Measures
See Tables 3 toto to55 for a summary of data. A total of 49 260 cases were signed out for the 18
months prior to switching to partial subspecialization and 57 294 cases were signed out in the 18
months after the switch, which represents a 6.9% increase in cases.
Table 3.
Quality Assurance Measures.
Before Partial Subspecialty After Partial Subspecialty P Value

Total number of cases 49 260 57 294 Not applicable
Shown at IDCC 4900 (9.95%) 4679 (8.17%) <.0001
Internal consult 2931 (5.95%) 2294 (4.00%) <.0001
External consult 1043 (2.12%) 1106 (1.93%) .0322
Discrepancy after external consult 20 (1.91%)7 (0.63%) .008
Level 1 errors 18 (90.00%) 5 (71.43%) .27
Level 2/3 errors 2 (10.00%) 2 (28.57%)
Abbreviation: IDCC, intradepartmental consensus conference.
Table 4.
Formal Internal Consults by Subspecialty.

Gastrointestinal 451 of 14 825 (3.04%) 203 of 15 751 (1.29%) <.0001
Breast/cervix 394 of 3616 (10.90%) 204 of 5841 (3.49%) <.0001
General 1571 of 14 227 (11.04%) 1159 of 15 553 (10.02%) <.0001
Dermatopathology 515 of 16 592 (3.10%)728 of 20 149 (3.61%) .007
Table 5.
Discrepancy After Multidisciplinary Clinic Review.

Shown at MDC 4017 (8.15%) 3841 (6.70%) <.0001
Gastrointestinal 1432 (35.65%) 1116 (29.05%) <.0001
Breast/cervix 1089 (27.11%) 1164 (30.30%)
General 921 (22.93%) 1016 (26.45%)
Dermatopathology 575 (14.31)545 (14.19)
Discrepancy after MDC review 88 (2.19%) 23 (0.60%) <.0001
Total GI discrepancies 41 (2.86%) 8 (0.72%) <.0001
Total breast/cervix discrepancies 34 (3.12%)5 (0.43%) <.0001
Total general discrepancies 13 (1.41%) 10 (0.98%) .41
Total dermatopathology discrepancies 0 (0.0%) 0 (0.0%) .99
Abbreviations: GI, gastrointestinal; MDC, multidisciplinary conference.
Turnaround time
Prior to subspecialization, the average TAT for all cases was 51.81 hours. After subspecialization, the
average TAT for all cases was 52.15 hours. Standard deviation or standard error information was not
available to perform statistical analysis.
Intradepartmental consensus conferences (IDCC)

Overall, significantly fewer cases were shown at IDCC and had formal consults in the 18 months after
transitioning to PSSO (P < .0001 for both GI and BR; Table 4). For GI cases, 451 (3.04%) of 14 825 cases
had formal internal consults prior to the transition and 203 (1.29%) of 15 751 had formal internal
consults following the transition to PSSO (P < .0001). For BR cases, 10.90% (394 of 3616 cases) and
3.49% (204 of 5841) had formal internal consults before and after the transition, respectively (P <
.0001). For cases that fall into the general benches, these numbers were 11.04% (1571 of 14 227 cases)
and 7.45% (1159 of 15 553 cases; P < .0001), respectively. Finally in dermatopathology, 515 (3.10%) of
16 592 and 728 (3.61%) of 20 149 had formal internal consults (P = .007).
Multidisciplinary conference reviews

Overall, significantly fewer cases were shown at MDC under the PSSO system (P < .0001; Table 5).
The distribution of cases under the 2 sign-out systems was significantly different (P < .0001): GI made
up a greater portion of the cases shown at MDC prior to subspecialization, whereas it made up a
lower proportion of cases shown at MDC after transitioning to PSSO, with a higher proportion of BR
and general cases. While there were significantly more discrepancies identified overall with GSO
compared to PSSO (P < .0001), there was no difference in the type of errors (P = .73, Fisher’s exact
test). The MDC discrepancies were then evaluated based on subspecialty benches. Both GI and BR
discrepancies following MDC review decreased significantly after transitioning to partial subspecialty
(P < .0001 for both). However, discrepancies did not change for cases on the general bench (P = .41).
External reviews
While the number of cases sent for external review did not change (P = .095), there were significantly
fewer discrepancies, between our diagnosis and the diagnosis on external review, after transitioning
to partial subspecialty (P = .008). However, there was no difference in the types of errors (P = .27,
Fisher’s exact test).
Immunohistochemical stains
See Table 6 for a summary of data. There was no change in the utilization of IHC stains in cervical
specimens. Similarly, the utilization of HCM and P63 in breast specimens remained the same.
Utilization of E-cadherin on breast specimens significantly decreased (P = .0018). Interestingly,
staining for HP in gastric specimens significantly increased (P < .0001).
Table 6.
Immunohistochemical Stain Utilization.
Antibody Organ Before Partial Subspecialty After Partial Subspecialty P Value

Total Cases Stained Total Cases Stained
P16 Cervix 1825 226 (12.38%) 1972 229 (11.61%) .46
MIB-1 Cervix 1825 58 (3.18%)1972 54 (2.74%).42
E-cadherin Breast 2359 139 (5.89%) 2368 93 (3.93%).0018
P63 Breast 2359 195 (8.27%) 2368 163 (6.88%) .07
HCM Breast 2359 159 (6.74%) 2368 163 (6.88%) .85
HP Stomach 3463 1718 (49.61%) 3603 2260 (62.73%) <.0001
Abbreviations: HCM, heavy chain myosin; HP, Helicobacter pylori.
Go to:
Discussion
The transition from GSO to PSSO was a difficult process, and at the time of publication, one that
continues to be adjusted. Overall, the switch was positive, with most trainees and PAs/GTs preferring
PSSO and the attending pathologists being relatively evenly split between the 2 systems. The
satisfaction of our clinicians with our department was very high before the transition to PSSO and
continued to remain high after the transition. There was no change in clinician satisfaction with our
department or our reports. For clinicians who are likely to review more pathology reports, there was
a trend toward increased satisfaction with pathology consultations and pathologist accessibility for
the consults, but they did not notice a difference in the overall quality of pathology reports and
consults.
Pathologists and trainees liked the mix of cases that they saw and the education and learning that
came with a more focused range of topics while on subspecialty benches. However, pulling out only a
few subspecialty areas meant that the majority of pathologists were still general pathologists but
without being able to evaluate the full spectrum of cases that go through SP. When compared to the
subspecialty benches, the education in the general benches felt more disjointed and dispersed, which
went with the high variability and complexity of types of specimens seen. Based on anecdotal
evidence and the responses in this survey, the subspecialty pathologists (those signing out the GI and
BR benches) were more satisfied with the transition to partial subspecialization, while many of those
signing out the general benches were dissatisfied with being caught in the middle—no longer being
true generalists, but also not being able to fully subspecialize. Comments from pathologists signing
out the general benches state that there is a need to subspecialize even more, as cases on the
general benches are often very complex and diverse, resulting in more consults, as evidenced by
similar rates of formal internal consults requested by general pathologists before and after the
transition to PSSO (further discussed below).
The dichotomy between the overall satisfaction for GSO and the preference for subspecialty sign-out
by trainees is likely because the dissatisfaction with subspecialty sign-out was mostly due to
dissatisfaction with the overall system, particularly in losing a dedicated preview afternoon and
needing to sign-out, gross, and preview every day. Anecdotally, there also seemed to be less frozen
section exposure for trainees. However, trainees preferred the directed teaching and learning while
on the subspecialty benches.
In general, there was no difference in PA/GT satisfaction identified before or after the switch to
partial subspecialty. Concerns about adequate space in the gross room were prevalent at both time
points; all respondents stating they were neutral or disagreed that there was adequate space in the
gross room. This is particularly true after making the switch to partial subspecialty: Under the GSO
system, 2 of the 3 residents were grossing on any given day while under the partial subspecialty
system and all 3 residents were in the gross room every day. The trend toward feeling as though
there was less ability to complete their work in the allotted time may have been impacted, in part, by
the introduction of barcoding and voice dictation software, rather than as a result of switching to
partial subspecialty. The respondents noted that they enjoyed the opportunity to gross more
complex specimens under the subspecialty system.
Quality assurance measures remained the same or improved following the transition to PSSO.
Turnaround time was not affected (51.81 vs 52.15 h, respectively) and fewer discrepancies were
identified after both MDC and external review. Significantly fewer cases were being shown at MDC
overall. Cases for MDC are selected by the respective clinical team. Most cases are selected for
discussion regarding multidisciplinary management approaches. However, some cases are selected
for review to clarify pathology diagnostic reports. With the introduction of subspecialty sign-out,
pathology reports became more consistent, which we believe eliminated some uncertainties in the
eyes of the clinicians, and therefore contributed to the decrease in the number of cases shown at
MDC. There were also fewer discrepancies after MDC review. When separated by subspecialty bench,
the decrease in discrepancies holds true for both the GI and BR benches. However, there was no
change in the number of discrepancies for specimens signed out on the general bench. As expected,
dermatopathology remained relatively stable during both time periods. These findings suggest that
when cases are signed out by specialists, fewer discrepant results occur.
The number of formal internal consults decreased overall. However, when these consults were
broken down by subspecialty bench for the 18 months after making the switch, there was a
noticeable difference in the number of formal consults obtained: The percentage of cases for both
the GI and BR benches decreased by over 50% (3.04% to 1.29% for GI and 10.90% to 3.49% for BR),
while the percentage of cases for the general benches decreased from 11.04% to 7.45% (Table 4).
Where these decreases were all statistically significant, there was a much more noticeable decrease
in the subspecialty benches. While the GI and BR pathologists can reliably show difficult and
interesting cases to other subspecialists at IDCC, the likelihood of a particular general pathologist
with a certain expertise (lung or soft tissue, for example) being at IDCC can be variable and depends
on who is on service. In these instances, a formal consult request is made instead of showing the case
at IDCC.
The percentage of E-cadherin stains ordered on breast specimens decreased after implementing
PSSO. The smaller group of breast pathologists have agreed that performing E-cadherin on core
needle biopsies (the majority of E-cadherin stains) which show both ductal and lobular features does
not have significant clinical utility and therefore are not ordering as many E-cadherin stains
compared to the GSO period. The utilization of other IHC stains for cervical and breast specimens
(P16 and MIB-1, and P63 and HCM, respectively) remained the same because these stains do
continue to have clinical significance and utility.
Interestingly, this study identified increased use of HP in gastric biopsies following the transition to
PSSO. Like using P16 and MIB-1 in cervical specimens and P63 and HCM in breast specimens, HP has
clinical utility and therefore a decrease was not expected. We noted a difference in IHC stain ordering
practices of SP fellows during this time, with one fellow tending to have a lower threshold to order
HP (data not included); this might have contributed to the difference. Further investigation into the
reasons and impact of increased HP utilization is also currently being reviewed.
These findings support transitioning to subspecialization. It may be preferable to transition to full

subspecialization due to decreased discrepancies following review of cases at MDC or external
reviews, overall decreased utilization of IHC stains, and improved trainee education. However, this
would not be feasible at our institution due to volume considerations and the number of subspecialty
pathologists in certain subspecialties.
We are currently working on revamping our SP system to address concerns that were elucidated
through this project as well as in discussions within the department. At the time of this publication, a
LEAN process is in progress to reevaluate our system. There is no immediate plan to finalize
subspecialization at our institution. However, we are evaluating the general bench, which may lead
to further subspecialization. Specific goals include improving general bench workflow, efficiency, and
satisfaction and restructuring FS duties to improve workflow and efficiency and to improve trainee
education—especially on general benches—to enhance resident experiences in grossing, previewing,
and signing out.
One goal of the transition was to ensure that trainees had more exposure to ancillary prognostic and
molecular testing (such as estrogen receptor, progesterone receptor, and human epidermal growth
factor receptor 2 testing in breast specimens, and mismatch repair protein expression in GI cases).
These tests have been incorporated into sign-out and residents now review breast prognostic
markers and mismatch repair protein expression for their cases.
Of note, clinician satisfaction with both systems was very high, and the transition from GSO to PSSO
did not have a significant effect on the quality of services our department provides. Ultimately,
regardless of whether or not a department chooses to subspecialize, it is necessary to remember that
maintaining patient safety and having a good relationship with clinicians is of paramount
importance.
Go to:
Acknowledgments
We would like to thank Timothy St John for his assistance in running searches in our laboratory
information system to obtain laboratory data related to QA.
Go to:
Appendix A
Attending Pathologist Survey (General)
How satisfied are you with the current mix of cases you see on surgical pathology when on service?
○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied
How efficient are you with the current surgical pathology sign-out pattern?
○ Very efficient ○ Efficient ○ Neutral ○ Inefficient ○ Very inefficient
How satisfied are you with the ability to teach residents while on service?
I feel that the number of hours I work while on service is appropriate.
○ Strongly agree ○ Agree ○ Neutral ○ Disagree ○ Strongly disagree
On average, how many hours per week do you work while on surgical pathology?
○ <40 ○ 40-50 ○ 51-60 ○ 61-70 ○ >70
Overall, how satisfied are you with the current surgical pathology sign-out rotation?
Comments
Attending Pathologist Survey Additional Questions (Partial Subspecialty)

In January 2014, we transitioned from a general surgical pathology sign-out to a partial subspecialty
sign-out. All gastrointestinal (GI) specimens are now signed out by GI pathologists, breast and
cervical specimens are now signed out by breast pathologists, and all remaining specimens are
signed out by general pathologists. With this in mind, please respond to the following
statements/questions.
8. I feel more comfortable signing out my cases now with partial subspecialty sign-out than in the
past.
○ Strongly agree ○ Agree ○ Neutral ○ Disagree ○ Strongly agree ○ N/A
9. I feel I am better able to teach residents now than in the past.
10. Which bench do you sign-out?
○ Breast/cervix ○ Gastrointestinal ○ General
11. Do you prefer partial subspecialty or general sign-out?
○ Subspecialty ○ General
12. Comments
Go to:
Appendix B
Trainee Survey (General)
How satisfied are you with the amount of time you have to preview your cases?
How satisfied are you with the amount of time you have to gross in your specimens?
How satisfied are you with the current mix of cases you see on surgical pathology?
How satisfied are you with the teaching you get from attendings on surgical pathology?
How satisfied are you with the amount of support you have in the gross room from attendings?
How satisfied are you with the PAs’ availability for teaching?
How satisfied are you with the teamwork between residents and PAs in the gross room?
How satisfied are you with the amount of support you have from the LAs?
How many months of surgical pathology (including bridge month) have you completed?
○ 1-2 ○ 3-4 ○ 5-7 ○ 8-11 ○ At least 1 hot seat or C-bench
On average, how many hours per week do you work while on surgical pathology?
○ <40 ○ 40-50 ○ 51-60 ○ 61-70 ○ >70
Overall, how satisfied are you with the current surgical pathology sign-out rotation?
Comments
Resident Survey Additional Questions (Partial Subspecialty)

I feel I am able to focus my learning more with partial subspecialty sign-out than in the past.
I feel I get better teaching from attendings now with partial subspecialty sign-out than in the past.
Do you prefer partial subspecialty or general sign-out?
Comments
Go to:
Appendix C
Pathologist Assistant/Grossing Technician Survey (General)
There is adequate work space to accommodate everyone in the gross room.
How satisfied are you with your availability to teach residents?
How satisfied are you with the teamwork between residents and PAs in the gross room?

I am able to finish my work within the daily allotted work hours.
Overall, how satisfied are you with the current surgical pathology rotation in the gross room?
Comments
Pathologist Assistant/Grossing Technician Survey Additional Questions (Partial Subspecialty)

7. I enjoy the scope and type of specimens I’m grossing in now with partial subspecialty sign-out than
in the past.
8. Do you prefer partial subspecialty benches or general benches?
9. Comments
Go to:
Appendix D
Clinician Survey (General)
What is your specialty?
What is your provider level?
○ MD/DO ○ PA ○ NP ○ RN ○ Other—please specify
How satisfied are you with pathologist accessibility for consultation?
○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied ○ N/A
How satisfied are you with the pathologist consultations?

The pathology reports I receive are complete.
The pathology reports I receive are clear.
The pathology reports I receive are readable.
The pathology reports I receive are accurate.
Overall, how satisfied are you with the surgical pathology department?
Comments
Clinician Survey Additional Questions (Partial Subspecialty)

11. The pathology reports I receive are more consistent now than they were in the past.
12. I feel more confident in the accuracy of the pathology reports I receive.
13. It is easier for me to obtain a pathology consult now than in the past.
14. Have you noticed an overall difference in the quality of pathology report or pathology consult
since we implemented partial subspecialty sign-out?
○ Yes ○ No
15. Comments
Go to:
Footnotes
Declaration of Conflicting Interests: The authors declare no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication
of this article.
Go to:
References
1. Sarewitz SJ. Subspecialization in community pathology practice. Arch Pathol Lab Med.
2. Heatley MK. Subspecialisation and despecialisation in anatomical pathology. J Clin Pathol.
3. Murphy WM. Anatomical pathology in the 21st century: the great paradigm shift. Hum Pathol.
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Public health information (CDC)Research information (NIH)SARS-CoV-2 data (NCBI)Prevention and

Journal ListAcad Patholv.4; Jan-Dec 2017PMC5496684

Keywords: anatomic and clinical pathology, assessment, competency-based feedback, medical

An external ﬁle that holds a picture, illustration, etc.

An external ﬁle that holds a picture, illustration, etc.

EPA: Five Levels of Supervision

the EPA title;

possible assessment methods for evaluation of EPA performance.

Entrustable Professional Activity Titles

Hand oﬀ information to a responsible technologist or pathologist as appropriate for consult requests

Relevant competencies and milestones

PC1, PC2, PC4

Practice-based learning and improvement

PROF2, PROF3, PROF4, PROF5

Interpersonal and communication skills

360° evaluations (eg, attending pathologist, medical technologists, other physicians)

Review of on call activities

An external ﬁle that holds a picture, illustration, etc.

Abbreviations: AP, anatomic pathology; CP, clinical pathology.

Public health information (CDC)Research information (NIH)SARS-CoV-2 data (NCBI)Prevention and

Journal ListAcad Patholv.4; Jan-Dec 2017PMC5528966

Keywords: quality, resident education, subspecialization, surgical pathology

General Surgical Pathology System

Day 1 Day 2 Day 3

Partial Subspecialty System

Week 1-2 Week 3-4

An external ﬁle that holds a picture, illustration, etc.

An external ﬁle that holds a picture, illustration, etc.

An external ﬁle that holds a picture, illustration, etc.

An external ﬁle that holds a picture, illustration, etc.

Pathologist Assistant/Grossing Technician Satisfaction

An external ﬁle that holds a picture, illustration, etc.

Before Partial Subspecialty After Partial Subspecialty P Value

Before Partial Subspecialty After Partial Subspecialty P Value

Before Partial Subspecialty After Partial Subspecialty P Value

Intradepartmental consensus conferences (IDCC)

Multidisciplinary conference reviews

Antibody Organ Before Partial Subspecialty After Partial Subspecialty P Value

These ﬁndings support transitioning to subspecialization. It may be preferable to transition to full

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

I feel that the number of hours I work while on service is appropriate.

○ Strongly agree ○ Agree ○ Neutral ○ Disagree ○ Strongly disagree

○ <40 ○ 40-50 ○ 51-60 ○ 61-70 ○ >70

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

Attending Pathologist Survey Additional Questions (Partial Subspecialty)

○ Strongly agree ○ Agree ○ Neutral ○ Disagree ○ Strongly agree ○ N/A

9. I feel I am better able to teach residents now than in the past.

○ Strongly agree ○ Agree ○ Neutral ○ Disagree ○ Strongly agree ○ N/A

10. Which bench do you sign-out?

○ Breast/cervix ○ Gastrointestinal ○ General

11. Do you prefer partial subspecialty or general sign-out?

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ Very satisfied ○ Satisfied ○ Neutral ○ Dissatisfied ○ Very dissatisfied

○ 1-2 ○ 3-4 ○ 5-7 ○ 8-11 ○ At least 1 hot seat or C-bench